Impact of Ebola epidemics on the daily operation of existing systems in Eastern Democratic Republic of the Congo: a brief review

Abstract

Aims

to provide insights into the recent Ebola virus disease (EVD) outbreaks on different aspects of daily life in the Democratic Republic of the Congo and propose possible solutions.

Methods

We collected information regarding the effects of EVD outbreaks on existing systems in the eastern part of the Democratic Republic of the Congo (DRC). We searched the PubMed database using the terms “impact effect Ebola outbreak system”, “Management Ebola Poor Resources Settings”, “Health Economic Challenges Ebola” and “Economic impact Ebola systems.” Only studies focusing on epidemiology, diagnostics, sequencing, vaccination, therapeutics, ecology, work force, governance, healthcare provision and health system, and social, political, and economic aspects were considered. The search included the electronic archives of EVD outbreak reports from government and partners.

Results

EVD outbreaks negatively impacts the functions of countries. The disruption in activities is proportional to the magnitude of the epidemic and slows down the transport of goods, decreases the region’s tourist appeal, and increases ‘brain drain’. Most low- and medium-income countries, such as the DRC, do not have a long-term holistic emergency plan for unexpected situations or sufficient resources to adequately implement countermeasures against EVD outbreaks. Although the DRC has acquired sufficient expertise in diagnostics, genomic sequencing, administration of vaccines and therapeutics, clinical trials, and research activities, deployment, operation, and maintenance of these expertise and associated tools remains a concern.

Limitations

Despite the data search extension, additional reports addressing issues related to social aspects of EVD outbreaks in DRC were not retrieved.

Conclusion

National leadership has not yet taken the lead in strategic, operational, or financial aspects. Therefore, national leaders should double their efforts and awareness to encourage local fundraising, sufficient budget al.location, infrastructure construction, equipment provision, and staff training, to effectively support a holistic approach in response to outbreaks, providing effective results, and all types of research activities.

Keywords:

• Ebola
• Ebola virus disease
• outbreak
• Democratic Republic of the congo
• health
• system
• response

JEL CLASSIFICATION CODES:

• I00
• I
• I10
• I1

Introduction

Most Ebola virus disease (EVD) outbreaks emerged from zoonotic spillover, causing hundreds of deaths in Central and West Africa^1–3. Almost 40 EVD outbreaks were reported in Africa caused by the Ebolavirus (EBOV), Sudan (SUDV), Bundibugyo (BDBV), and Taï Forest (TAFV) strains⁴. Over the last decade, two major EVD outbreaks occurred in West Africa (2013–2016) and the eastern part of the Democratic Republic of the Congo (DRC) (2018–2020), causing 11,310 and 2,287 deaths, respectively^1,3,5–7. Since the discovery of EBOV in 1976, the DRC has been affected by 15 outbreaks, of which the last eight occurred over the past six years. EVD outbreaks are associated with disruptions in the functions of a country’s global system. The magnitude of these outbreaks can be correlated with measurable negative impacts on the affected systems. During EVD outbreaks several outcomes were observed, such as a loss of money and economic activities and capital, an increase in unemployment and brain drain, slowdown or closure of health facilities, disruption of internal and external trade, decrease in tourism and travel activity, and an increase in social and cultural barriers⁸. In this review, we provide insights into the impact of the recent Ebola outbreaks on different areas of daily life in the DRC.

Methods

We conducted a comprehensive study to collect information regarding the effects of EVD outbreaks on existing systems in the eastern part of the DRC. We searched for related literature in the PubMed database until October 2023 using the following terms: “management Ebola poor resources settings”, “health economic challenges Ebola”, and “impact effect Ebola outbreak system” and “economic impact Ebola systems.” We only considered studies focusing on work force, governance, epidemiology, diagnostics, sequencing, vaccination, therapeutics, ecology, healthcare provision, health system, as well as the social, political, and economic aspects. We excluded studies that only addressed fundamental aspects of the biology, immunology, virology, and sequencing of the Ebola virus, as they did not meet the scope of our research.

