Last month, a rebel attack in Beni, the epicenter of the ongoing Ebola outbreak near the eastern border of the Democratic Republic of Congo (DRC), once again halted the efforts of response teams working to contain the virus. With over 10 major episodes of violence since the outbreak was declared in August, insecurity and community mistrust has made it difficult to gauge the true extent of Ebola’s spread. Though the outbreak could still be limited, cases appear to be increasing — especially in Beni, where cases have doubled in recent weeks — with 80% of new infections arising among people with no link to “known transmission chains” (where everyone who is infected is known and you can track who has been exposed with some accuracy). This means that we might only be seeing the tip of an iceberg of hidden transmissions and the outbreak could spiral out of control and spread into neighboring countries. Given this danger, the current strategy for containing the disease needs to be adjusted.
Eastern DRC has been home to one of the deadliest and most intractable conflicts in modern history; over 50 armed groups are still active in the region. Originally formed to protect their communities, many of these rebel militias have become entangled in the messy web of politics, shifting allegiances, and underhanded mining deals that fuel the conflict.
This backdrop and the inability of the government or international agencies to assure basic safety, much less basic needs, has entrenched a distrust of formal institutions in the population. These dynamics have been made more complicated by the fact that DRC is supposed to hold elections in December that have already been delayed twice since 2016.
Given that outbreaks can grow quickly and exponentially, definitive action is needed now.
The current plan for stopping this outbreak is based on contact tracing (the identification and monitoring of people who were exposed to Ebola-infected individuals for the 21 days during which they may develop infection) and “ring” vaccination (immunizing these contacts and those close to them with an experimental Ebola vaccine). This approach efficiently contained an Ebola outbreak in western DRC just a few months ago but requires a comprehensive and precise understanding of who is infected and who their contacts are — something that necessitates having unimpeded daily access to their communities for months.
That has not been possible this time around: Areas affected by violence have been inaccessible for days at a time. Therefore, while contact tracing and ring vaccination should continue where transmissions can be tracked, mass vaccination of larger portions of populations should be considered in areas where that is not possible such as Beni, which has a population of about 230,000. Expanding vaccinations in this manner could immediately halt the spread of the disease.
While such a mass vaccination sounds ambitious, the World Health Organization (WHO) and others have executed much larger national campaigns in over 40 low-income countries, including DRC, where millions of children were immunized against polio or measles within a single week. These campaigns were also implemented successfully during conflicts in Somalia, Afghanistan, and Liberia. Though a mass-vaccination effort targets an entire population, it need only reach the proportion required for “herd immunity” — immunizing enough people so that the virus cannot spread. Early studies of the Ebola vaccine found that it might be possible to achieve herd immunity by vaccinating as little as 42% of the population.
To be successful, the mass vaccination effort would require the buy-in of the communities and the Ebola response teams being able to securely access the areas in question for the day or two it would take to immunize everyone. Promisingly, a recent study showed that even communities with high levels of distrust appear to be open to vaccination.
Anthropologists are already on the ground working tirelessly to engage community leaders and armed groups. In areas not amenable to outreach, a neutral “white helmet” security force, ideally drawn from the African Union or other countries without past involvement in the DRC conflict, should be deployed with the sole mission of securing vaccination efforts. It should be made abundantly clear to the population that this force has no allegiance to any political or institutional actors and is there only to deter violence against responders. At the end of the day, communities and militias do not want their loved ones to die from Ebola and would respect such a presence if they were reassured its mission is strictly medical.
Mass vaccination will also require an adequate supply of the Ebola vaccine. Its manufacturer, Merck, has committed to maintaining a supply of 300,000 doses at all times. Doing so could become difficult if vaccination efforts are expanded, but at the current juncture, the number of people who would need to be vaccinated in order to stunt the outbreak still appears to be within the range of existing stockpiles. Nonetheless, production of the vaccine should be increased and the bottlenecks to doing so should be assessed and cleared to ensure an adequate supply.
It’s true that the Ebola vaccine is still experimental and its health risks are not yet fully known. However, for people living in areas where everyone who is infected is not known, the heightened risk of unknowingly contracting a fatal Ebola infection may, at this point, outweigh the potential danger posed by the vaccine.
After the West African Ebola epidemic spiraled out of control, many wondered why more aggressive measures were not taken sooner. We may be at a similar make-or-break point in this outbreak.