Malaria & Ebola in the DRC

By Arista Jhanjee

In November 2018, the World Health Organization (WHO) declared that the ongoing Ebola outbreak in the Democratic Republic of the Congo (DRC) constitutes the second largest outbreak in history. Rivaled in scale only by the 2014-2015 epidemic in West Africa, the outbreak may yet last for several months, according to WHO.

As of December 26, 591 Ebola cases had been detected, 357 deaths from Ebola have been occurred, and 203 patients have recovered.

The virus continues to spread rapidly and UNICEF has reported that children are particularly vulnerable to the disease, as one in three Ebola patients in the DRC is a child. The WHO has described the circumstances in the transmission zone as “unforgiving” and stated that the “risk of national and regional spread is very high.”

Insecurity in the region, the ineffectiveness of health facilities’ procedures for combatting transmission, and high population density and mobility contribute to this challenge. Violence related to civil conflict and opposition from community members often hinder the process of identifying those who have interacted with confirmed Ebola patients.

While the toll of Ebola is high, history has shown that its effects on the health system and care seeking can lead to a significant increase in malaria deaths.

A sudden spike in malaria cases in North Kivu, DRC recently garnered international attention, as the increase in malaria incidence since September of this year was revealed to be eight times higher than the same period last year.

The upsurge in malaria incidence prompted the DRC National Malaria Control Programme to initiate a four-day, mass drug administration (MDA) campaign on November 28. The initiative, supported by the WHO, UNICEF, the U.S. President’s Malaria Initiative, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, sought to deliver anti-malarial drugs and insecticide-treated bednets to 450,000 individuals.

Program implementers aimed to decrease malaria-related mortality, as well as lessen the added burden imposed by malaria cases on health facilities involved in the Ebola outbreak response, by disrupting malaria transmission and providing an alternative platform for treatment.

Such efforts to address malaria alongside Ebola take on added significance within the context of the DRC’s contribution to the global malaria burden. The DRC is second only to Nigeria in its annual number of cases. According to the 2018 World Malaria Report, the two countries together account for 36% of global malaria cases.

Malaria is also a leading cause of illness and death within the DRC: 40% of outpatient visits in the country are related to malaria, which is responsible for 19% of deaths among children under five years of age.

The lack of security that makes the Ebola response so challenging also hampers malaria control and elimination efforts, as do gaps in funding, infrastructure, and access to malaria-related services.

While the DRC’s MDA program may have taken place within a unique disease environment and context, it mimics similar initiatives undertaken during the Ebola epidemic in Liberia, Guinea, and Sierra Leone a few years ago.

As in the case of the current outbreak, the similarity between preliminary symptoms associated with malaria and those present in Ebola patients made accurate diagnosis difficult during the 2014-2015 epidemic. Research carried out during and after the outbreak revealed that malaria-related health facility visits, diagnosed cases of malaria, and malaria treatment declined significantly during the months of the epidemic. Such declines were particularly evident in areas that were heavily affected by Ebola.

The studies suggested that individuals with malaria symptoms resisted visiting facilities due to a fear of contracting Ebola or being misdiagnosed with the disease. Additionally, the reluctance of health workers to operate in Ebola-stricken areas likely reduced capacity of health centers.

Estimates indicate that the number of excess deaths due to malaria likely exceeded those caused by Ebola, particularly in Guinea.

To address these issues, the WHO issued a “Guidance on Temporary Malaria Control Measures in Ebola-Affected Countries” in November 2014. The guidelines recommended the distribution of artemisin-based combination therapies (ACTs), a type of anti-malarial drug, through MDA campaigns “in areas that [were] heavily affected by the Ebola outbreak and where malaria transmission [was] high and access to malaria treatment [was] very low.”

In an effort to prevent malaria transmission from taking place, medications were given to community members and healthcare workers whether they presented malaria symptoms or not. Evaluations of MDA program efficacy in the countries affected by the 2014-2015 Ebola outbreak demonstrated that the campaigns significantly lowered the incidence of malaria symptoms in those who completed full treatment courses, although initiation of treatment by community members sometimes proved to be a challenge.

Ebola and malaria will continue to occur in areas where health systems are weak.

The good news is that we are getting better at addressing this dual challenge. There is evidence that tools like MDA and the new vaccine for Ebola are effective in reducing cases and deaths during outbreaks. Guidelines from WHO are helping first responders improve outcomes.

The DRC government is working closely with global health donors and implementers to respond to the current Ebola outbreak, using these tools and guidelines, but it is imperative that they maintain and accelerate their commitment to addressing both diseases during and after the current outbreak.