Ebola veteran promises an end to Congo’s epidemic

Later this month, virologist Jean-Jacques Muyembe-Tamfum from the Democratic Republic of the Congo (DRC) will receive a prestigious award from Japanese Emperor Naruhito “for his research to confront Ebola and other deadly viruses and efforts to train legions of disease-fighters.” The recognition, which comes with close to $1 million, is overdue, says David Heymann, an epidemiologist at the London School of Hygiene & Tropical Medicine (LSHTM). In 1976, at age 34, Muyembe was the first virologist ever to see an Ebola patient, and he has helped fight all nine of the outbreaks to strike his country since. Muyembe “has never gotten the credit that he really deserves,” Heymann says.

But Muyembe, now 77 and head of the National Institute for Biomedical Research in Kinshasa, may be too busy to travel to Tokyo for his award. On 22 July, DRC President Félix Tshisekedi tapped him to head the government’s response to the latest outbreak, in the DRC’s northeast, after Minister of Health Oly Ilunga Kalenga suddenly resigned. Muyembe may be facing the most difficult fight of his life.

Now 1 year old, the epidemic has sickened more than 2700 people, at least 1800 fatally. That makes it the second biggest after the West African epidemic of 2013–16, which had more than 28,000 cases. Over the past 4 weeks, four people have fallen sick in Goma, a city of 2 million on the Rwandan border, heightening fears of further spread. A new, highly effective vaccine, produced by Merck & Co., has been given to more than 180,000 contacts of Ebola cases, but it has only slowed, not halted, the epidemic, which was declared a Public Health Emergency of International Concern by the World Health Organization (WHO) on 17 July.

In an April report, Muyembe gave a scathing analysis of the response to the outbreak, then led by Ilunga. Now, he has a chance to show he can do better. Speaking to Science on the phone from Goma, Muyembe says the outbreak can be brought under control in 3 to 4 months. “It is ambitious,” he says. “But I think we can achieve it.”

Back in 1976, Muyembe had no idea how dangerous the new disease would turn out to be. He took blood from patients and biopsies from cadavers without using gloves. “If I had not washed my hands I would have died,” he told an interviewer last year. The virus was eventually identified in the blood of a sick nurse whom Muyembe had accompanied to Kinshasa. Strict quarantine and isolation measures helped end the outbreak after 318 cases; eight subsequent outbreaks were even smaller, which helped the DRC build a reputation for knowing how to contain the virus.

Ebola outbreaks in the DRC

The current outbreak, the 10th to strike the country since the virus was discovered in 1976, is already by far the largest.

19761977199520072008–200920122014201720182018–2019**as of 6 August; epidemic is ongoingCasesDeaths 50011542763184940030020010020002500

GRAPHIC: N. DESAI/SCIENCE; DATA: WORLD HEALTH ORGANIZATION 

This time, the challenges are much bigger, Muyembe says—starting with the fact that the outbreak hit the provinces of North Kivu and Ituri, a conflict zone where the government is seen as absent at best, and an adversary at worst. “There is this impression that they have been abandoned by the political authorities in Kinshasa,” Muyembe says. The government’s sudden rush to tackle Ebola has only deepened people’s suspicions about the health care workers and the vaccine.

The distrust has led people to flee, hide, refuse the vaccine, and even attack health care workers, seven of whom have so far been killed. As a result, response workers are missing many chains of transmission. “I think there’s basically a battle going on between the vaccine and the mistrust,” says Jeremy Konyndyk, a senior policy fellow at the Center for Global Development in Washington, D.C., who visited the region in April and wrote a report about the response effort for WHO. (One version is public; a more candid one written for WHO Director-General Tedros Adhanom Ghebreyesus is not.) “The mistrust means they can’t ever quite stamp it out. The vaccine means it can’t ever quite explode,” Konyndyk says.

Muyembe says he hopes to win back trust by relying more on locals and less on people from Kinshasa or abroad to staff the response. “We want to use the medical students and so on who speak the local language to go in the community for surveillance and even for vaccination,” he says.

