The Ebola outbreak in the Democratic Republic of the Congo has reached a dangerous phase, with the response operation acknowledging it hasn’t got a full picture of where the virus is spreading in a large urban center.

That concerning development is tempered slightly by signs that people living in Beni, the current hot spot of transmission, are beginning to comprehend more fully the danger the virus poses, said a senior World Health Organization official.

That understanding is translating into better cooperation — a welcome development in an outbreak response that has had more than its share of bad luck.

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“There is underground community transmission in Beni. It may not be at a very intense level. But it is enough to continue and drive transmission in this town. And we need to stop it,” said Dr. Mike Ryan, assistant director-general of the WHO’s emergency preparedness and response program. “We need to pull the roots of this thing out of this city.”

By underground transmission, Ryan means that there are cases that have no discernible connection to previous Ebola patients, cases that cannot be mapped onto any known chains of transmission.

As of Wednesday, there have been 88 cases reported in October — more than a third of all cases in the outbreak, which likely began in July. The total to date is 247 confirmed and probable cases and 159 deaths.

If the response teams don’t know where the virus is spreading, they can’t apply the containment measures that will stop that transmission. In a city the size of Beni — population: 200,000 — that’s a dangerous prospect.

“Beni is going to be a grind. There’s no other way to look at it,” said Ryan, who was in the northeastern Congo city when he spoke to STAT. “This is rooting out an entrenched virus in an urban environment, in a traumatized population where there is clear compromises to security.”

North Kivu, the province in which the outbreak is occurring, is under siege and has been for years. Heavily armed militia groups in the region launch regular attacks against the Congolese army. Just last weekend, there were back-to-back attacks against an army checkpoint and within the city itself. Civilians and army personnel were killed and a number of children were abducted.

An earlier attack in Beni in late September prompted civil society groups to declare days of mourning — so-called “ville morte,” which is French for “dead city” — as a form of civilian protest of the violence. The city shut down for five days, and the Ebola response teams were forced to substantially scale back on their work.

A week later, cases started to climb and that rebounding of transmission still hasn’t been brought under control.

After the latest round of violence, the Ebola response team received a much-needed break of a sort, with community leaders in Beni deciding against declaring a new ville morte period.

“Beni is going to be a grind. There’s no other way to look at it.”

Dr. Mike Ryan, WHO

Ryan said officials from the Congolese ministry of health, the WHO, and other partners in the response discussed the issue Sunday with the civil society leaders, who realized how dangerous it would be to again scale back containment efforts. On Monday, the response operations were back at full steam.

“I think in some ways it represents a turning point in the community in general. I think they were extremely frustrated, very angry about the attack. But I think also in the last couple of weeks they’ve really recognized that Ebola is also a major threat and it’s affecting their community,” Ryan said.

He suggested there are other signs that the people of Beni are becoming more cooperative with the response teams. For instance, there’s increasing demand for the experimental vaccine being used to help contain the epidemic. So far, more than 21,500 people have been vaccinated, roughly 10,300 of them in Beni.

The vaccine is not being offered to everyone. Those on the front line — health care personnel and burial teams among them — have been vaccinated. But in the broader community, the strategy being deployed is called ring vaccination, which involves vaccinating the contacts of known cases and the contacts of those contacts. The idea is that if people who might otherwise develop the disease are protected, the virus won’t be able to spread.

In the past, contact tracing has been hampered by the fact that people didn’t want to be listed as contacts, and a portion evaded the daily checks from the response teams to see if they had developed symptoms. As word gets out about the vaccine, though, attitudes are changing, Ryan said.

“It’s gone from people not wanting to be associated with contact lists to demanding to be on the contact list. Faith in vaccination is growing,” he said.

A steadily increasing pool of survivors — 65 to date — is also serving as good publicity for the Ebola treatment units, where patients are cared for in isolation by health workers decked out in the necessary protective gear. Word is circulating as well that patients in the ETUs, as they are called, are being treated with experimental drugs. Both the drugs and the vaccine are serving as “pull factors” that enhance community cooperation, Ryan said.

Still, huge challenges remain. For instance, the response teams have been trying to figure out why so many young children are getting sick in this outbreak, including children under 5 years old. Young children normally make up a small portion of Ebola cases.

Ryan said there are probably a number of factors contributing to the phenomenon. Some of the youngest children may have been infected through breastfeeding, for instance. But a big driver is likely the heavy local reliance on practitioners of traditional medicine who work in what are known as “tradi-modern” clinics.

Conditions and the level of medical expertise in these clinics — which are generally the first port of call when someone gets sick — vary from place to place. Some of the practitioners have some medical training, others do not. And fundamentals of infection control, such as only using syringes once, aren’t universally applied, Ryan said.

Ebola response workers know of at least 202 of these tradi-modern centers. Describing one he had visited this week, Ryan said, “It was a room in a house. You would have passed by it a million times and never knew that it was a treatment center.”

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The outbreak is happening during peak malaria season, and some of the children who became infected with Ebola were cared for in tradi-modern clinics. It’s clear transmission has happened in a number of these centers, Ryan said.

The response teams have been trying to enlist these clinics in the fight against Ebola, checking in with them daily to hear if any patients were showing signs of the disease. The strategy is starting to pay dividends, Ryan said, noting that there seems to have been a decline in pediatric cases in the past week.

Ryan is a veteran of many outbreak responses, for Ebola and other diseases. He calls himself “a pathological optimist” and said he believes the response teams will get the upper hand on the virus, though it’s going to take “weeks of very, very hard work.”

A break from the violence that keeps the city on edge would be welcome. “The greatest gift we could receive right now is … calm and peace,” said Ryan. “Because we’re fighting one war against the virus. And it doesn’t really work very well when you have to deal with another one.”

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