The mighty Congo River both connects Kinshasa with Equateur Province where an Ebola epidemic began in May 2018 and separates the Democratic Republic of the Congo (DRC) from Congo-Brazzaville, hidden in the haze on the other bank.

“Epidemiological surveillance in the Democratic Republic of the Congo is a massive challenge,” said Pierre Dimany while looking out to the river. Pierre is the Kinshasa coordinator of the National Programme for Border Hygiene (PNHF), a partner of IOM, the UN Migration Agency, in the Ebola response.

On Tuesday 24 July, the country’s ninth epidemic was officially declared over, some two-and-a-half months after it began. In previous epidemics, cases were usually confined to remote areas in DRC’s vast rainforest, but this time around a total of four were reported in the Equateur provincial capital Mbandaka. This sparked fears that the fever, which often kills in a matter of days, would take hold of the city and work its way downstream to Kinshasa, where an estimated 12 million people live.

“We were all scared,” admitted Djo Ipaso Yoka, a young teacher recruited to carry out screenings at a post in Mbandaka at one of the points of entry to Wendji Secli motorbike taxi park.

The epidemic started in two health zones deep in the equatorial forest, Bikoro and Iboko. The first victim, a health worker, had treated an old woman, who had come into a village from the forest because she was sick. From there the virus spread to Mbandaka in Bikoro health zone.

Although the epidemic in Equateur was declared over, the country is constantly threatened by outbreaks. A new epidemic, the tenth in the DRC, was declared just days after the end of the Equateur outbreak. This latest medical emergency has sparked grave concern, as it is occurring in the east of the country close to a town with road links into neighbouring Uganda.

Villagers wait to be screened on a road leading out of Itipo. Photo: IOM

Population mobility

Population mobility, including cross-border movements, was rapidly identified as being of vital importance. In the very early stages of the latest epidemic IOM worked with the PNHF and the World Health Organization (WHO) to deploy epidemiologists at points of entry, as well as other strategic sites with high population mobility.

IOM also undertook, with the backing of the Health Ministry and the WHO, participatory population mobility mapping in Bikoro, Itipo and Mbandaka to identify the sites where people congregate or transit: usually ports, markets, churches and motorbike taxi terminals. 

IOM aims to conduct a similar mapping exercise in Kinshasa.

Although the epidemic is over, IOM continues to conduct and strengthen points of entry surveillance, risk communication and promote hand washing at the points of entry to strategic places, while also conducting daily flow monitoring at high mobility sites.

Screening stations range from lakeshore plastic tables shaded by a sun umbrella to bamboo huts surrounded by lush greenery. Some temporary road checkpoints consist simply of a long stem of bamboo, others a rope made of creeper vines. 

The procedure is the same at all points of entry: those screened wash their hands with chlorine solution, have their temperature taken and their data is noted down by the community health workers. Supervisors collect and compile the data. Any suspected cases, such as someone vomiting or running a fever of 38 degrees Celsius or more, are isolated and the Government’s incident management team, supported by WHO, is called to take the suspected case to the treatment centre.

A boy washes his hands at the Itipo-Iboko Point of Entry. Photo: IOM

Resistance to hand washing

In practice, for a variety of cultural and practical reasons, screening and hygiene measures can be difficult to impose, particularly for local residents, who have to cross the same road block more than once in the day. 

At a screening station on a road leading into Itipo, a young woman wearing a thick layer of bright red face paint skipped through the point of entry controls, cast a fleeting glance at the hand washing facility and ran off.

A health officer in a fluorescent waistcoat shook his head and explained that she is a Walé, a local term given to first-time mothers observing a traditional period of isolation and a set of taboos.

“There’s no way a Walé can wash her hands here. They’re not allowed to. They are allowed to wash only where they stay,” he said.

The next group of people to arrive obediently wash their hands but some wrinkle their noses at the smell of chlorine. Many people need some degree of coaxing or explanation before using chlorine solution. Some simply do not like the smell of chlorine. Health officers sometimes propose liquid soap at the same time in a bid to make using the chlorine solution more palatable. 

A WHO study in June in the area hit by the epidemic led by the social anthropologist Julienne Anoko found that some respondents saw chlorine solution as “a strategy to spread the virus and the sickness.” According to Anoko’s study, others believe the thermometers used, which are held up close to the temple, sap vital energy from the person whose temperature is being taken.

