Lessons Learned from Ebola Outbreak 9 in Equateur Province, Democratic Republic of the Congo

"...communication to local communities and coordination across a range of agencies were key features of the response."

On May 31 2020, the Democratic Republic of the Congo (DRC)'s Ministry of Health (MoH) declared an Ebola outbreak in the southern part of Mbandaka city, the city's surrounding area, and Bikoro. This is the 11th outbreak in the DRC since the virus was discovered in 1976. In an effort to help guide responses to the 11th outbreak - as well as other disease epidemics - this K4D Helpdesk report reviews details and lessons learned from the 9th outbreak in 2018.

The report begins with a brief background on situational factors in Equateur province of relevance to emergency health interventions and a short summary of the May to July 2018 Ebola outbreak and sequencing of the response. The population of Equateur is primarily Mongo, the DRC's largest ethnic group, with the Twa, a minority indigenous group, living primarily in rural areas. The Twa have been disproportionately affected by previous Ebola outbreaks and face compounding risk factors due to limited resources or rights to land, marginalisation, and exploitation, including in accessing health services, and their interests are rarely incorporated into customary or administrative arrangements. Bushmeat hunting among Twa communities increases their vulnerability to infection as well as to discrimination on the basis of being blamed for previous outbreaks. In light of these realities: "Ethnic inequalities in access to health services, representation and involvement in the response are critical to reaching communities at heightened risk of infection and with limited access to treatment."

Section 3 highlights lessons learned from assessments on the timely and coordinated response in the 2018 outbreak, drawing out considerations on how to build on these achievements in future responses. As noted here, "Building on lessons learnt from earlier responses to Ebola in West Africa, improvements in the timely release of funds, movement of personnel, communication to local communities and coordination across a range of agencies were key features of the [2018] response." For example, coordination with the health system and existing traditional and biomedical health providers has been identified as a critical factor in the effectiveness of the Equateur Ebola response. This included early capacity development such as training of formal and non-formal health workers, efforts to ensure resources earmarked for Ebola did not undermine other health needs, and alternative treatment models, such as Community Care Centres (CCCs).

Section 4 explores the limited available evidence on the effectiveness of the rVSV-ZEBOV vaccine that was deployed on an "emergency use" basis for the first time in the Equateur response of 2018. Vaccination efforts were reportedly well accepted, with a high uptake rate. However, Alcayna-Stevens, cited here, reported that "Communication around the vaccine is crucial as negative community perceptions and understandings of why some people are vaccinated and others not augments social risks associated with distrust, suspicion and stigmatization." Bedford explained that these negative perceptions, which risked leading to refusal, included concerns that the vaccine is a lethal injection, that it will give a person Ebola, or that it can prevent women from becoming pregnant and cause sterility. Also, communities reported being unable to read the information provided (in French) to explain the consent procedures. They also reported the importance of being able to ask questions about the working of the vaccine after the outbreak had finished. There is a gap in information on local perceptions and experiences of the vaccine since the 9th outbreak concluded.

Section 5 reviews available information on health-seeking behaviours in Equateur, including:

• Vocabulary and idioms (in contrast to biomedical language) can be revealing of important local disease categories and logics, such as the linking of Ebola to the breaking of social prohibitions or the disrespect of taboos related to age, life stages, and childbirth.
• Church leaders, particularly evangelical priests, are relied upon for information about or "treatment" (e.g., seclusion) for the virus, increasing the risk that affected people may not be traceable or seek care.
• While distrust of biomedicine is common in the region, barriers to accessing formal medical care are a key factor in health seeking behaviour.
• Communication and community engagement strategies should work with (rather than refute) misperceptions on the source of the outbreak, mistrust of officials (including international agencies), and local beliefs about the nature of illnesses more broadly.
• Engaging those who may influence or control whether a person with symptoms is or is not identified to response teams and presented for care, such as men, is critical to reaching some vulnerable groups - alongside efforts to engage with those groups directly. (In these efforts, appropriate language and settings for engaging groups such as women and Twa communities should be considered, and local groups may be mobilised to engage with these groups such as women's associations, church groups, and Twa-led indigenous associations.)
• Transparency about all elements of the response and among agencies working in the area is encouraged to minimise suspicions of the response.

Section 6 explores keys political, social, and economic factors in the region that may impact transmission, surveillance, treatment, and indirect effects of Ebola response. For instance, the public sector ranks poorly on corruption indices, leading to distrust of government in Kinshasa and state representatives in both rural and urban Equateur. This distrust can undermine the Ebola response, in that communities associate official interventions with previous incidents of repression and state violence. Furthermore, political voice and citizen participation are limited in Equateur, posing challenges to community mobilisation and access to vulnerable groups. In addition, gendered social norms and practices (e.g., women as primary care givers) may make men or women more vulnerable to infection at different stages. Women in some contexts also need their husband's permission to seek treatment and may therefore face barriers to accessing treatment or themselves or their children.

The literature indicates that two-way communication between response workers and affected communities is key. This communication should be guided by rapid assessment of community-level social dynamics that may affect different groups' vulnerability to exposure, challenges to accessing treatment, and secondary effects of the virus has been identified as a critical early step in effective Ebola response. Such an assessment could reveal, for example, the risk posed by practices such as religious gatherings. Undertaking effective collaboration with local leaders and influential people could then lead to community self-imposed quarantining and social distancing, which has been shown to be a more effective preventative measure than mandatory or coercive measures.

Key lessons learned from the 2018 Equateur response and related humanitarian interventions, and indications of where further research could be illuminating, are:

• Immediacy of the response and coordination of agencies are critical to effectiveness, particularly around appropriate communication of the disease to affected and neighbouring communities. Additional evidence would be helpful as to the mechanisms behind which the immediacy and adequacy of finance and cooperation were possible in this particular response.
• There is evidence indicating that the rVSV-ZEBOV vaccine was effective in reducing the risk of spread of the virus in Equateur, but further evidence is needed to understand the extent of its effectiveness and community perceptions of Ebola vaccination programmes.
• Health-seeking behaviour is highly context specific. A detailed understanding of local perceptions on the causes, spread, and treatment of illnesses is needed to effectively respond to an Ebola outbreak.
• Certain social groups are at a greater risk of exposure and transmission of Ebola in Equateur due to gender norms and discrimination towards Twa indigenous groups. More investigation is called for on secondary social, political, and economic impacts of Ebola response.

Finally, another gap in the literature identified in this review that might be addressed for future Ebola responses is the sustainability of prevention measures after the outbreak has been declared over and international actors transition to other humanitarian crises.