The current Ebolavirus disease (EVD) outbreak in the provinces of North kivu and Ituri is the tenth outbreak affecting the Democratic Republic of Congo (DRC);the first outbreak occurring in a war context , and the second most deadly Ebolavirus outbreak on record following the 2014 outbreak in west Africa.
The DRC government’s response consisted of applying a package of interventions including detection and rapid isolation of cases, contact tracing, population mapping, and identification of high-risk areas to inform a coordinated effort. The coordinated effort was to screen, ring vaccinate, and conduct laboratory diagnoses using Gene pert (Cepheid) polymerase chain reaction.
The effort also included ensuring safe and dignified burials and promoting risk communication, community engagement, and social mobilization. Following the adoption of the “Monitored Emergency Use of Unregistered Products Protocol,” a randomized controlled trial of four investigational treatments (mAb114,ZMapp, and REGN-EB3 and Remdesivir) was carried out with all consenting patients with laboratory-confirmed EVD. REGNEB3 and mAb114 showed promise as treatments for EVD.
In addition, one investigational vaccine (rVSV-ZEBOV-GP) was used first, followed by a second prophylactic vaccine (Ad26.ZEBOV/MVA-BN-Filo) to reinforce the prevention. Although the provision of clinical supportive care remains the cornerstone of EVD outbreak management, the DRC response faced daunting challenges including general insecurity, violence and community resistance, appalling poverty, and entrenched distrust of authority.
Ebolavirus remains a public health threat. A fully curative treatment is unlikely to be game-changer given the settings of effectiveness, zoonotic nature, limits of effectiveness of any therapeutic intervention, and timing of presentation. introduction The Democratic Republic of Congo (DRC) has been facing its tenth outbreak of Ebola virus disease (EVD) since 1 August 2018. This outbreak is currently ongoing in the Northkivu and Ituri provinces of DRC.
Previous outbreaks in DRC occurred in remote and hard-to-reach areas, while the ongoing outbreak is occurring in urban environments. Furthermore, there are other unique challenges during this outbreak, such as community resistance and security issues due to the epicenter being in a conflict zone. In the history of EVD outbreaks, this has been the second most deadly after the one that occurred in West Africa in 2014.
The DRC is located in central Africa, neighboring with nine countries (Angola, Burundi, Central African Republic of Congo, Rwanda, and Zambia).A majority of the population from North-Kivu and Ituri provinces travel for trade and business between their neighboring countries in the East (Burundi, Rwanda, Tanzania, and Uganda). Hence, controlling the outbreak in those two providences would prevents its spread to these countries.
As of 17 November 2019, a total of 3296 EVD cases were reported, including 3178 confirmed and 118 probable cases, of which 2196 individuals died and 1075 survived (overall case fatality ratio 67%) in the eastern DRC. Most of these cases have been reported in the community, however a few cases have also been reported in healthcare settings.
The DRC Ministry of health (MoH), supported by the World Health Organization (WHO) and a range of regional and international partners are implementing EVD response plans of interventions, such as screening of suspect cases at points of entry, case detection, contact tracing, laboratory testing, cases management and infection prevention and control, safe and dignified burials, ring vaccination (This involved contacts of infected individuals, and contacts of those contacts); and therapeutics, laboratory facilities with capacity for EVD confirmatory testing, Safe and dignified burials, community mobilization, and free access to healthcare services, have been used for containing and eliminating this deadly disease.
Logistical challenges due to poor infrastructure continue to affect surveillance, case detection and confirmation, contact tracing, access to vaccines and therapeutics, risk communication, and community engagement activities. In the complexities of EVD transmission, the proximity of these regions to wildlife species and the Virunga National Park is unclear.
Due to regular rebel attacks in these areas, the close interaction between human, animal, and environmental factors, in combination with high population movement indicates the need for further incorporation of the One Health approach into the integrated EVD response plans.
One health approach in disease control:
Outbreaks of zoonotic diseases such as EVD and Severe Acute Respiratory Syndrome (SARS) are a reminder of the inextricable links between humans, animals, and the environment. These linkages call for new tools for cooperation and collaboration between public health professionals and conservationists to better address the vital issues of these emerging infectious diseases.
Maintenance and extension of the classic control modalities, such as epidemiological surveillance, clinical medicine, and clinical virology are essential. In addition, new tools such as mathematical modelling, remote sensing, and ecologically based approaches are also important.
Specifically, in order to understand the sylvatic cycle of viruses, the transition to human populations, the relationship between vectors, pathogens and reservoirs in wildlife ecosystems, the change in the distribution of vectors and reservoirs after natural habitat fragmentation, and how these conditions are generating potential new roles and ecological niches for species.
Wild ecosystems historically disturbed by agricultural and industrial activities with changes in biotic and abiotic factors (water bodies distribution, soil profiles, plant coverage, breeding microclimate, vertebrate and invertebrate populations, etc.), constitute new selective pressures for pathogens and therefore new opportunities for adaption. It allows vectors/reservoirs to exploit the new resources, favoring viral contact with potentially new host populations (e.g. humans). From all these aspects, the integrated approach of one health shows its usefulness in controlling re-emerging infectious diseases.
Limitations of implementing one health approach in the Democratic Republic of Congo
Successfully implementing the one Health approach also requires a global network of qualified individuals working locally, regionally, nationally and internationally to share information, conduct disease surveillance in human and animal populations, monitor the environment, improve food safety and security, and communicate effectively to the public. Such implications need participation of the nation to make the one Health approach effective.
The eastern part of DRC where the EVD outbreak is ongoing is facing some challenges such as community resistance and security issues due to the epicenter being in a conflict zone. This area has experienced successive wars and rebel attacks over the past 20 years, which has led to increased movement of the population.
Such conditions in this area may hamper the implementation and delivery of a one Health approach in prevention and control of infectious disease. Effective implementation of one Health approach in both its eastern parts, as well as the rest of DRC, requires the DRC government’s support in establishing security and stability in the region.
As the number of new Ebola cases increases in the eastern DRC, issues involving human, animal, and environmental health have gained global attention. National and regional public health sectors should give priority to deploying surveillance systems and enhanced diagnostic tools regarding emerging pathogens. A broad collaboration among clinicians, public health workers, veterinarians, and veterinary public health officials is necessary for prompt response strategies and ensuring the prevention and management of zoonosis.
The reduction of zoonotic risks in farms should be a priority in order to improve the overall health of human and animals. The ongoing EVD outbreak in eastern DRC gives an insight into the integration of the one Health approach into the implementation of infectious diseases control programs in DRC.