It's the worst Ebola outbreak to have hit the Democratic Republic of Congo (DRC) – and the most complex.
Since August, the country's authorities, together with many partners, have been trying to contain a new epidemic of the deadly virus in the provinces of eastern North Kivu and Ituri.
As of November 21, there were 373 suspected cases of Ebola, including 347 confirmed cases. At least 217 people have already died.
Since 1976, there have been 10 outbreaks of Ebola in the DRC, considered one of the most experienced in the fight against the virus.
The situation this time, however, is different.
The provinces of North Kivu and Ituri are among the most unstable and densely populated in the country and have some of the highest rates of human mobility.
At the same time, some warn that a "perfect storm" of insecurity, community resistance to vaccinations and political manipulation threaten efforts to contain the spread of the virus.
Together, these factors mean that the latest epidemic is unlike anything the DRC, which has to hold a crucial presidential election on Dec. 23, has ever experienced.
What is the Ebola virus and how is it spreading?
Ebola virus disease (Ebola) is introduced into the human population through close contact with blood or other bodily fluids from infected animals. These include, but are not limited to, monkeys or dogfishes.
The virus is known to cause high fever, vomiting and diarrhea, as well as internal and external bleeding; it subjects the body to a state of shock and causes a decrease in blood perfusion to vital organs, eventually leading to failure of multi-system organs.
Once infected, patients have very little chance of surviving.
When did the last epidemic in the DRC begin?
At the end of July 2018, the provincial government of North Kivu reported 26 cases of acute haemorrhagic fever resulting in 20 deaths.
Six blood samples were sent to the National Institute of Biomedical Research (INRB) in the capital, Kinshasa, where four of the six blood samples were found to be positive for Ebola.
"The result of the genetic analysis performed by the INRB confirmed the Ebola Zaire strain, but is not related to the epidemic strain of Ecuador, which means that we are in the presence of a new home, "said Lianne Gutcher, communications officer at the World Health Organization (WHO). Al Jazeera.
The country's health ministry officially declared the outbreak on August 1, 2018.
The epicenter of the epidemic is now Beni, in North Kivu, although the medical charity Doctors Without Borders, also known by the French acronym MSF, warns that it could be transferred to Butembo, a city near 'Uganda.
How does this epidemic compare to previous ones in the DRC?
The Ebola virus is considered endemic in the DRC, with the first cases occurring in 1976 appearing simultaneously in Yambuku – in the north of the country, near the Ebola River, from which the disease gets its name – and in Nzara, in the northern part of the country. South Sudan.
Although there is still no cure, the introduction of a vaccination program earlier this year has been presented as the next step towards more effective management of future outbreaks. .
The DRC has been affected by two epidemics this year.
The first was declared in May after the death of 29 people in the town of Mbandaka in Equateur province. Although the proximity of the city to the Congo river raised fears about the transfer of the virus to Kinshasa, the timely implementation of a vaccination campaign quickly contained the virus.
This outbreak was announced on July 24th.
Uganda and the DRC were able to prevent the spread of mammoth epidemics as it did in West Africa between 2014 and 2016, which infected 28 000 people and caused the deaths of 11,300 people. But considering the fact that the current epidemic in North Kivu is perhaps the first time that the virus is spreading in an area already undergoing a large-scale humanitarian crisis, the spread of the epidemic continues. Ebola proves much more difficult.
It is already the largest epidemic in the DRC and is expected to become the second largest epidemic of Ebola ever recorded.
"The difference is that we are now operating in a war zone," Axelle Ronsse, emergency coordinator for MSF's response to the fight against Ebola, told Al Jazeera. She spoke of the violence perpetrated by militias who have been raging for a long time in the east of the country.
WATCH: How can we contain Ebola? (25:00)
What impact has the security crisis had on efforts to contain the virus?
North Kivu is home to a number of armed groups, including the Allied Defense Forces (ADF), a Ugandan rebel group, which has been operating with impunity since 1995.
The endless upheavals in the region have resulted in regular dispossession and constant movement of refugees into neighboring countries or the province itself. At present, there are more than one million internally displaced persons in North Kivu.
