'Very concerning’: How pharmacy is at the heart of fighting Ebola
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Ebola was first identified back in 1976, and for 15 years until 1994, no human cases were detected.
Since then, outbreaks have been identified with “increasing frequency”, according to the UK Health Security Agency (UKHSA), and the Democratic Republic of Congo (DRC) has just had its 17th.
The World Health Organisation (WHO) declared the latest Ebola outbreak in the DRC and Uganda a “public health emergency” on May 17.
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The outbreak was confirmed two days earlier by the DRC’s Ministry of Health (MoH) and was caused by the Bundibugyo virus strain found in the country’s eastern province Ituri.
And pharmacists are playing a key role in the strategy to fight it.
Dr Bobo Makoso at the Cinquantenaire Hospital ETC in Kinshasa (International Medical Corps)
Coordination
Dr Bobo Makoso is a health coordinator for humanitarian charity International Medical Corps (IMC) based in the DRC’s capital Kinshasa. He manages one pharmacist in Ituri and a group of pharmacy managers involved in running the pharmaceutical services in Goma.
He previously managed the pharmaceutical response as part of the IMC’s role in dealing with the Ebola outbreak last year in the remote Kasai province, which was declared “over” by the DRC in December.
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“We implemented the Ebola treatment centres (ETC) and deployed in Ituri, Nord-Kivu and Sud-Kivu,” Dr Makoso tells C+D. “Normally, the IMC is the first responder for Ebola epidemics. Pharmacy is included in the strategies for any Ebola responses.”
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Alongside them, the IMC has deployed teams of healthcare workers to “support screening, treatment, infection prevention, frontline health worker training and community outreach” in the affected areas.
“The IMC very quickly deployed our teams in the field one or two days after the epidemic was declared,” says Dr Makoso. “When we arrived in Bunia, in Ituri, there was some ministry of health organisations there coordinating the response.”
The ETC at Bunia General Referral Hospital (International Medical Corps)
Growing danger
The IMC has led the Ebola response in the DRC since 2018, when it was called in to fight the country’s ninth outbreak.
It runs ETCs that offer care and treatment for those who contracted the disease and set up screening and referral units (SRUs) to “minimise transmission in health facilities and communities”.
The IMC said 782 cases have been reported in this outbreak so far, along with 181 confirmed deaths and 49 suspected deaths.
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Most are in Ituri, with some cases spread across Nord-Kivu and Sud-Kivu. The IMC said this outbreak has “already become the third largest in history”.
“There is a mistrust of Ebola in the community, but the pharmacist is there to treat patients with medication and talk with people about their likelihood of recovery from Ebola. They convince people to change behaviours and adhere to the Ebola treatment.”
Dr Makoso
Dr Makoso says the pharmacist and pharmacy managers closely monitor what is being used at the ETCs.
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The IMC use their own software called the Pharmaceutical Information Management System (PIMS) to help procure supplies and medicines, then distribute them.
“We have forecasting and procure pharmaceuticals, personal protective equipment (PPE) and other commodities,” he says. “They are making sure every critical supply are available at the right time and right place.”
A sanitation worker mixes chlorine and water for handwashing at the ETC (International Medical Corps)
Strain
But the main challenge in managing the outbreak is that there are no vaccines to treat against the Bundibugyo strain.
There have only ever been two outbreaks of this strain before, once in Uganda in 2007, then in the DRC five years later.
It has a lower fatality rate, but the IMC says it can “go undetected for longer” which could make this strain “even more dangerous” and those who are vaccinated against other strains could be “vulnerable”.
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“Most of the time, the strain is Ebola Zaire,” says Dr Makoso. “This Bundibugyo strain, we don’t have enough knowledge about it. There is no specific treatment of this. Cures include the treatment of secondary infections including pain treatment, nutrition treatment and supporting care in the ETC.”
The IMC says detection was “delayed” in this outbreak because equipment had been made to detect the Zaire strain, not the Bundibugyo one.
It says the “current caseload may underestimate the true scale of transmission” as the outbreak spread for “several weeks” before being identified.
Health workers putting on their PPE before entering an ETC in Bunia General Referral Hospital (International Medical Corps)
Spillover
The IMC said it’s spreading in “a difficult context marked by conflict, population displacement and porous borders” which can increase the risk of transmission.
Most cases are confined to the northeast and east provinces in the DRC, but there are concerns of cross-border infection with Burundi, South Sudan and Rwanda.
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Uganda has already reported 19 cases and two deaths as of June 9.
Complicating things further, there are frequent conflicts over mineral resources in the DRC areas, and there are challenges accessing remote areas too.