We extended our search to the electronic archives of EVD outbreak responses in the DRC. We consulted situation reports (SitRep) and reports of outbreaks from government and non-governmental organizations on their websites or platforms. We also accessed archived interviews, documentaries, and other records to enrich our data and provide insightful information. The documents consulted were downloaded to a specific folder in portable document format (PDF) or copied and pasted into the database in HyperText Markup Langage (HTML) format. The collected data were grouped by parameters of interest and summarized as follows: 1) the occurrence of an outbreak in a region; 2) the qualitative adverse effects observed on functioning systems; and 3) the important actions taken. From the records, we screened useful information targeting specific topics of interest such as economic, social, political, financial, human, governance, countermeasures implemented. From this information, we built a database using Microsoft Excel 365®, which we submitted for qualitative analysis. We presented our results in the form of brief or detailed narratives, depending on the amount of information collected in the database.

Review of key points

The workforce

EVD outbreaks affect a wide range of active populations across diverse sectors. The people affected primarily depended on the type of contamination observed throughout the outbreak. Contamination resulting from zoonotic spillover first affects people in contact with the reservoir, their siblings, and neighbors. Thereafter, the outbreak spreads to the community through human-to-human transmission patterns, mostly amplified by pastors, traditional healers, and healthcare workers^2,4.

Outbreaks resulting from resurgence or relapse mostly spread into the survivor’s environment before affecting healthcare professionals if the survivors seek care. Focusing on human capital affected by EVD outbreaks remains a demanding exercise. EVD outbreaks negatively affect diverse sectors both within and beyond the health system. Health facilities usually amplify EVD outbreaks, resulting in the absence of most caregivers, especially those who are not directly involved in responses. As Mulenga-Cilundika et al. state“…health workers were severely affected during the EVD epidemics. In particular, the reduction in and even absence of the workforce during these epidemics… This has further reinforced the shortage of healthcare providers in the world”⁹. The depletion of healthcare workers can overwhelm the remaining personnel, increase workload, and impair routine activities, resulting in poor performance¹⁰. As Elston et al. state “The health system was severely compromised due to overwhelming demand, healthcare workers deaths, resource diversion and closure of health facilities”^9,11. During their absence, all caregivers from the public sector were paid, although their activities are significantly reduced. In the DRC, a considerable drop in routine activities, such as antenatal visits, births, common surgery, vaccination, consultations, routine laboratory testing, was observed, depending on the magnitude and duration of the outbreak¹¹. Non-subsidized facilities were pushed to suspend payments, temporarily close their facilities, and send temporary staff, which led to the loss of clients⁹. Resuming activities in the post-epidemic period took some time to reach optimal levels, especially in areas where outbreaks were associated with high mortality, a high rate of caregiver contamination, and population displacements. As Burkle state“The Ebola epidemic has tragically revealed how limited country health assets are and how long it takes to recover and rehabilitate a destroyed public health infrastructure and health system”¹².

Economic and political cost

The 2018–2020 DRC EVD outbreak occurred during a challenging time, the community had a strong distrust of response teams, and was within an area that has had over two decades of armed conflicts and an electoral campaign associated with negative messaging toward response activities¹³. This societal context affected several sectors during the outbreak in the provinces concerned. Disruption of activities was proportional to the magnitude of the epidemic in the region. Disruptions included the closure of businesses due to staff desertion or evacuation, restriction of population movement and travel bans, decrease in the movement of goods, and the loss of the tourist appeal^9,14,15, as Van Bortel et al. state “Communities also face structural repercussions (e.g. disruptions to business and industry, closure of community services, markets and schools, decreased health and support services)”⁸.

The previously mentioned phenomena gained momentum when at-risk communication around the epidemic was not sufficiently clear, and social networks were manipulated by uninformed or ill-intentioned persons commanding official communication channels. In some areas, local and international companies were forced to close their doors under the pressure of their respective headquarters^15,16. Most state-owned companies still paid their employees for a while because of the financial coverage by the government, but most of the affected population was unemployed. However, private-sector employees lost their jobs and did not receive a paycheck when companies closed. In both cases, the economic situation of the region sharply deteriorated, leading to colossal capital losses, unemployment, urban banditry, or terrorism, especially among the young population^15,17.

