Four people died in the most recent Ebola outbreak that occurred in a remote, forested area of the Democratic Republic of Congo (DRC). This small outbreak (five laboratory-confirmed and three probable cases) was quickly curtailed. The international humanitarian organisation Doctors Without Borders/Médecins Sans Frontières (MSF) shares lessons learned from this first occurrence of the deadly virus since the end of the large-scale Ebola outbreak that devastated West Africa in 2014-2015.
1. Train the frontline health workers
One of the reasons this outbreak remained small is named Dieumerci (“Thank God” in French).
Dieumerci is the head nurse at the health centre in the northeast of the DRC where the first cases occurred. He rang the alarm bell as soon as he detected a risk in a seriously ill man who turned out to be the second Ebola case of the outbreak. Before Ebola is properly identified and epidemic control measures taken, healthcare workers are at high risk of becoming its first casualties and health centres are at high risk of becoming places where the virus is spread. In the West African outbreak, the virus went unnoticed for weeks before it was identified. But unlike in West Africa before 2014, Ebola is known in the DRC: the Ebola River, where the virus was first discovered, runs 100 kilometres away from Likati river. That doesn’t mean that it is a common disease in the area, but still, Dieumerci recognised the symptoms. Dieumerci’s quick action is not something that should be taken for granted. The 1,000 inhabitants of the village where he works live along a stretch of road a few hundred meters from the start of the world’s second-largest tropical forest. Here there is no phone line or cell phone reception, and no electricity except for a few solar panels that would wait months for repair if they were to break, and some generators that are always at risk of running out of fuel.
Healthcare workers play a crucial role not only for the health of the people they serve directly, but also for general epidemiological surveillance: Ebola of course, but also more common deadly infectious diseases such as measles and cholera. However human resources for health remain inadequate in many developing countries. On that fateful day where the second Ebola patient came to the health centre, Dieumerci could have easily been on a sick leave, or visiting family somewhere else in the country. One cannot rely on an individual to play the crucial role of on-the-ground surveillance. What is needed are proper surveillance systems in resource-poor countries, which were clearly lacking in West Africa at the time of the epidemic.
So all in all: thank you Dieumerci. We should hope that during the next outbreak – Ebola or any other infectious disease – there will be another Dieumerci to ring the alarm bell for everybody’s sake.
2. Finally, a forgotten disease that is taken seriously
The word “Ebola” doesn’t ring the same after the West Africa epidemic that killed at least 11,300 and infected over 28,000. Dieumerci’s alarm bell sent shock waves across the world. Congolese authorities immediately activated their outbreak response team and had strong support from WHO and other organisations.
Henry Gray, MSF’s field coordinator in this outbreak, had previously worked with MSF on seven previous hemorrhagic fever interventions in DRC, Uganda and West Africa. “The pressure we felt was very different from previous comparable outbreaks: it was clearly at the top of the agenda. When it comes to Ebola, we have all learned that it’s better to be safe than sorry in order not to repeat the disaster of 2014-2015. But it is sad to still see that other outbreaks in countries like the DRC do not trigger the same mobilization, even in regards to the main killer diseases like cholera or measles. Once the Ebola outbreak was over, we were able to re-assign some of the MSF staff towards a serious cholera outbreak in Kimpese, in the other side of the country where our teams have treated 1,100 cholera patients. Considering the dire health needs in many parts of the country additional support is always welcome”.
3. The old tricks are timeless – back to basics
The promise of new tools (drugs or vaccine) should not overshadow the necessity of putting in place the basic pillars of outbreak control. It starts with good surveillance and is followed by the five pillars of outbreak control: safely isolating and treating the sick; actively looking for potential new cases and surveilling those who have been in contact with them; burying the dead safely; engaging and mobilising the affected communities; offering psychological support. In West Africa, the havoc wrecked by Ebola on the entire health system made more indirect than direct victims of the virus: children were prone to contagious diseases because they were not vaccinated; complicated births lead to the deaths of mothers and/or children because there were no healthcare workers to care for them; untreated cases of malaria become fatal…
When important international health actors come in to give a hand to control the Ebola outbreak they should give support to the local health facilities that often have much smaller means and equipment: training the staff, ensuring that there is basic protection equipment available (even such basic equipment as gloves are often lacking in remote health posts) and that there pharmacy is stocked with first aid supplies and basic medicines for widespread diseases like malaria. MSF’s experience in DRC has shown that training for frontline workers, even when done ad-hoc, can bring sustained effects to improve their performance in surveillance.
