The struggle to get Ebola vaccine to rebel-held areas of Congo

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WHEN A YOUNG woman living near Beni (the epicentre of the Democratic Republic of Congo’s latest Ebola outbreak) came down with a fever, a nurse told her to go to the clinic for a test. But by the time the virus was detected in her blood, she was in the back of a car bumping her way towards Kalungata, an area controlled by the Mai-Mai, a plundering, raping militia. She probably fled because of a widespread belief that people go to clinics to die.

One week later a cluster of Ebola cases cropped up in a village close to where the woman was hiding. It took three days of talks with a Mai-Mai chief before vaccination teams were allowed in. This was too late. The vaccine does not work on those who already have symptoms, which can appear within 48 hours of infection. The disease, which causes copious bleeding and death, spread to 45 people in the area, killing 23.

The overall toll from this outbreak stands at 241, making it Congo’s third-deadliest and the world’s fourth-largest. Congo, with its long experience in battling the virus—it had one of the world’s first recorded outbreaks in 1976—is seen as a model for the way in which it isolates and treats people to break transmission. But this outbreak, its tenth, is proving harder to contain. The problem is that Ebola is spreading to areas rife with machete-wielding rebels. Fighting has driven more than 1m people from their homes in the provinces affected by the outbreak.

The violence is escalating. On November 15th an extremist group called the Allied Democratic Forces (ADF) killed eight UN peacekeepers. A day later the ADF fired at hotels housing humanitarian workers.

“I was in the restaurant when we heard bangs,” says Guido Cornale, senior coordinator of the Ebola response for UNICEF. “We put the lights off and got under the tables.” Bullets flew through windows, but did not injure any of the health workers.

Geography complicates matters, says Oly Ilunga, the minister of health. The outbreak is near the frontier with Uganda and refugees regularly slip across. It is also the first time in Congo that Ebola has reached a city as big or as bustling as Butembo, a trading stop on one of Congo’s few highways. And it has spread through remote villages that are hard to get to at the best of times—and are now reachable only in armoured cars escorted by UN blue helmets.

The new vaccine may yet turn the tide. Without it, thousands of people would have already died, says Dr Ilunga. When health workers reach remote villages they tend to vaccinate everyone in them. This is a change from World Health Organisation’s (WHO) standard “ring vaccination” strategy of jabbing only those most likely to come into contact with an Ebola patient. Unfortunately some people refuse, says Michel Yao of the WHO in Beni.

Other weapons are being developed. This week the WHO began the first multi-drug trial of potential cures for Ebola. No one knows whether they will work, but the four treatments show promise.

Peter Salama of the WHO reckons it will take at least six months to end this outbreak. But Robert Redfield, the CDC director, warns that Ebola may become endemic, or entrenched, in the region. In addition, if new treatments succeed in saving lives, they could also increase the (remote) possibility of survivors becoming carriers of the virus who then pass it on through sex. Either way, it may become necessary to vaccinate whole populations, and not just the people most obviously at risk. If the men with machetes allow it.

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