Tourism and travels were reduced or disrupted, especially for foreigners, following health or security updates issued by the respective countries or their diplomatic representatives. Thus, the airports, harbors, train or bus stations, hotels and inns, and offices was heavily impacted, overwhelming the quasi-permanent unemployment situation in countries affected by the Ebola virus. As Dramé et al. state “Sectors such as transport, tourism, hotels, restaurants, education and the health system have been strongly affected by the epidemic. Large companies have reduced or even stopped their activities and repatriated qualified expatriates (experts), which has led to a significant reduction in economic productivity”¹⁵. However, when the outbreak spread and was longer than expected, hotels, inns and private houses were massively rented by international entities or national staff involved in the Ebola response. Hence, all business in the affected regions was conducted around Ebola response activities.

The eastern DRC population has high mobility aided by good road infrastructure, economic reasons, and humanitarian concerns¹³. Therefore, any economic, social, or political disturbance was feared, as it could set the region into chaos, based on pre-existing alarming situations in the region that have occurred previously, such as the formation of armed groups, intercommunity conflicts, hunger, displacement of refugees, and pleomorphism of ethnicity; however, the fragile balance of the region was preserved thanks to political leadership. As Burkle states“Team building and gaining confidence from local staff must be culturally earned through considerable forethought to prevent mistrust and to mitigate unrest, riots, and outright conflict”¹². The region was spared from descending into chaos, and a major humanitarian crisis was narrowly averted, in contrast to the predictions of most observers.

Governance in affected regions

Like most low- and medium-income countries (LMIC), the DRC has a weak health system with poorly developed long-term policies targeting unemployment, emergencies, and humanitarian crises. These factors render countries vulnerable to unexpected events¹⁸. As Bowles et al. declare“Weak health systems not only pose a threat to their citizens, but also have spillover effects on other health care systems and global trading partners”¹⁹. Accurate interventions rely primarily on the expertise of national and international entities¹².

However, most international organizations follow their internal rules while operating in the field in contrast to the needs expressed by host countries. However, there are still some intersections found between the host country and its partners that allow the partial resolution of emergencies. Indeed, all countries at-risk of EVD should build their own holistic approach-based solutions to internally solve most emergencies, despite international support. As Dramé et al. mentioned “These highlight the relevance of a holistic understanding of and response to the pandemic”¹⁵. Even in the DRC, with 15 recorded EVD outbreaks, there is no long-term holistic emergency plan outlined for any type of unexpected threat including epidemics, natural disasters, armed conflicts, and famine. Successive governments mostly organize a coordinated response involving several parties, including international and national entities, experts, and community leaders. As Mulenga-Cilundika et al. mention “A call for international health systems fund to respond to public health emergencies that imperil the routine functioning of health systems, such as the 2014–2015 EVD outbreak in West Africa, was triggered”⁹. These governments did not have sufficient resources to deal with unexpected events caused by EVD outbreaks such as unemployment, the relocation and settlement of displaced people, the management of social tensions, and economic crises. For future epidemics, it is imperative that national leadership provides additional resources to fill most of the economic gaps observed, avoid a major humanitarian crisis, and prevent any breakdowns in the national health system.

Health system

The DRC health system should be constructed to handle most emergencies arising in the field of competence. To be efficient and effective in emergencies, the healthcare system should have its own infrastructure, equipment, and experts, a tiered and well-coordinated system, logistics, and contingency plans for quick and timely interventions. Health facilities are almost paralyzed during Ebola outbreaks, leading to the decrease in or interruption of routine activities and spread of the outbreak. As Dramé et al. showed “Fear of infection led to a decrease in the number of people attending health centres for other diseases. Public health interventions such as vaccination, antenatal care, diagnosis and treatment of common diseases such as diarrhoea, malaria, pneumonia, HIV/AIDS, tuberculosis, as well as effective emergency case management dropped sharply”¹⁵. For example, the magnitude of the Ebola outbreak led to the placement of staff of the affected facilities on technical leave in Mangina (North Kivu Province, 2018). This measure was useful for outbreak control, although negative consequences were quickly observed. Indeed, the new healthcare facilities chosen were either overwhelmed when patients sought care there, or patients were not attended to at all, partly due to the distance patients had to travel, the high case fatality rate among caregivers, and the costs they had to pay for transport, accommodation, food, and care². This situation has greatly overwhelmed the economic burden on patients in addition to their illness¹⁸. Additionally, facilities selected for patient relocation may have had a limited technical capacity or were understaffed, making it more difficult for care providers and patients because of the workload and cost, respectively. Outside the affected health zone, the system continued to operate and support responses to activities. The tiered management of all components of the response, including field laboratories and treatment centers, led to the successful management of the tenth outbreak in the DRC¹³. However, it is essential to consider the additional costs incurred by the decentralization policy if they are not completely covered by the government.