"Violence affects our day-to-day work," Ronsse said. "We are not targeted but it's about being in the wrong place at the wrong time."
Similarly, Gutcher, WHO, says that some attacks have resulted in severe impediments to medical activities or their temporary closure.
"Violence within the community has also sometimes interfered with the ability of safe burial teams to conduct safe and dignified burials."
In October, the rebels killed 13 civilians and abducted a dozen children during an attack on Beni.
In November, seven Malawian peacekeepers and a Tanzanian soldier were killed in another attack on the city.
Instability has also made it difficult for health professionals to locate other people who may have been in contact with alleged victims, in what is called "the search for". contacts ", considered a fundamental pillar of any effort to contain Ebola.
Last month, the New England Journal of Medicine (NEJM) wrote that "effective contact research and community engagement can quickly identify people who are ill and facilitate the provision of early clinical care." who have demonstrated their survival effectiveness. "
Jessica Ilunga, communications officer for the DRC's Ministry of Public Health, told Al Jazeera that each security-related incident had a negative impact on activities in the field. She added that the underlying security context also created a climate in which health workers faced an unprecedented level of resistance from the community.
"The predominance of traditional healers, to whom the public has more confidence than modern medicine, has also resulted in a significant number of nosocomial transmissions of the virus," Ilunga said.
Citing instability in eastern DRC, the WHO raised the national crisis to "very high" in late September. The crisis is still not considered a public health emergency of international concern and the World Health Organization does not recommend imposing trade or travel restrictions on the DRC.
How did the DRC and the international community react to this crisis?
Since the introduction of the immunization program by the DRC government and WHO, a key intervention has been to immunize suspected patients and then administer a second "ring" to those who may have come into contact with these suspected cases. .
The vaccine is developed in Canada but is registered and produced by the American pharmaceutical company Merck.
According to WHO, about 300 medical specialists have been deployed in the country to support the intervention plan. Approximately 32,500 people at risk were vaccinated, including 10,600 health workers and 8,600 children.
On November 24, the government and the WHO announced that they would conduct clinical trials to evaluate the safety and effectiveness of the drugs used in Ebola patients, with the goal of finding the most effective treatment against the virus.
Authorities have already started using drugs on a case-by-case basis for about 151 people. Those who used these drugs had a survival rate of 63%, while those who had not received drugs had a mortality rate close to 80%.
"Now that testing protocols are in place, patients will be offered treatment in this setting in the facilities where trials have begun," said WHO.
Beyond vaccinations and medications, efforts have been made to disseminate information through door-to-door advocacy. More than 2,500 homes were visited, including nearly 1,400 in the city of Beni alone.
"In the face of rumors and misinformation, some families have chosen to take care of sick parents at home, some patients leave health centers to find alternatives or actively avoid follow-up," Gutcher said.
The authorities have also trained about 1,700 volunteers to help them in their community efforts. In Uganda, 758 health workers in 19 health centers were vaccinated.
The WHO announced in mid-November that the epidemic would end in mid-2019.
Ilunga, from the DRC's Ministry of Public Health, said his government hoped the efforts to contain the epidemic would result more quickly, but concedes that "the success of this response also depends on a certain many factors we do not control, such as security. "
|A health worker is transporting a four-day-old baby suspected of having Ebola in an Ebola treatment center supported by MSF (Médecins sans frontières) in Butembo, Democratic Republic of Congo. [File: John Wessels/AFP]|
Why are epidemics still happening in the DRC?
Microbiologists say that viruses such as the Ebola virus often occur among animal populations facing limited movement.
However, health professionals fear that if the Ebola virus becomes endemic in the troubled areas of northeastern DRC, it would mean "a lasting and unpredictable spread of the deadly virus, with major consequences for travel and trade. ".
"This means we will have lost the ability to reconnect, stop the transmission chains and contain the epidemic," said Tom Inglesby, director of the Johns Hopkins Health Safety Center, when 39, a press conference in early November.
Ilunga believes that the country must accept the fact that the disease "will resurface regularly "and"make preventive and curative treatments more available and improve the population's knowledge of the virus ".