‘On a knife edge’: Ebola outbreak threatens to escalate as violence rises

The Ebola outbreak in the Democratic Republic of the Congo is threatening to spiral out of control, with ongoing violence aimed at the Ebola response workers undermining efforts to stop spread of the deadly virus.

STAT spoke to a number of experts involved with or closely monitoring the situation to try to get a sense of where the outbreak in northeastern DCR is heading.

Each one agreed: A disaster is unfolding.

“The numbers in the last month have been horrifying,” said Dr. Jeremy Farrar, director of the Wellcome Trust, a major funder of the Ebola response. “It’s on a knife edge. I’m not sure how else to describe it, really.”

The World Health Organization is doing scenario mapping trying to figure out just how bad this outbreak might become. But Dr. Mike Ryan, executive director of the emergencies program, won’t share what they see as they look at their models. “That’s for planning purposes, not for speculation,” Ryan insisted in an interview with STAT on Monday.

The statistics are grim: Double-digit daily increases in the case count are now the norm. Most new cases are people who never hit the radar of the teams searching for those who have been exposed to the virus, so they were never offered the experimental Ebola vaccine being used to try to contain the outbreak. Treatment centers are under armed guard, protecting health workers but discouraging people with Ebola from seeking their care, people familiar with the situation say.

Ebola treatment centers and roadside checkpoints have been torched; response workers have been beaten. On April 19, Dr. Richard Mouzoko, an epidemiologist from Cameroon working for the World Health Organization, was murdered when gunmen burst into a meeting he was leading.

Given the real threat to their staff, some organizations have reduced the number of non-Congolese workers they have on the ground in Butembo and Katwa, the epicenters of transmission. Contingency planning has some agencies simultaneously trying to figure out what conditions would prompt them to return some international staff to the outbreak zone and what might trigger a total withdrawal.

Even the WHO’s Ryan admitted that if this were some other emergency, not an Ebola outbreak, the danger the response workers face would likely have led to a withdrawal by now.

“I honestly, honestly, honestly think that in very many other humanitarian situations, that decision might have been taken already,” Ryan said.

But that’s not an option with Ebola, which is currently killing about 66% of people who are being infected in this outbreak, now in its 10th month. As of Sunday, there were 1,572 cases reported and 1,045 deaths. It’s the second largest outbreak on record and will soon be four times bigger than the third on the list.

“If we leave, the disease spreads. And then it will be huge,” Ryan said. “And then we’re going to end up expending more resources, we’re going to end up with more people dead, and we’re going to end up taking exactly the same risks to stop it, but at a much higher scale of exposure.”

As it is, the cost of running the operation is crippling. Ryan said recently the organizations working on the response have an urgent funding gap of $54 million, which, if not soon filled, could see some forced to scale back their operations because they cannot pay staff.

The frustrating thing for the people leading and working on the outbreak response is that the steps needed to stop an Ebola outbreak are well-known. Even in the days before the vaccine was developed, finding and isolating cases, monitoring the health of their contacts, and quickly isolating those who become sick and burying safely those who succumb has time and again broken the chains of Ebola transmission.

But this time, persistent resistance from the people in the affected communities, fueled by decades of conflict in the region, has rendered the response teams incapable of putting into effect these tried and true measures.

“Do we lack the operational capacity to stop Ebola? No. Do we lack the tools to stop Ebola? No. What we lack right now is the environment, the access, the enablement,” said Ryan. “Too many disabling factors — from security to money — that really hold us back on a daily basis.”

The failure to contain the epidemic is raising fears of catastrophe.

Michael Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy, called the situation unprecedented.

“We are truly in uncharted Ebola-control territory,” Osterholm said. “Even in the 2014-15 [Ebola] epidemic in West Africa, once public health programs and vaccination efforts were put into place, it brought about a rather rapid reduction of cases. We’ve never encountered a situation where a geographic region becomes almost completely impossible to work in because of insecurity.”

If a way isn’t found quickly to bend the outbreak trajectory, an explosion of cases will follow, Farrar, from the Wellcome Trust, predicted.

“I think at the moment it’s in a phase where it could expand out of control very easily. Or we’re on the cusp of that already,” he said, suggesting cases could soon rise by 30 or 40 a day as opposed to the current 15 to 20.

Farrar and others warned that official numbers likely don’t capture the true picture of the outbreak at this point, because the response teams’ ability to move about and conduct surveillance in the affected areas is limited and frequently interrupted.

The International Rescue Committee, one of the partners in the response, is working on the assumption that the true number of new cases every day is already double what the official figures show, said Bob Kitchen, vice president for emergencies and humanitarian action, who was recently in the outbreak zone to assess the state of affairs.

In January and February it appeared that control measures were beginning to have an impact. The number of new cases being diagnosed daily was starting to decline and it looked like the outbreak might be coming under control.

But in late February, fire-bombings at the Ebola treatment centers at Katwa and Butembo marked a tipping point, with Ebola control operations and staff coming under regular attack ever since.

Each violent event forces a temporary slowdown of control operations. Last Thursday teams vaccinated nearly 1,000 people in one day — a record. On Saturday, they weren’t able to vaccinate anyone in Butembo, because it was too unsafe for them to move about, Ryan said.

“That interrupted access, three days of access, then two days without access … you can’t run an effective public health operation that requires daily follow up, daily vaccination, daily contact with families,” he said.

Kitchen’s organization has a lead role on promoting proper infection control in hospitals and public spaces — things like teaching clinics about the dangers of re-using needles, which is thought to be one of the drivers for transmission in this outbreak. About a quarter of the cases have contracted Ebola in a health-care setting; this mode of transmission accounts for the extraordinarily large number of infections among young children — more than 400 cases — in this epidemic.

Because of the violence, all but two of IRC’s international staff have been pulled back to Goma, a regional hub that is about eight hours drive south of the major outbreak zone. To date the virus hasn’t moved into Goma, though the fear of that possibility haunts the outbreak responders.

Community anger at the Ebola response workers is just running too high in Butembo and Katwa, where opposition politicians and others have insisted Ebola isn’t real or is a disease outsiders brought to the area.

“All the guesthouses, all the hotels, all the health facilities — the government has placed security outside,” Kitchen said, arguing that being guarded by Congolese soldiers actually increases the risk for international staff in this part of the country, which has been at odds with the central government for decades. “You’re just waving a flag. … ‘We’re over here.’”

Overcoming the resistance is proving to be extraordinarily challenging. The people of Butembo and Katwa are highly suspicious of outsiders, Ryan and others said. So suspicious, in fact, that their definition of outsiders includes people from Beni, a city about 36 miles north that was the hotspot for Ebola transmission last autumn. Some of the organizations brought in workers from Beni thinking it would help with containment efforts, but they were not accepted.

“Butembo is just this sort of enclave. So anyone from outside of Butembo and Katwa are seen as outsiders and are distrusted,” Kitchen said.

The IRC is working through what conditions on the ground would have to look like before it felt safe redeploying more international workers to the hot zone. “But if attacks continue, yes, I do foresee having to withdraw our expats and manage remotely as best we can,” he added.

Farrar warned that the best-case scenario likely involves this outbreak dragging on for months. “We will still be having these conversations throughout 2019,” he said.

Worst-case scenarios stray into unthinkable territory. “Once you lose control …  the numbers just go up and up and up. And then you just can’t follow everybody. And then it’s self perpetuating, really,” he warned. “We’re not quite there yet, but we’re pretty close.”

“Predicting the future is always stupid,” Farrar said flatly. “But from where we are today to bring the epidemic under control is going to take a monumental effort. … All of the interventions we have working at maximum efficiency — and then a lot of luck.”