More broadly some are tempted to doubt the existence of Ebola on the grounds that people died with some of the symptoms of Ebola, for example vomiting, even before the start of the Ebola epidemic.

A health worker at Kinshasa's N'djili airport disinfects a plane arriving from Mbandaka. Photo: IOM

The next stage and a new epidemic

With the declaration by the Health Ministry and WHO that the ninth Ebola epidemic had ended, the Ministry and its partners, IOM among them, were set to embark on an ambitious three-month transition phase spanning the period August to October. The focus here was to wrap up the activities currently underway in the field and to implement consolidation and stabilization activities. That was to be followed by a phase focusing on resilience, starting in November and set to run through December 2020.

The transition and resilience phases have started in Equateur but are going ahead in parallel to the response to the new epidemic that has been declared in the east of the country at the start of August.

Indeed, days after the announcement of the end of the epidemic in Equateur, the authorities in the eastern North Kivu province notified the Health Ministry of 26 cases of hemorrhagic fever, 20 of which had proven fatal, in Mabalako health zone close to the town of Beni. On 31 July, laboratory tests on samples sent to Kinshasa showed positive for Ebola in four cases out the six tested, confirming that the DRC was facing its tenth epidemic. The Ministry has said genetic sequencing has shown that the strain of the virus that caused this latest outbreak is not the same as the one identified in the epidemic in Equateur.

IOM has been sending staff to the affected area and aims to replicate the work it did in Equateur in conjunction with the Health Ministry and WHO. The migration agency has started a mobility mapping exercise to track population movements in the area, which borders on Uganda. It also intends to carry out health screening and promote hygiene at key points of entry. IOM will support Health Ministry to strengthen coordination with neighbouring countries at national and community level.

The response to the epidemic in Beni is complicated by the security situation in the area, which has been the scene of massacres on a regular basis for the past several years.

In fact, the Ebola-affected area in Beni has seen a mix of different types of human mobility. In addition to a high volume of daily cross border movements with neighbouring countries, there are large communities of people displaced by insecurity. There are also frequent inter-provincial movements around the artisanal mining sites. The high volume and complex nature of human mobility around Beni heightens the vulnerability of disease transmission.

A UN helicopter on the ground in Iboko, DR Congo. Photo: IOM

Back in Equateur where its recent outbreak has been declared as over, Phase Two of IOM’s emergency response aims to shore up the gains made during the Ebola response, maintain heightened vigilance, learn from past mistakes and identify good practices for the future and help make the health system more resilient and therefore better able to handle any future outbreaks.

Surveillance will be maintained and ramped up to enable rapid detection of, and response to, any new cases of Ebola, including in neighbouring provinces and countries.

The Ministry and its partners will provide health services for the clinical management of Ebola survivors as well as social and psychological counselling for them and for the families of those who were infected in a bid to avoid any social stigma. They will strengthen infection prevention and control in targeted health facilities and in the community and will reinforce grassroots networks for promoting awareness of and taking action on Ebola and other contagious diseases.

Laboratory capacity will be maintained at a national and local level for the confirmation of possible cases.

Partners, who responded to the crisis, will prepare and conduct an After-Action Review and will ensure the transfer of resources and knowledge in order to build resilience. They will also finalize a national plan for health security and draft a resilience plan as well as improving food security in the health zones hit by Ebola and putting in place a logistics platform to facilitate a timely response to any future outbreaks.

“The consolidated effort in the stabilization phase is equally important. Reflecting on lessons learned from the immediate response to stabilize the situation and further strengthening response capacity is essential to building resilience” said Aki Yoshino, IOM’s Migration Health Programme Coordinator in the DRC.

IOM will also continue working closely with the Ministry of Health and WHO to put an international health regulation strategy in place, and help implement the strategy at the national and local levels to continue strengthening IHR core capacity at points of entry.

“In the next three months, IOM will also support the Health Ministry to facilitate cross border coordination activities with Central African Republic and Republic of the Congo to strengthen information sharing and preparedness and response capacity to manage cross border mobility in the event of a public health emergency,” Yoshino added.

The UN Migration Agency has been seeking to raise USD 4.5 million to continue and expand its work in the fight against Ebola. It has, so far, raised just over half the target sum, with Japan contributing USD 1 million, the WHO USD 0.8 million and the European Civil Protection and Humanitarian Aid Operations (ECHO) EUR 0.5 million.