The Democratic Republic of Congo has confirmed its first Ebola death in the eastern city of Butembo, a trade hub with Uganda that is home to almost a million people. This first urban death, combined with ongoing violence in the northeastern outbreak area in DRC and some community resistance, is worrying experts that the slowing outbreak could still escalate.
Having already killed 87 people, this outbreak is close to becoming the eighth-largest Ebola outbreak in history. While officials have been pleased with the decreasing pace of cases and a successful vaccination and contact tracing campaign, this new case in an urban setting is worrisome, Peter Salama, the World Health Organization’s emergency response chief, told HuffPost.
“When you have an Ebola case confirmed in a city with 1 million people, no one should be sleeping well tonight around the world,” Salama said.
The patient traveled from the current outbreak hotspot, the town of Beni, 35 miles southwest, to Butembo after disregarding medical advice, Salama said. The patient died at a health facility there.
While WHO team members are on site and working to quickly trace and vaccinate those with whom the patient came into contact, the potential for further spread could “change the trajectory of the outbreak,” Salama said. Two more cases are suspected in the trading hub, the DRC’s Ministry of Health reported Wednesday. Butembo is known for being critical to import and export between DRC and East Africa, Reuters reported.
And since the patient died at a health facility, the potential for Ebola’s spread among the patients and health workers there is of particular concern, as health care workers have been “the No. 1 driver of transmission,” Salama said. So far in this outbreak, which is in an area of northeastern DRC that has never seen Ebola before, 16 health care workers have been infected and one has died.
For Salama, the bigger danger is the 40 people identified as having been in contact with infected patients in the “red zones” ― areas health care workers are unable to reach because of ongoing violence. North Kivu is home to more than 1 million displaced people because of the many armed rebel groups in the area, which is why the United Nations’ largest peacekeeping mission is based there. The U.N. considers the region a U.N. security threat of Level 4, based on a five-level scale.
“I think it’s very unlikely we’re missing very large numbers of cases, but it is entirely possible that we are delayed in picking up cases,” Salama said of the contacts of Ebola patients in the dangerous areas, but he said that the 21-day waiting period would soon expire for many of the 40 contacts ― meaning they would be cleared.
“Whenever you have a simmering ember, you can still have a forest fire.”
Jeremy Konyndyk, a senior policy fellow for the Washington-based Center for Global Development who previously led parts of the 2014 Ebola response for the Obama administration, pointed to those potential cases as a major concern.
“We had a phase during 2014 in West Africa where, likewise, case counts were declining and it appeared things had turned a corner. But, in fact, there was significant spread that just wasn’t being seen, and subsequently allowed the later explosion.” More than 11,300 people were killed in the 2014-2016 West Africa outbreak, which cost the world billions and infected 28,600.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease, told HuffPost on Tuesday that one can never be complacent with Ebola.
“Whenever you have a simmering ember, you can still have a forest fire,” Fauci cautioned.
An Added Fight Against Insecurity And Community Resistance
On top of the first case in an urban area, two major attacks by the Allied Democratic Forces (ADF), rebels who oppose the Congolese government, have complicated response efforts.
On Aug. 24, ADF overran a DRC military base north of Beni, Salama said. On Monday, the group executed a series of ambushes on Congolese and U.N. security forces. Both incidents have been close to the Beni airport, where the WHO has flown in the 200-plus staff stationed in the Congo. Indirect messages have been sent to the ADF to urge them to cease violence in the area as the Ebola outbreak response continues, Salama said, while stressing that, despite the violence, the response had not been overly hindered.
Hassan Coulibaly, a field director for the International Rescue Committee, on the ground in Beni, told HuffPost that operations had not been badly affected by the recent fighting, which often happens at night when health care workers are not allowed to travel.
Coulibaly told HuffPost that the most important issue in beating the spread of Ebola at this stage was battling community resistance.
He estimated 8 to 10 people’s families had refused the WHO’s and Red Cross’s offers of safe burial practices. Traditional burials can put family members at risk for transmission. A local politician had also been spreading rumors that Ebola was not real, and some in the area had resisted vaccination and treatment, according to Coulibaly.
Salama said local religious leaders had quelled the remarks of the politician, and community and health workers had been working to combat misconceptions that the arrival of Ebola was tied to the coming elections in DRC or had been brought in by foreign organizations.
He stressed however that, overall, vaccination rates were very high ― more than 6,300 people have been vaccinated, and 98 percent of those offered the vaccine have taken it.
He credited the high response rate to the new tools health care workers are able to offer in the experimental vaccines and treatments. Health workers no longer are just harbingers of a coming quarantine but have tools at their disposal to prevent and potentially save ― a game-changer in the fight.
“Ebola treatment units will no longer be seen as a place to be isolated where you may likely die, but actually a place where you may even more likely survive,” he said.
Salama added that he is excited to announce that discussions for a multi-country, multi-outbreak randomized trial for the five experimental therapies is in the final stage and could be deployed as soon as this outbreak.
While the DRC Ministry of Health wrote Tuesday in its daily report that “several violent incidents against medical personnel and care facilities were also reported,” Salama said he could only think of one, when a health care worker was injured and a community health center was burned down by a group of youths in Manbango, which is outside Beni, after learning of the death of a prominent villager.
Despite the measured WHO warning, Ron Klain, who was President Barack Obama’s Ebola czar during the 2014 outbreak, told HuffPost that “many signs are now flashing yellow” after the Butembo news. While Klain applauded the WHO for its quick response and cited the transformative new tools of experimental vaccine and treatments, the ongoing “security risk, potential urban spread, community resistance are all indications of the limitation of our current global epidemic response system. It is quite possible that a broader response will be needed, with more leadership and engagement from other countries ― including the United States ― that can and should do more to help.”
A Different Kind Of Outbreak Situation
For Salama, this outbreak is a prototype of the rising number of outbreaks of the future: one that spreads to more populated areas. As HuffPost has previously reported, outbreaks of the worst kinds of pathogens ― ones with the highest mortality rates and limited countermeasures ― are on the uptick due to population increases, more global travel, and changing migratory and environmental patterns that result in encroachment upon animal and other populations. And with more people living close together, outbreaks like this one will become even more common, Salama said, calling it a “highly different paradigm.”
“No longer will the standard be isolated rural communities that are the focus of these outbreaks, but actually dense areas of the world with high populations.”
Fauci also expressed how the rising number of emerging and reemerging pathogens has led to heightened response from the WHO and other global health organizations ― and necessitated its continuance.
“We’ve got to sustain the need to keep developing better and better ways to address outbreaks ― we tend to often be reactive as opposed to proactive.”
“When you have an Ebola case confirmed in a city with 1 million people, no one should be sleeping well tonight around the world.”
Eight days ago, Salama said that the next 7 to 10 days would be critical to turn this Ebola outbreak around. As the world nears the end of that window, he says, the promising data point to a slowing outbreak ― but that this new case in Butembo, plus the security concerns, makes this far from over.
“Because of all of the complicating factors, it’s extremely important that we just continue to push really hard and support DRC and surrounding countries to be on top of this and not to have any false sense of security. It’s by no means over until the last case is really and truly dealt with.”