Gaining trust may also mean scaling back security precautions—a risky strategy. Early on, the government decided to use armed guards to enforce public health measures, hoping to contain the virus quickly, Konyndyk says. Some suspected Ebola cases—which could include anyone with a fever and diarrhea—were forced to undergo treatment, and guards accompanied health workers. “In some places, armed escorts were unavoidable at first,” Konyndyk says, “but then that also set the tone for the rest of the response.”

Muyembe’s April report detailed many other problems that he will now have a chance to fix. It accused the health ministry of “weak governance and a leadership deficit,” and criticized “exorbitant expenses” for things like “luxury hotels” and “large rental cars.”

To have the science on the one hand and speak truth to power, and on the other hand, to be connected with the people. I think that’s what we will need.

Peter Piot, London School of Hygiene & Tropical Medicine

Others, too, have criticized what some call the “Ebola economy.” “People got paid very high rates initially, because it was thought the outbreak was going to be short and you needed to get people there quickly,” says Seth Berkley, head of Gavi, the Vaccine Alliance in Geneva, Switzerland, who recently visited the DRC. The influx of money into a very poor region has itself caused tensions and led to accusations of nepotism. Berkley says he was told of a preacher who had been asked to include information about Ebola in his sermons. “The next day he sent a proposal saying, ‘You should pay me $1000 for every sermon, and I’ll get your messages out.’” (The World Bank pledged $300 million on 24 July to help the DRC government and its partners fight Ebola.)

The April report recommended “redirecting part of the funds directly to community outreach projects,” regaining the confidence of the population by improving security conditions, and ramping up the fight against other infectious diseases and malnutrition in the area. Muyembe says he has now enlisted the ministries of the interior and defense and others to help him reach those goals.

His ability to talk to people from all backgrounds may also help Muyembe, who obtained his Ph.D. in Belgium in the early 1970s. Heymann says when he accompanied Muyembe to the 1995 outbreak in Kikwit, the first in a city, his first visit was not to the hospital but to the district commissioner, whom he asked to call together all the local chiefs. “He met them that night and he told them in their language that this was an outbreak, and it was likely caused by evil spirits in people who were sick. … And if you touch them, or their dead bodies, you would get the evil spirits,” Heymann recalls. “That was how he engaged the communities.”

“There are very few scientists who can do something like that,” says LSHTM Director Peter Piot, who worked with Muyembe during the 1976 outbreak. “To have the science on the one hand and speak truth to power, and on the other hand, to be connected with the people. I think that’s what we will need.”

Muyembe will also have an important say in whether to deploy a second, experimental Ebola vaccine developed by Johnson & Johnson. Proponents, including several prominent Western scientists and a WHO vaccine advisory panel, say stocks of the Merck vaccine may run out, and argue that the outbreak presents a chance to learn more about the new vaccine, which is given in two shots that might lead to longer-lasting immunity than Merck’s single-dose product. Ilunga rejected the use of a second vaccine, partly because it could confuse the public and divert resources. A meeting of experts this week will reconsider that decision, Muyembe says. (The new vaccine is already being tested in health care workers in Uganda, where three people died from Ebola in June after crossing the border from the DRC.)

Given the many other problems Muyembe faces, the vaccine debate is a bit of a sideshow, Berkley says. Vaccines alone clearly won’t solve the problem: The second vaccine, complicated to administer because the two shots come 8 weeks apart, “is even more of a red herring, because it certainly is not going to control this epidemic,” Berkley says. “Hopefully, it doesn’t hurt it, but it’s not going to help it.”

The main reason to use the vaccine would be to study its safety and efficacy, Muyembe says—not to end the epidemic. “I think it is very important to test this vaccine,” he says. “It is during the outbreak that we can develop our research and try molecules and try new vaccines to be prepared for the future.” Even as he is fighting his 10th battle with the virus, Muyembe is already thinking about the next one.

By Kai Kupferschmidt at https://www.sciencemag.org/news/2019/08/ebola-veteran-promises-end-congo-s-epidemic