The DRC health system also receives support from different partners for targeted interventions, although the government supports the remaining issues. As Malvy et al. mention “With considerable efforts from the affected countries and with international support, the outbreak was ultimately controlled”². In most LMICs, top priority has rarely been placed on preparedness for emergency situations. Governments’ responses to emergencies are mostly expected to mobilize only a small amount of money, as extra budgets are missed in most LMICs. Under these conditions, the health system should work harder to 1) obtain enough resources, 2) build adapted infrastructure, 3) train local experts, and 4) prepare adequate medical countermeasures that can trigger appropriate public health actions within and beyond affected areas¹⁹.

Medical countermeasures

From the tenth DRC EVD outbreak onwards, most countermeasures were available at the beginning of the epidemics. This special condition prompted sustained and efficient responses from contacts, confirmed cases, and frontline workers. In previous outbreaks, the response was limited to traditional measures such as patient isolation, contact-tracing, non-specific treatment, infection and prevention control measures, mitigation of risks in public areas (hospitals, schools, and churches) and among travelers, and safe and dignified burials. In addition, Ebola specific vaccines and therapeutics have been associated with point-of-care diagnostic tools and portable genomic sequencing capacity to 1) improve prevention and care management, 2) provide an accurate and easy-to-use detection tool for the virus, and 3) provide a real-time genomic surveillance system that can guide public health decision-making during the outbreak^20–23. As Nachega et al. state “A range of novel Ebola diagnostic tools were trialed and introduced, including automated PCR machines and rapid test kits for point-of-care diagnosis”²⁰.

Two types of Ebola vaccines were available during the outbreak. The Ervebo® vaccine (Merck, Rahway, NJ, USA) delivered with a single injection in a ring-vaccination strategy for contacts of infected individuals and their contacts plus frontline workers. Ervebo® vaccine was used within the outbreak hotspot, whereas Janssen^® heterologous two-dose prophylactic vaccine (Zabdeno^® and Mvabea^®) fit better for a geographical vaccination strategy²⁴. As Nachega et al. state “Since June 2018, approximately 300,000 people in EVD-affected health zones have been immunized with the Merck rVSV-EBOV vaccine and another 20,000 in Goma with the Janssen Ad26.ZEBOV vaccine”²⁰. Both vaccines were efficient as they 1) interrupted the transmission chain, 2) protected exposed/at-risk individuals, 3) helped in the prevention, control and containment of EVD propagation^{2,4,7,25–29}.

However, the economic costs of large-scale vaccine implementation in the field with accompanying logistics were high and supported by DRC partners. Ebola vaccines and specific therapeutics are not available for free sales and their real costs are unknown. Obtaining an accurate estimate of the real price, packaging, shipment, stockpiling, and distribution from the manufacturer to the end user is not easy²⁵. Currently, the provision of these products in countries in need is only possible through a bilateral or multilateral partnership involving sponsors, collaborative entities, and health organizations. As Woolsey and Geisbert state “Another major hurdle is mitigating the economic risks for manufacturers and distributors of EBOV vaccines since the demand may not be high enough to warrant stockpiling. Outbreaks also tend to occur in resource-poor countries leaving little financial incentive for commercial development”²⁴. At this stage, no LMIC has looked for vaccines/therapeutics’ licensure nor for in-country manufacturing¹⁹.

Even though countries in need, such as the DRC, could afford Ebola vaccines and therapeutics, several steps should be taken, and several criteria should be met before expecting local licensure or manufacturing. As Woolsey and Geisbert highlight "Stockpiling is an important step toward controlling EBOV outbreaks as it is critical for ensuring timely access to vaccines for at-risk populations”²⁴.

