The devastating 2014–2016 Ebola epidemic in West Africa prompted changes in the way the world responds to outbreaks and other health emergencies. Lessons from that outbreak were applied in the 2018-2020 Ebola response in the Democratic Republic of the Congo (DRC). Here are eight ways responding to Ebola has changed.
1. Research at the heart of the response
An Ebola patient is cared for at the ALIMA treatment centre in Beni, DRC. © WHO / Chris Black
The WHO Research and Development Blueprint initiative was created in 2016 to allow the rapid activation of R&D activities during epidemics. With support from partners, the work of the R&D Blueprint team enabled the fast-tracking of effective tests, vaccines and treatments in the 2018-2020 DRC Ebola response. Integrating ethically sound, rigorous research into emergency responses ensures that the world is better prepared for the next disease outbreak.
2. Test results turned around quickly
A GeneXpert cartrige. © Maciek Nabrdalik / VII for UNICEF
Rapid laboratory testing can make or break an Ebola response. Faster test results mean faster access to care, which increases the chances of survival for confirmed patients. A rapid diagnosis helps prevent the spread of the disease among the family, friends, and others in the social network of a person confirmed to have Ebola. The faster these contacts are identified, the faster they can be vaccinated and protected from the disease. Quick testing is also critical for monitoring the effectiveness of outbreak control activities, for the work of burial teams, for the clinical management of patients, and for the Ebola survivors’ programme.
Making a quick diagnosis also eases the anxiety felt by families and communities as their loved ones await results.
In the DRC, laboratory testing used a small diagnostic platform called GeneXpert. The first and only manual step is for a trained and skilled lab worker to inactivate the sample in a biosafe glove box, which renders it safe to be tested. The sample is then inserted into a cartridge and the rest is automated. A diagnosis can be made in hours.
In the DRC local staff performed laboratory testing. The quality of testing met international standards, was simpler to use than conventional testing methods, and was easier to set up. New labs were activated within 48 hours, meaning laboratories could move with the outbreak.
3. A licensed Ebola vaccine
An Ebola vaccination team in Mangina, DRC. © WHO / Junior Kannah
Trials of the rVSV-ZEBOV Ebola vaccine began in Guinea in 2016. These studies provided data on the effectiveness of this vaccine.
When Ebola struck western DRC’s Equateur province in early 2018, the vaccine was deployed immediately after national approvals were obtained. The use of the vaccine as part of an Ebola outbreak response was a major milestone for global public health.
“I just spent the day out with the vaccination teams in the community, and for the first time in my experience, I saw hope in the face of Ebola and not terror,” said WHO’s Dr Mike Ryan in May 2018.
In eastern DRC, the vaccine was deployed just one week after the declaration of the outbreak in August 2018, helping save lives and slowing the spread of Ebola. More than 300 000 people were vaccinated from August 2018 to March 2020.
Because the rVSV-ZEBOV vaccine was not licensed, it was used under “expanded access” or “compassionate use” research studies. People who voluntarily took part in the study provided consent, and they were followed up after vaccination to monitor safety. The results from the DRC vaccine studies confirmed that the vaccine is very effective in preventing Ebola.
The vaccine was licensed in Europe and the United States in late 2019. After WHO prequalified the vaccine, it was licensed in DRC and five other African countries in early 2020.
4. Landmark advances in Ebola care and treatment
An Ebola treatment centre in the city of Beni. © World Bank / Vincent Tremeau
Therapeutic treatments for Ebola have not yet been licensed. For this reason, in 2018 WHO and the DRC authorities agreed on protocols for using these on a compassionate basis. For the first time in an Ebola outbreak response, every patient was offered voluntary and equitable access to groundbreaking treatments.
In November 2018, a trial was set up in outbreak-affected areas to evaluate four available Ebola treatments. In August 2019 data from the trial showed two of the four Ebola treatments substantially decreased mortality, especially if people sought treatment early. The survival rate for those receiving either mAb114 or REGN-EB3 was as high as 90% for patients who had a low viral load.
The trial was a critical step towards finding an effective treatment for Ebola. It also demonstrated that it is possible to conduct ethically and scientifically sound research in the context of an infectious diseases outbreak, while simultaneously supporting the joint goals of saving lives and ending the outbreak.
The design of Ebola treatment centres is also changing. In the DRC, innovative Biosecure Emergency Care Units for Outbreaks - transparent safe individual ‘rooms’- were used by WHO partner ALIMA. This makes it easier for staff to safely care for patients, providing intensive care level monitoring and treatment, and enables families to see their loved ones safely and easily. It also helps eliminate some of the fear and rumours in communities about what happens inside ETCs.
Finally, WHO guidelines have helped improve and standardize supportive care (treatment for the symptoms and complications of Ebola).
5. Survivors supported
A young Ebola survivor has his eyes tested at a special clinic in Beni. © WHO / Junior
During the Ebola epidemic in West Africa it became apparent that survivors suffer continuing health problems. Ebola survivors need comprehensive support for the medical and psychosocial challenges they face. They also need to be followed and supported to minimize the risk of continued Ebola transmission.
In the DRC, the Ministry of Health, WHO and partners are ensuring that all survivors are offered enrollment in a comprehensive programme of follow-up care. The programme provides clinical, biological, and psychosocial support. Each survivor is provided with follow-up visits every month over a period of six months and then every three months for a year.
Eye problems were common among survivors in West Africa. For this reason, eye clinics for Ebola survivors and specialized training for Congolese ophthalmologists have also been organized. By identifying and treating these problems early, serious consequences, including blindness, can be averted.
6. Social science and community engagement integrated into the response
A WHO team speak to students at a school in Beni about how to protect themselves from Ebola. © World Bank / Dalia Lourenco
Engaging with the sociocultural dimensions of epidemics is critical to mounting an effective response. In the DRC, proactive community engagement was central to the response.
Community feedback and information about the social science context was actively gathered and integrated since the beginning of the outbreak. Operational briefs were regularly produced to inform the response on the different local social and cultural contexts of outbreak-affected areas. These help shape communication with affected communities about Ebola, the vaccine, contact tracing, patient care and other response measures.
A key lesson from DRC was that a ‘one size fits all’ approach to community engagement isn’t effective. Each community is unique, and engagement has to be hyper-contextualized to affected communities. Communities asked for responders who are local, familiar and speak local languages. WHO and response partners heard this feedback and worked to place local workers on vaccination, disinfection and other response teams.
7. WHO’s emergency response structure has changed
In 2016 WHO established the new Health Emergencies Programme . It was a profound change, adding operational capabilities to WHO’s traditional technical and normative roles. The programme is designed to bring speed and predictability to WHO’s emergency work. It brings all of WHO’s work in emergencies together with a common structure across headquarters and all regional offices in order to optimize coordination, operations and information flow.
In 2019, adjustments were made to the programme to emphasize the critical importance of preparedness. The programme now has two divisions: one for preparedness and one for response.
8. A fast-acting funding mechanism set up
One of the lessons learned from West Africa was that disease outbreaks often move faster than the money allocated to respond to them. As part of the Health Emergencies Programme, WHO set up a rapid response funding mechanism called the Contingency Fund for Emergencies (CFE) so that money is immediately available to jump-start an outbreak response.
Since then, WHO has used the CFE to respond to more than 100 separate events, including Ebola outbreaks in DRC, the Rohingya crisis in Bangladesh, and cyclones in Mozambique.
Note: This story was originally published in August 2019. It was updated in April 2020 to reflect further advances in responding to Ebola.