An IMC staff member talks to community members about the ETC (International Medical Corps)
The charity says the DRC has experienced the most outbreaks worldwide, partly because of its “ecology, health-system challenges and ongoing humanitarian crises”.
It suspects there is repeated spillover into humans from the virus being present in the region’s wildlife.
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The Bundibugyo strain has historically had a 30-50% mortality rate, according to the IMC.
But even though the current outbreak is “concerning” because of the lack of vaccine, it is “not considered a pandemic risk” because it spreads through direct contact with bodily fluids, not through the air.
A pre-triage zone in construction (International Medical Corps)
The availability of supplies, keeping them secure and accessing remote areas also pose issues for Dr Makoso’s team.
He explains that buffer clinical stock held in Goma could not get through some borders that had been closed because of the outbreak.
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“It was very difficult to bring the supplies in the Goma to deploy in Ituri. But we dealt with different authorities who gave helped us arrive in Ituri and treat the first patient there.”
They have to mitigate challenges with the cold chain and electricity by relying on generators or using solar panels to support medicine delivery.
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“The availability of suppliers in the country means sometimes we go abroad to procure those drugs and sometimes we can have difficulties for clearance.”
Security is also a concern, he says. “We need to be cautious moving from the warehouse to the health facility to make sure no one is stopping the supply of drugs to the facilities. And geographically, the roads are in the poorest conditions and are very damaged during the rainy season.”
IMC staff training local health workers on how to properly don and doff PPE (International Medical Corps)
Surveillance
Dr Makoso says the pharmacist is one of the critical staff members in the ETCs, which conducts surveillance on the Bundibugyo strain, focusing on rapid identification and isolation of cases.
The pharmacist ensures that infection prevention control (IPC) measures are followed for both patients and staff. This ensures the best possible hygiene is followed in the ETCs.
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“They deal with doctors and nurses to regularly provide supplies in the facilities and give training to those on using PPE and other commodities. They make sure medical waste is well managed and setting up standard operating procedures (SOPs) to correctly and safely store medical supplies in the ETC.”
The IMC says health facilities are at the most immediate risk for the disease to spread as access to personal protective equipment (PPE) “remains extremely limited” and “infection-control capacity is critically weak”.
A group of community health workers supported by the IMC conducting a door-to-door awareness session on the prevention and symptoms of Ebola virus disease for members of a household in Bunia (International Medical Corps)
Mistrust
The IMC works with MoH staff, including their own pharmacist, in the ETCs, and has up to 20 staff in every province working with MoH healthcare workers.
Its staff delivers risk communication and community engagement (RCCE) strategies and takes on contact tracing those who may have been exposed.
The IMC said “strong RCCE is essential” to stop outbreaks to support overwhelmed health systems and prevent misinformation spreading.
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The humanitarian organisation meets with local leaders to share information on Ebola and build trust with them, and this can increase the “acceptance of lifesaving measures” such as isolation, contact tracing and safe burials.
It said “fear, rumours and mistrust” can “create resistance to response efforts and enable transmission to continue” so working with local communities
Dr Makoso says there is a “mistrust” of Ebola in the community, but the “pharmacist is there to treat patients with medication and talk with people about their likelihood of recovery from Ebola. They convince people to change behaviours and adhere to the Ebola treatment.”
A sanitation worker putting on PPE at the ETC in Bunia General Referral Hospital (International Medical Corps)
Support
The IMC ensures all its staff are prepared before being deployed in the field, and luckily most of the staff in the DRC have had previous experience dealing with Ebola.
“Before we deploy the team in the field, they have briefings on the situation, are provided with training on how to protect yourself and receive mental health support,” says Dr Makoso.
“There is an evacuation policy so if they are contaminated, they can be evacuated to other specialist facilities.”
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But even though there is no pandemic risk, Dr Makoso said the situation is not improving and the outbreak’s progression is different to last year’s in Kasai. He is “afraid” more provinces will be affected.
“The transmissions are continuing. Last Wednesday, there were 37 new cases. We fear Kinshasa, Tshopo and Haut-Uele can also be affected. We work in Kinshasa with NGO partners to prepare those zones and ready to respond to any cases of Ebola.
“The situation is very concerning. We need to be very careful, very vigilant in surveillance of the epidemic. We need to control it.”
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Dr Makoso says the pharmacists and pharmacy managers are giving “life-saving services” to stop the epidemic spreading. But he calls on the international community to offer more help.
“The international support is very important in terms of funding and in pharmaceutical commodity supplies,” he says. “Sometimes we face PPE being out of stock. Internationally, we need support to see research of a specific treatment, and support vaccine research.”
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