Diagnostic tools capacity

Over the past ten EVD outbreaks in the DRC, diagnostic capacity has been deployed across sites to support the response. During the ninth, tenth, and eleventh outbreaks, the Institut National de Recherche Biomédicale (INRB) progressively deployed more than one field laboratory to 1) bring the diagnostic tools closer to the outbreak hotspot, 2) reduce the turn-around time for results, and 3) support quick decision-making based on the obtained results¹³. As Tambo et al. mention “The development of new tools, strategies and approaches, such as improved diagnostics and novel therapies including vaccines, is needed to prevent, control and contain Ebola as well as SARS, bird flu, Lassa fever, dengue and MERS outbreaks”²⁵.

The deployment of multiple field laboratories during the same outbreak led to additional tasks involving human resources, technical skills, equipment, supply chain/logistics, and coordination¹³.

The INRB has demonstrated its full operational capacity to quickly and permanently scale-up lab deployment to support biological responses, wherever and whenever required. As Mukadi-Bamuleka et al. state “In response to the scale and mobility of this outbreak, the Institut National de Recherche Biomédicale (INRB) in Kinshasha, DRC, deployed 13 field laboratories and strategically positioned them across the outbreak areas”¹³. However, the challenges and costs arising from multiple deployments must be highlighted. Human skills were quickly built and improved among national and local personnel, to support field deployment, whereas routine activities continued at the INRB headquarters (HQ). As Mukadi-Bamuleka et al. show “INRB fostered capacity building to quickly hand over Ebola response tools and competences to local staff to empower the health system and decentralize the diagnostics”¹³. Some staff from the INRB HQ have been deployed in the field for almost two years, creating vacancies that the institution should fill to maintain the work chain. Thus, the tenth outbreak, generated additional costs involving the recruitment, training, management, and payment of new staff, whereas personnel deployed on the ground returned to their positions after the outbreak. In the latter case, new positions must be created to balance the high number of personnel recruited during the outbreak shortage. The quality of training provided to the replacement staff was optimal for sustaining consistent and high-quality laboratory work, either in the field or in the laboratories at the INRB HQ. Thus, during outbreaks with more than one laboratory deployment, all resources were tremendously increased to meet the required criteria to run diagnostic activities and high standard research (clinical trials, survivors follow-up, research of Ebola reservoir, and serosurveys), especially in challenging and demanding conditions. DRC partners mostly supported the costs of such investments²⁵. Although technology and skills transfer are an unquestionable legacy for the country, sustaining the deployment and maintenance of such equipment over time remains challenging, as national policy has not yet taken the lead. The success obtained in the implementation of field laboratories for EVD diagnosis (13 in a single outbreak), Ebola Therapeutics Clinical Trial (four), and Ebola survivors follow-up (five) across the three affected provinces of the eastern DRC is irrefutable proof of the INRB’s scientific, technical and managerial capacity to support health emergency situations in the-country and beyond. As Mukadi-Bamuleka et al. state “Five laboratories supported survivor activities, 1 conducted genomic sequencing, and 2 performed differential diagnoses”¹³. Additional resources are required to implement, run, and maintain a functional biorepository capacity in Kinshasa and Goma for samples with full capacities of 1,400,000 and 400,000, respectively. The unexpected costs generated by biorepositories represent additional, unplanned fees that must be supported by the INRB or national government in the future. In addition, the wealth of Ebola biorepositories should be considered a precious legacy for future generations, because they may be involved in further research activities.

