T

he latest Ebola epidemic in the Democratic Republic of the Congo is shaping up to be the most dangerous and difficult test of the world’s ability to contain the disease since the catastrophic West African outbreak in 2014 and 2015.

Like an outbreak earlier this year, in the western part of the country, cases have been reported across multiple locations, disease transmission is taking place in cities where hundreds of thousands of people live, and there’s the potential for the virus to spread across several international borders.

But this outbreak is occurring in a part of the Congo that has long been a conflict zone, with over 1 million displaced people, scores of armed combatant groups, and “red zones” where outsiders hoping to contain a deadly disease may not be able to travel.

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The possibility that the virus could spread unchecked in one of these areas raises prospects of an outbreak that could make this year’s earlier brush with Ebola seem like a training exercise.

“That’s really the worst-case scenario: That we can’t get in quickly enough to an alert [of possible cases] or we just have a blind spot because of security. And then an outbreak really begins to take hold in those blind spots and becomes a multicountry regional outbreak,’’ Dr. Peter Salama, the World Health Organization’s deputy director-general of emergency preparedness and response, told STAT.

“That’s what keeps me up at night.”

The outbreak was declared in North Kivu on Aug. 1, a week after the previous epidemic was deemed contained. Genetic analysis of viruses from the two show that while they are caused by the same species of ebolaviruses, Ebola Zaire, they are not linked.

Two weeks into this outbreak, the toll has already surpassed that of the earlier epidemic, which was centered around Bikoro, near DRC’s western border. There were 54 cases and 33 deaths over roughly four months in the Bikoro outbreak. As of Tuesday, there were 73 confirmed and probable cases and 43 deaths in North Kivu, and the case count is rising steadily.

North Kivu is in northeastern Congo, near the border with Uganda and Rwanda. It’s the country’s most populous province, with 8 million people. It is also its most dangerous.

Under a scoring system used by the U.N. to determine the level of risk for its personnel in conflict zones, North Kivu is at level 4. Level 5 means the U.N. must evacuate; it is simply too perilous to be present.

The security concerns mean that the WHO insists responders have armed escorts as they move about — a requirement the medical aid group Doctors Without Borders always refuses on the ground that it undermines the group’s ability to claim neutrality.

The operational strictures they face mean Ebola responders will need to be “very flexible” and “pragmatic,” WHO Director-General Tedros Adhanom Ghebreyesus said this week in Geneva.

Already that has led to trimming of ambitions. Whereas in the Bikoro outbreak the WHO hoped to run trials of five experimental Ebola therapies, this time there is no immediate thought of trying to generate data on whether the treatments are effective and which are the most potent.

Dr. David Heymann, a former WHO assistant director-general, and now a professor at the London School of Hygiene and Tropical Medicine, is on an expert committee that advises Salama’s emergency response center.

“The committee recommended that there be no research until outbreak containment was underway — and well underway,” Heymann said Wednesday. Unlicensed drugs can only be used in studies, or in a “compassionate use” setting; the latter will be the approach here.

Likewise, the protocol that would normally be used to determine who should be offered Merck’s experimental Ebola vaccine may have to be modified in some locations. Until the vaccine is fully licensed, the WHO has been advised to use it employing a system known as ring vaccination — find out who has been in contact with a confirmed Ebola case and vaccinate them and all their contacts.

In the current outbreak, vaccination teams may not have the time to conduct the interviews that would be needed to trace all contacts and the contacts of contacts, Salama said.

“If, for example, we find that we can only visit a small village that’s in a red zone area, and it has 200 people, and we can only go once and we’ve only got a couple of hours because of security, then my instruction to the team will be: Go in and vaccine the 200 people because we don’t have the time, security wise, to do detailed contact tracing of that small village,” he said.

Dr. Daniel Bausch is a longtime Ebola responder who is director of the U.K. Public Health Rapid Support Team, a partnership between Public Health England and the London School of Hygiene and Tropical Medicine. Bausch recalled taking part in the response to a Marburg virus outbreak — Marburg is from the same family of viruses as Ebola — in northeastern Congo in the late 1990s, when the WHO had to negotiate with armed groups to operate.

It wasn’t easy, but it was successful, Bausch said, while acknowledging this time will be tougher.

“It’s not the first one that has happened in an area of insecurity, but it’s potentially at least more disseminated an area of insecurity. And a very, very complex area,” Bausch said, pointing to the refugee population. “I do think it is a little bit of uncharted waters.”

Bausch’s team has sent one person to take part in a WHO-led rapid assessment group that is in North Kivu now. From the outset the WHO has said it will have to limit the number of responders it deploys, because of the strain it will place on the U.N. peacekeepers to safeguard their security.

And rather than setting up multiple response outposts, the workers will likely have to cluster in the town of Beni, where they can safely function, using it to make “in and out’’ forays to other, less secure places.

“We don’t want to have people based anywhere to the east, not far to the north, and not beyond 30 kilometers” — roughly 19 miles — “really to the south,” Salama said. “And you’ve got a kind of circle of a 20- to 30-kilometer radius to the west and north which is reasonably secure. And you’ve got very little room to move on the east, in terms of secure zones.”

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