Health officials say that the Ebola outbreak in East Africa could become one of the worst ever recorded unless the response ramps up. There have been signs of improvement, but many hurdles remain. Here’s what will determine how fast the epidemic can be contained.
An early failure to identify the Bundibugyo virus, the species responsible for the outbreak, followed by a lack of testing equipment, led to major delays in identifying infected people. That has made current case counts almost certainly lower than reality.
Without fast test results, health workers can’t rule out malaria, which has similar early symptoms to Ebola disease. And without rapid confirmation, health workers can’t move on to the next steps: isolation and contact tracing, to prevent further spread.
Congo’s national biomedical research institute, with help from international health agencies, has expanded genetic testing for the virus at the outbreak epicenter and out into potentially affected areas. Most tests are processed the same day.
But challenges remain.
Many samples still have to be transported for hours over rutted dirt roads to central labs. There is no electronic record system in the local health systems, which slows the sharing of results. Many test sites were connected to the internet for the first time just this week.
Another hurdle is persuading people to get tested.
Some infected people will make their way to new Ebola treatment centers, especially if communities gain trust after they see people being saved there. Ideally, each patient would be kept in isolation until they test negative, but there is a shortage of the building materials needed to set up these spaces.
Community testing is also critical for those who don’t go on their own to testing centers, but that process is labor intensive and slow.
Without proven treatment or a vaccine to protect against the Bundibugyo virus, only public health measures like contact tracing can bring the outbreak under control.
To stop the outbreak, 95 percent of people who have been in close contact with someone infected must be identified and monitored for symptoms. Uganda is succeeding in tracing almost all contacts, the World Health Organization says, but on the Congolese side of the border, the situation is far more challenging.
The outbreak is occurring in an active conflict zone, and the disease is spreading in crowded displacement camps. As it does, contact tracers are hampered by community mistrust. Contact tracing rates have improved over time, reaching about 70 percent in recent days, but the authorities warn that thousands of contacts of Ebola patients are still not being followed.
There are many reasons people don’t want to engage with public health workers.
Some fear being forced into an isolation center when they need to work to feed their families in communities where hundreds of thousands of people rely on humanitarian aid for survival.
And with misinformation rife on social media, they may not believe that the epidemic is real.
Some are frustrated that the international community shows up with help for Ebola outbreaks, but there is little to be had for the malaria cases that kill children in large numbers, or for safe childbirth or malnutrition.
There is also fear that if they or a family member dies in a health center, they will be denied traditional funeral rites, including bathing of the body. That is a cultural touchstone, but it poses a major risk for spreading the virus.
All of these factors keep people from seeking help if they develop symptoms, and may also prompt them to evade contact tracers.
While there are approved vaccines and treatments for Ebola, there are none that specifically target the species of the virus behind this outbreak. For now, the only treatment that the W.H.O. recommends is supportive care. That can include IV fluids, antibiotics for bacterial infections and management of organ failure and other complications.
The W.H.O. and other organizations are currently setting up clinical trials for potential vaccines and treatments, but even if they are found to be effective, it may take several months before any can be used for the current outbreak.
The Coalition for Epidemic Preparedness Innovation, a nonprofit organization, is providing more than $63 million to create and test Bundibugyo vaccines. So far, it’s supporting four vaccines, with more potentially to be added to the portfolio.
These vaccines are variations on ones that are already used against many pathogens. “Now what we need to do is adapt the designs we’ve got to Bundibugyo and scale up the manufacturing as quickly as possible,” Richard Hatchett, the chief executive of CEPI, said.
For people who are already sick with Bundibugyo virus, researchers hope to test several drugs, among them monoclonal antibodies, which lock onto the surface of a virus and prevent it from getting into cells. One of them, known as MBP-134, has already proven especially promising against Bundibugyo in tests on monkeys. Clinical trials have demonstrated that it is safe for people.
Antiviral drugs, which could lower the risk that exposed people develop Ebola in the first place, may also help stop the spread, too.
A clinical trial is in the planning stages to give the drug obeldesivir to people who have had contact with patients but have yet to develop symptoms. One attraction of obeldesivir is that it is a cheap pill, rather than an expensive infusion like MBP-134.
These trials may take months to deliver results. Many past Ebola outbreaks ended before clinical trials could even begin.
Areas most likely to see travel in and out of the outbreak’s epicenter
People outside eastern Congo and its immediate border countries — Uganda, Rwanda, Burundi and South Sudan — are at very little risk.
If an infected person travels to a high-income country, the case would most likely be identified quickly and spread controlled. There is no clear evidence the virus is airborne, and it is instead contracted through contact with the bodily fluids of an infected person.
But people within the outbreak region are at high risk.
Much of that risk has to do with the population’s vulnerability. The three affected provinces of Congo have a population of about 15 million. At least a third of these people are displaced at any one time, the United Nations says. When in camps, they live in highly congested settings with limited sanitation facilities.
Many people in the region make a living in trade and artisanal mining, which takes them back and forth across borders.
Uganda closed its official crossings with Congo in the first days of the declared outbreak. But that is no guarantee of safety. As many as 30,000 people a day generally traverse the border, and many are now using informal border crossings that don’t have health screenings.
The virus has also spread from the epicenter in Ituri south to the provinces of North and South Kivu, which are under the control of a militia that does not cooperate with the Congolese government. There are busy borders in this region, too: Fifty thousand people a day typically cross the border from Goma, in North Kivu, to Rwanda. That border is now closed to most traffic.
There is a possibility that an infected person whose infection is too early to be detected in an airport screening could travel by air.
Where the Ebola virus is more likely to arrive if it is internationally exported
Modeled on existing global travel patterns, projections from Epistorm show the relative risk of the virus reaching different countries if an international export of the virus does occur.
There is a higher risk of the epidemic seeding if an infected person were to go to another low-income country with a weak surveillance and health system.
It’s far too soon to be sure, but there are some indications that the death rate from Bundibugyo may be less than has been seen with the virus that has caused most Ebola outbreaks.
In the initial stages, the symptoms of the disease — fever, weakness, gastrointestinal pain, vomiting — can mimic those of myriad illnesses common in Africa, including malaria, typhoid and dysentery. As they get worse, some patients experience severe damage to their blood vessels and organs, and they may eventually die of multi-organ failure.
In the case of Bundibugyo, more patients seem to be experiencing symptoms on the milder end of the spectrum, according to doctors in the Congo who have treated both kinds. Although it’s too early in the outbreak for firm conclusions, their observations jibe with reports from the previous two outbreaks of this virus.
That’s good news in some ways, but it also means that people may be symptomatic and spread the virus to others for longer before they get sick enough to seek care.
“I think this also explains how it is spreading so fast,” said Dr. Babou Rukengeza, Save the Children’s Ebola response lead in the Congo. “It’s clear that we are behind the outbreak.”