Genomic sequencing capacity

During the tenth, eleventh, and fourteenth outbreaks in the DRC, field sequencing laboratories were deployed onsite to provide real-time guidance for public health decision-making, thanks to the data provided by viral genomics tools²². During twelfth, thirteenth, and fifteenth outbreaks, samples were shipped to an intermediate level of the health system laboratory (INRB-Goma) for sequencing. In both circumstances, operability and maneuverability of onsite genomics capacity enhanced the quality of the response by providing accurate data regarding the confirmation of epidemiological links, the discovery of unknown transmission chains, determination of medical countermeasures to be used, such as vaccines and therapeutics, and rapid contact-tracing^13,21,22,29, as Mbala-Kingebeni et al. show “…we did rapid in-silico testing on available and deployed diagnostics and medical countermeasures…Our data suggest that the amino acid differences in EBOV/“Tum” should have little effect on the rVSVΔG-ZEBOV-GP vaccine and immunotherapies”²³. “The rapid viral characterization of the strain backed up the rVSV-ZEBOV candidate vaccine for the ring vaccination strategy recommended by WHO”²⁹. Several challenges have been linked to the implementation of high-throughput sequencing in the field during the ongoing outbreaks. If samples, equipment, and reagents’ transportation issues can be addressed quickly, other concerns might be more difficult to solve. As Kinganda-Lusamaki et al. state “While the sequencing laboratory in Katwa improved turnaround times between sample collection and sequencing, various infrastructural, logistical and funding challenges continued to impact the speed and consistency with which we could generate sequence data”²². Reagents for sequencing are sensitive to temperature fluctuation and are expensive, especially the Illumina^® technology²². Deployed personnel had to be adequately trained to perform the required activities. If national and international health authorities agreed on the usefulness of genomic tools, it is unclear whether the required support will be permanently available²². Although INRB is the national public health laboratory for genomics, it still relies on external support from organizations such as the Pathogens Genomics Initiative, to efficiently run and maintain activities within its facilities in Kinshasa and the field. This advocacy targets the DRC’s Ministry of Health to recognize genomic sequencing as a fully-fledged tool for outbreak control and endemic disease surveillance²⁵. This implies new budget lines allocated to support the implementation and operation of the genomic sequencing laboratories wherever and whenever it will be necessary. The allocated budget should cover various aspects including logistics, purchase and maintenance of equipment, provision of reagents and other laboratory supplies, information technology tools (computer, software, and Internet connection), specialized training for lab-technicians and bioinformaticians, staff remuneration, and the integration of sequencing staff and data into the health system. As Daniel Mukadi-Bamuleka states « The genomic sequencing has clearly highlighted the need to re-structure the health system in order to include new components the toolbox for outbreak response…and allocate enough financial, human, material resources to sustain that transition at each level of the system”³⁰.

Zoonotic reservoir for Ebola viruses

Ebola virus is known to spread mostly through zoonotic spillovers from wildlife. As Malvy et al. mention “Ebola virus disease is considered to be zoonotic, with occasional spillovers to humans, apes, and possibly other animals”²; and Shevin T. Jacob et al. state “EVD outbreaks typically start from a single case of probable zoonotic transmission, followed by human-to-human transmission via direct contact or contact with infected bodily fluids or contaminated fomites”⁴. To date, there is no direct evidence of Ebola virus transmission from bats although several authors have suggested their possible role^4,31,32. Several studies have been conducted throughout Central and West Africa to detect the Ebola virus or their RNA in specimens collected from bats, rodents, and other small mammals captured in wildlife during epidemic and interepidemic periods. Although most studies have not detected the virus, one study reported the presence of anti-EBOV GP antibodies in fruit bats from the Likouala Department, Congo-Brazzaville³³.

Since 2015, the INRB has conducted several wildlife (bats, rodents, and other small mammals) surveys within outbreak hotspots and areas with a high circulation of the Ebola virus (Equateur, North Kivu, and Ituri Provinces). During EVD outbreaks, most countermeasures target mitigation and control of infection in humans, whereas only a few measures are dedicated to ecological research. Usually, emergency funds are raised to support the control of infections rather than ecological studies. However, few studies have been conducted on wildlife in West and Central Africa, including the DRC. The cost of most studies cannot be accurately estimated, but it includes the deployment of the workforce, equipment, and reagents, and the organization of field activities. The INRB has liaised, through bilateral or multilateral partnerships, to conduct ecological studies throughout different outbreaks in the DRC. Additional efforts, advocacy, and policies should foster local research with specific budgets allocated for ecological studies during the epidemic and interepidemic periods. As Mbala-Kingebeni et al. mention “Studies on the ecology and animal reservoir of Ebola viruses are thus urgently needed so exposure to infection can be anticipated or avoided”²⁹. In regions at risk for EVD emergence, such as the Equateur, North Kivu, and Ituri Provinces, existing frontline laboratories tailored for emergency purposes can host further ecological studies²⁵. However, the frontline laboratories will require additional equipment, supplies, skills, technical and financial resources.