Moreover, we must keep in mind that deployment of international aid is not only a means to stop the spread of the disease; it is most importantly of all to benefit the affected community. For this reason, in areas where people have very limited means health care must be free. For example, a person with a fever who is transferred to a health centre to be tested and turns out to be negative for Ebola should not be charged for tests or transportation. The few dollars required are a mere drop compared to the overall cost of containing the outbreak, but they can be an unbearable sum in poor areas and ultimately a deterrent for patients to seek diagnosis and treatment.
4. Location, location, location
Like the majority of hemorrhagic fever outbreaks prior to West Africa, the recent one occurred in a very remote, forested area where the virus was already known to exist within an animal reservoir (assumed to be fruit bats) that is occasionally transmitted to apes, monkeys or men.
Some people are indeed very mobile in the region, but they can only go as far and as fast as their available transportation, but there is pretty much nothing beyond walking and the occasional motorbike. Dieumerci’s village is 45 kilometres from Likati, the closest town home to 18,000 people, where the majestic cathedral and large (but under equipped) hospital are remnants of a time when a railroad was still linking local coffee and cotton plantations to the rest of the country. But today the railroad has been eaten by the forest.
The first material necessary to set up a basic treatment centre for Ebola patient was sent from Likati to the village on the back of motorbikes and it took days for the road linking the two to be repaired, as it was cut in several areas by fallen trees and broken makeshift bridges. Once the repairs were good enough to allow four-wheel vehicles to pass the road, the outbreak was already over. Still, those cars were the first to be seen in many years, and it seemed like most villagers came to witness this event. By contrast, from Guéckédou in Guinea, where the West Africa outbreak started, people can jump on a motorbike and be in the heart of the capital Conakry and its 2.5 million people within two days. As in all previous outbreaks before West Africa isolation played a key factor for the containment of the virus.
5. Medical innovations are not the magic bullet
MSF was willing to use the Ebola treatments that are still in development and actively preparing for it. However, the outbreak stopped before the process to allow the use of experimental products was complete and none could be used this time. This outbreak, however, acted as a booster to speed up the process of preparing medical protocols so that new drugs, still in the experimental phase, can be used in a way that is as safe and ethical as possible.
The rVsV-ZEBOV vaccine (the most advance and suitable candidate for an Ebola outbreak today) is an investigational vaccine that therefore needs to be implemented through a study protocol. Such a study protocol and a vaccine strategy, including informed consent under good clinical practice, were mandatory to access the vaccines (under the FDA framework of Expanded Access). The study protocol was developed and approved by the MSF Ethics Review Board a few months ago and was prepared in order to be ready for implementation should an outbreak occur. A dedicated team from MSF’s research arm Epicenter was also ready to be deployed for the implementation of the protocol.
Unfortunately, the negotiations at the DRC Ministry of Health level only took place when the outbreak had already been declared and it took some time to explain the nature of this intervention, including its difference from a vaccination campaign, and the potential constraints that we were to be faced with during its implementation, such as the remote location and ensuring the cold chain. Nevertheless, MSF managed to obtain authorisation from all the regulatory bodies to start activities and this should serve in case of a future outbreak. The limited size of this outbreak and the rapid control measures put in place early on were the reasons why the vaccine was not finally needed. In most likelihood, the next outbreak (there will be a next outbreak) will happen in a similar setting. We can continue to learn how to best tackle it and ensure that the West Africa outbreak remains an isolated tragedy.
 See MSF analysis on the new Health Workforce Action plan currently under discussion at international level
 See MSF book “The politics of fear”, chapter 5.
 See MSF medical publication “Sparks creating light? Strengthening peripheral disease surveillance in the Democratic Republic of Congo” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913685/