There has been an eerie mirroring of
events between the ongoing outbreak of Ebola virus disease in the
Democratic Republic of the Congo (DRC) and the 2014–15 outbreak in
Liberia. The DRC has vast historical experience from containing eight
prior outbreaks, but the country has not previously had to respond to
urban Ebola spread.
The current and ninth DRC outbreak was declared by the Ministry of Health on May 8, 2018.
By May 14, Ebola virus had escaped the rural epicentre of Bikoro and
travelled 150 km into Mbandaka, an urban centre populated by 1·2 million
people.
In a similar manner, during late June, 2014, Ebola virus disease
escaped rural Sierra Leone into Foya District of rural Liberia and
proceeded to enter the densely populated New Kru Town community of
Monrovia, a city of over 1 million inhabitants.
The unprecedented case counts of the west African epidemic were largely
due to this unprecedented migration into unprepared urban centres. At
the height of the outbreak in September, 2014, Monrovia alone was
accounting for 51% of all the Ebola cases in Liberia. Given the parallel
scenario of cases emerging in Mbandaka, the response in the upcoming
weeks and its sensitivity to the local context will be critical in
informing the final outbreak size in the DRC.
Understanding
the cause of spread in Liberia provides important lessons for the DRC.
Why did the index urban case decide to leave Bikoro for Mbandaka?
First,
to seek care. She may have come to the city to seek medical care since
care in her village was inadequate and she was observing others die in
spite of the treatment they were receiving. Given this root cause of
movement, case investigation should hone in on hospitals and clinics
visited for treatment to identify highest risk contacts. In Liberia,
Monrovia's case zero in 2014 visited Redemption Hospital and exposed
nurses and a doctor. Some of those exposed at Redemption Hospital went
to a clinic in a neighbouring community and infected two nurses, who
themselves sought treatment in another community and infected multiple
health-care workers.
Second, it is
also possible the case left her village to evade cultural threats. If
she fled to the city since she attributed her illness to supernatural
cause, such as a curse, it could have led her to relatives in Mbandaka
with anticipation of finding a spiritual solution from traditional
healers. In late June, 2014, migration to Monrovia in response to Ebola
disease as a perceived curse prompted the second wave of transmission. A
16-year-old girl from a village in Sierra Leone had seen her family
members systematically die from a strange disease. The prevailing belief
was that the girl and her family were bewitched since their grandfather
stole a goat. In pursuit of a spiritual solution, she and her brother
drove to Monrovia from Sierra Leone, leading to cross–border
transmission and a large disease cluster in densely populated Monrovia.
In light of these motivations, how can a trustworthy and trusted response be delivered to control the spread of the virus (panel)?
Panel
Five actions for delivering a trusted response for the control of Ebola virus transmission
- Provide sufficient point-of-need care to prevent rural to urban spread
- Implement and laud successful treatment innovations
- Debunk rumours and generate data through community engagement
- Balance public health with individual rights
- Practice safe burials
First,
sufficient point-of-need care should be provided to prevent rural to
urban spread. Access to effective health-care for diagnosis and case
management will shift the disbelief and distrust around Ebola and
prevent outward migration. Rules barring people from travelling in and
out of villages will then be possible.
Second,
successful treatment innovations should be implemented and lauded. In
Liberia, all patients entering Ebola treatment units (ETUs) were given
an intravenous line for fluid administration. Some patients also
received ZMapp, a putative immunotherapy for Ebola virus disease.
A positive feedback loop is essential for building trust in ETU care.
Survivors should be paraded in communities to emphasise the role of ETUs
in saving lives.
Third, through
community engagement, rumours need to be debunked and data generated.
Community youth, pastors, and imams should be trained in conducting
daily door-to-door surveillance on visitors, the sick, and potential
dead.
The communication should be horizontal rather than vertical. The
resulting data will govern the response by guiding distribution of
ambulances, burial teams, and food for affected homes.
Fourth,
public health priorities must be balanced with consideration for
individual rights. No patients in the ETU should be allowed to leave
until certified as being clear of Ebola virus.
Finally,
practicing safe burials is essential. Local community leaders,
religious leaders, and youth leaders should be mobilised to identify
secret deaths and burials so that the dead body management teams can
conduct safe and dignified burials. In Liberia, a Muslim burial team was
formed to handle bodies in protective suits while allowing the
appropriate ablutions.
At a
macrocosmic level, the relationship between virulence and
transmissibility is perturbed by population–level beliefs and practices.
Beyond the establishment of ETUs and targeted vaccination,
understanding root causes of disease emergence in urban DRC will be
essential to preventing additional rural to urban spread and to
containing the outbreak within urban centres.
We declare no competing interests.
References
Ebola Virus Disease: Democratic Republic of Congo. External situation report 2.
http://apps.who.int/iris/bitstream/handle/10665/272536/SITREP-EVD-DRC-20180514.pdf?ua=1
Date: May 14, 2018
Date accessed: June 4, 2018
Ebola epidemic—Liberia, March–October 2014.
MMWR Morb Mortal Wkly Rep. 2014; 63: 1082-1086
A randomized, controlled trial of ZMapp for Ebola virus infection.
N Engl J Med. 2016; 375: 1448-1456
Interrupting Ebola transmission in Liberia through community–based initiatives: interrupting Ebola transmission in Liberia.
Ann Intern Med. 2016; 164: 367-369
Article Info
Publication History
Published: June 25, 2018
DOI: 10.1016/S0140-6736(18)31435-1