Social consequences

The 2018–2020 DRC EVD outbreak occurred in 29 health zones throughout three provinces in the eastern part of the country^1,5–7. The concerned region has been affected by recurrent insecurity events, strongly interfering with the common lifestyle of the population in the different aspects. For security reasons, health professionals involved in the Ebola response were seriously exposed to their own lives. As Mukadi-Bamuleka et al. state “On several occasions, teams were attacked by rebels, militia, and other hostile groups”¹³. In this context, the conduct of the response was subject to adapted rules, such as 1) security approval before authorizing the movement of personnel, equipment, and supplies in the field; 2) escorting the convoys of response teams by security forces, either visibly to act as a deterrent, or discreetly depending on the circumstances; 3) setting curfews at specific hours in unsafe areas; and 4) safeguarding Ebola response facilities (Ebola treatment centers, laboratories, coordination offices, and vaccine storage centers) by armed guards to prevent attacks, sabotage, or disruption. As Mukadi-Bamuleka et al. state “To manage security in the field, transportation of all personnel movement, equipment, and supplies had to be approved by a security commission. Depending on the context, some convoys had to be escorted by security forces, using military devices such as armored vehicles and pickup trucks with machine guns and bulletproof vests for passengers. In unsafe areas, a curfew was set from 6:00 pm to 6:00 am… In unsafe areas, laboratories were protected by armed guards to prevent eventual attacks, sabotage, or disruption”¹³. In addition, several health professionals lost their lives in the line of duty during the 2018–2020 Ebola outbreak. On 27–28 November 2019, two accommodation bases for the response teams were simultaneously attacked in Biakato (Ituri Province) and Mangina (North Kivu Province) by a local armed group, killing four staff members, including a member of the vaccination team, two drivers, a policeman; and six seriously injured persons. As Dr Tedros Adhanom Ghebreyesus, World Health Organization Director-General said, “We are heartbroken that people have died in the line of duty as they worked to save others,” Dr Matshidiso Moeti, WHO Regional Director for Africa said “The world has lost brave professionals.” “My heart goes out to the family and friends of the first responders killed in these attacks”³¹. Other security events were reported throughout the response land and period, including the murder of a Cameroonian Doctor in Butembo on 19 April 2019. As WHO reported “Dr Richard Valery Mouzouko Kiboung…he was killed while responding to the Ebola outbreak in Butembo, in the Democratic Republic of the Congo”³².

The lifestyle of the population has been significantly modified by outbreaks, response activities, and response players deployed in the field. For example, infection and prevention control (IPC) activities have been systematically implemented everywhere in public and private places, including special events during which crowds are assembled such as political meetings, religious services, and social events. People were not allowed to shake hands and were told to wash their hands regularly with chlorine 0.05% before accessing banks, supermarkets, offices, schools, churches, markets, or popular events. These practices were progressively anchored in the local people’s minds to the point where it became a habit. Safe and dignified burials (SDBs) were systematically conducted for most community deaths within or beyond the Ebola outbreak areas^34–36. As Malvy et al. mention “Safe burial practices also contribute to effective control of Ebola disease outbreaks”². Following the practice of SDBs on all corpses by the response teams in the concerned regions, most bereaved families could not organize the deserved tributes of their deceased loved ones. In addition, most corpses were placed in mortuary bags instead of coffins prior to their burials. SDBs and mortuary bags provoked the ire of the community which denounced the disrespectful and trivializing treatment of their loved-ones. The aftermath of the SDBs made most community members reluctant, resistant, and even hostile toward Ebola response personnel and activities³⁷. As Van Bortel et al. show “In many cases, bodies of the deceased are removed and buried by trained burial teams to prevent transmission, which might compound the loss experienced by loved ones, preventing traditional rites or coping processes for grieving, paying respects or gaining closure. These disruptions to traditional practices can result in feelings of resentment, anger or fear (e.g. beliefs about misfortune when not paying respect to the deceased) and can reduce access to community support usually associated with traditional mourning practices”⁸. During the 2018–2020 outbreak, school, academic, and religious activities continued in the affected zones, although they were strongly and regularly disturbed by the dynamics of the epidemic and the inherent responses provided. Schools, universities, community verandas and churches were the starting points for population mobilization. Therefore, their influence played a key role in the design and distribution of information, and the construction and implementation of outreach and deployment strategies. As Burkle states “Partnering early and often with local religious and cultural leaders is fundamental”¹². Thus, these facilities were regularly visited to 1) send key messages to the community on the disease, virus, vaccines, therapeutics, SDBs and IPC, community engagement, surveillance, organization of the response, and Ebola survivors; 2) mobilize the population and trigger community engagement; 3) distribute IPC tools and communication materials; and 4) receive community feedback on activities implemented. As Burkle shows “Through a crash course in public health, the imams convinced the families of those who died that the traditional washing, touching, dressing, and keeping vigil over the bodies could be changed without jeopardizing the guarantee that their loved ones would still receive the benefits their Muslim faith demands”¹². In the highly affected areas, pupils, students, church members, and the community benefited from guided tours of the response facilities to 1) better understand their structure, operation, equipment, and personnel, and 2) unravel the mysteries and break the rumors that surrounded their management and contents.

