Urban Ebola outbreak a new challenge for authorities

News that a fresh outbreak of Ebola virus disease in the Congo’s northwestern city of Mbandaka — an urban area of about one million people — is raising deep concern about the spread of the disease in cities. This is the ninth time Ebola has been recorded in the Congo since it made its first known appearance near its northern Ebola River in the 1970s.

The current outbreak is not the first in an urban area. The 2013-2016 West African outbreak was the largest, most severe and most complex Ebola epidemic the world has ever seen, killing 11,300 people. A small number of cases were reported in Mali, Nigeria, Senegal and the Democratic Republic of Congo, but these countries intervened early and effectively to limit disease transmission. A handful of cases were also reported in countries outside of Africa, including Spain, the United Kingdom and the United States.

The 23 prior outbreaks of EVD in Africa had all been largely rural. As such, there was no expectation or experience of a massive urban outbreak and officials were caught off guard, with the World Health Organization slow to recognize the threat. EVD has a very high mortality rate, killing between 25 and 90 percent of those infected. When Ebola enters a more urban area, there are more people to spread the disease and more contacts for health authorities to trace, thereby widening the scope of those possibly infected beyond the reach of practitioners on the ground.

EVD’s high morbidity rate and lack of approved antidotes is what concerns international healthcare professionals. Hence the WHO is deploying an experimental antidote to head off a potential urban spread of the disease. WHO officials are arguing that the outbreak is major, with one saying: “We have urban Ebola, which is a very different animal from rural Ebola. The potential for an explosive increase in cases is now there.” The inability to detect cases is a major contributor to EVD spread despite community information programs.

The EVD outbreak in the Congo is different this time because of urban factors, such as Mbandaka’s geographical location, population density, and lack of health infrastructure. The city’s location on the banks of the Congo River — a major thoroughfare for trade and transport — is raising concern about EVD’s spread. There is a wide array of river traffic carrying people and goods between Mbandaka and Kinshasa (a city of 12 million people) and Brazzaville (two million), both of which are within a 200 kilometer radius. The capital of the Central African Republic, Bangui, where more than 730,000 people live, is also not too far away. The probability of the outbreak spreading is now high.

The WHO is moving quickly with the Congo case based on lessons learned from the last outbreak, but it is warning that an urbanized EVD may be deemed a public health emergency of international concern. If the three cases so far confirmed in Mbandaka become 10 or 12 infections, then there is an urban epidemic. 

The first 4,000 batches of the experimental Merck VSV-EBOV vaccine have arrived in the Congo to start a vaccination program around the infected individuals. But one can simply see the mathematical equation involved in trying to stop the spread of the disease based on the interaction of individuals in dense urban areas and transit routes. 

With the current EVD outbreak, Congolese officials are already issuing warnings to people to “absolutely avoid touching and washing the deceased.” Unsafe burials were a major source of transmission in the 2014 outbreak. The WHO has already sent 300 body bags to affected communities to ensure safe burial practices if the EVD outbreak takes off within Mbandaka.

Successful experiences in eliminating the EVD threat are important for two reasons. First, preventing the spread of the disease to key states such as Nigeria and Senegal, which serve as crucial economic and transport hubs in the region, is critical as a catastrophic epidemic would increase the region’s isolation and reduce its access to critical resources. Second, the experiences of other African countries that successfully contained EVD relatively early can be informative for government officials, international organizations and aid agencies seeking to capture the underlying factors that affect countries’ resilience to such outbreaks, especially in urban centers. Such an understanding could help inform activities to mitigate the impact of EVD or other similar health threats in potential hot zones.

Cities are dense, diverse and complex environments that are in a constant state of flux. This complicates humanitarian engagement within urban contexts and populations, making it challenging to implement strategies and to design and adapt to changing disease vectors on the ground. With poor infrastructure and hygiene, weak planning regulations and little capacity for infection control, this current outbreak may be an epicenter of intense virus transmission. Only time will tell whether this outbreak gets substantially worse. Hopefully the quick action taken by the WHO and other agencies will stop this EVD outbreak from spreading to other African cities and beyond.

• Dr. Theodore Karasik is a senior adviser to Gulf State Analytics in Washington. He is a former RAND Corporation Senior Political Scientist who lived in the UAE for 10 years, focusing on security issues. Twitter: @tkarasik