Funding and research activities during outbreaks

Since 2018, large-scale research has been conducted during EVD outbreaks in the DRC owing to multilateral cooperation. These resource-demanding studies are mostly funded by international partners and are focused on Ebola vaccines, therapeutics, immune responses in vaccinees and survivors, viral clearance and mutations, pathogen reservoirs, and diagnostic tools. Although the Congolese side has demonstrated expertise while conducting clinical trials and other studies, there is still a huge gap in the local fund raising capacity to support outbreak research and investigation in the DRC^{1,7,13,21–23,27,35,38–42}. In most EVD affected countries, outbreak research is not at the top of national government priorities. To implement and sustain strong research capabilities, substantial funding should be provided locally by the governments of the affected countries before waiting for additional support from international partners. As Elmahdawy et al. “Funding is required to contain direct and indirect costs from sickness and mortality in the hardest hit countries and provide financial support to enhance growth in fragile economies affected by the outbreak”¹⁸; and Tambo et al. highlight “It is also imperative to increase funding to support efforts of existing and new consortiums and research projects in Africa”²⁵.

Limitations

Despite the extension of the data search with additional keywords, we did not retrieve additional papers or reports addressing issues related to the governance, economic, social, and political aspects of EVD outbreaks in DRC.

Conclusion

EVD outbreaks are still a public health concern that affect various sectors of daily working life in the concerned countries, especially in outbreak hotspots. Emphasis should be placed on the workforce that is burdened by exposure to the disease, absenteeism, high workload, risk of non-payment, and temporary or permanent closure of businesses. National governance will strive to ensure or strengthen holistic management of the multidisciplinary consequences of Ebola epidemics to maintain the flow of activities capable of sustaining economic growth. At the national level, predicting the management of emergencies and their related consequences in fragile regions will provide greater stability, and prevent the disintegration of existing systems. Additionally, concerned countries should provide sufficient funds through different mechanisms to 1) support the operational costs of interventions in the field, 2) fill all financial gaps encountered in emergency situations, and 3) support ecological and other research activities during and outside outbreaks.

Countries at risk for Ebola outbreaks should have or maintain tiered management of the response components in addition to pre-positioning materials, equipment, and adequately trained personnel to maintain a full response capability. Medical countermeasures have demonstrated tremendous efficacy in Ebola response. However, issues related to their purchase, manufacturing, distribution, stockpiling, and licensure remain unresolved for most Ebola-affected countries, as funding, partnerships, and sponsorships are required to bring or maintain them in the country.

The lifestyle of the population was significantly modified in Ebola affected areas, because of the infection and prevention control measures implemented by the response teams, in most public and some private areas. Safe and dignified burials promoted during EVD outbreaks provoked the ire of the community, resulting in reluctance, resistance, and even hostility against response teams and activities. However, the influential leaders of schools, universities, churches, and communities played a significant role in the information design and popularization, outreach strategies, and community engagement.

Transparency

Author contributions

DM-B wrote the manuscript; AN-N and DM-B ensured data curation and verification; PM-K and SA-M reviewed the manuscript; and JJM-T initiated, reviewed, and validated the manuscript.

Acknowledgements

None stated.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Previous presentation

None.

Declaration of funding

No funding was received to produce this article.

Declaration of financial/other relationships

Authors declare no competing interests.

Data availability statement

The data sharing agreement will be available three months after the official paper release.

The data is available in the meantime on request by contacting DM-B.