Viral Rash: Types, Symptoms, and Treatment in Adults and Babies
The Ebola Death Toll Exceeds 1,600. This Is What It's Like On The Front Lines
Health workers carry an Ebola victim's coffin on May 16 in Butembo, a city at the epicenter of the outbreak in the Democratic Republic of Congo.
Two weeks ago a mother buried her two sons. This week she was buried in the same cemetery.
After her burial, a family member was trying to walk away but couldn't bring himself to leave.
"He eventually went and stood, arms folded, in front of the victim's son's grave, stared at his picture on the cross and looked up four graves over to her grave," photographer John Wessels said. "He did this for at least 10 minutes. It was heartbreaking."
The mother and her children are among the more than 1,600 people who have died as a result of the ongoing Ebola outbreak in the Democratic Republic of Congo, according to estimates from the World Health Organization.
A health worker puts on protective gear before entering the red zone of an Ebola treatment center in Bunia on November 6.
Community members along the road from Beni to Mangina watch from a distance as health workers collect the body of a suspected Ebola victim on August 23. They also watched the workers disinfect the house and burn mattresses, "a very confusing and shocking scene to watch," photographer John Wessels said.
The current Ebola outbreak began last summer in the country's North Kivu province and now constitutes a public health emergency of international concern, WHO announced on Wednesday, July 17. This is only the fifth declaration of its kind in the organization's history.
The region is also grappling with a long-term conflict and dozens of armed groups causing intermittent violence. WHO has received additional support from the United Nations and local police to protect treatment centers.
"The displacement of people due to these attacks makes it harder for the (Ebola) response to be effective," Wessels said. "It also means that some days the response is shut down due to insecurity and fighting in the area. All of this adds up to make it a highly complex and stressful environment for community members and doctors alike."
Soldiers of the Armed Forces of the Democratic Republic of the Congo (FARDC) prepare to escort health workers attached to Ebola response programs in Butembo on May 18.
A police officer stands guard in front of a window riddled with bullet holes at an Ebola treatment center in Butembo that was attacked in the early morning hours on March 9.
An injured suspected Mai-Mai rebel fighter is thrown into the back of a truck outside an Ebola treatment center in Butembo after the March 9 attack. He was shot in the leg by government forces, Wessels said.
Wessels, a South African photojournalist based in Congo, has been on the ground documenting the crisis since it started in August.
He has witnessed families gutted by the virus and seen entire communities ravaged. "There is a lot of stigma around the disease, and we could not imagine what people affected by it are going through," he said. "The stress must be overwhelming."
"The fact that it is now declared a global health emergency really doesn't change anything on the ground. It is still at the same intensity and is still as dangerous as it was before."
Health workers burn medical waste generated during the care of Ebola patients in Mangina on August 21.
A worker helps an unconfirmed Ebola patient into her bed inside a treatment center in Butembo on November 3. "Health workers and doctors take shifts to watch over the patients," Wessels said. "Wearing full (protective gear) like that can be very taxing, so sometimes shifts are only up to an hour long or less."
Family members watch an Ebola victim's burial on May 16 in Butembo. "Burials in the context of Ebola can be complicated as the family can't touch the body and can only view it very quickly," Wessels said. "This goes against some cultural practices and so there is a lot of anger surrounding how safe burials are performed."
The Ebola virus first appeared in 1976 in two simultaneous outbreaks, one in what is now Nzara, South Sudan, and the other in Yambuku, Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name.
Ebola is a severe, often fatal illness with an average death rate of 50%. It spreads between humans through direct contact with an infected person's bodily fluids, including infected blood, feces or vomit, or direct contact with contaminated objects, such as needles and syringes.
Despite the danger, Wessels said he doesn't need to wear protective gear while covering the outbreak. He does, however, follow strict protocols and take precautions to avoid exposure to the virus, like keeping a safe distance from possibly infected zones and washing his hands as often as possible.
Young girls look at a poster explaining the symptoms of Ebola in Mangina on August 19.
A family member reacts during an Ebola victim's burial in Butembo on May 16.
A family member visits an Ebola patient inside a Biosecure Emergency Care Unit (CUBE) in Beni on August 15.
Wessels said he plans to continue covering the deadly disease to get the word out about the human toll on the country he has called home for the past two years.
"I'm hoping the world sees how shocking, stressful and heartbreaking this crisis is for the people of North Kivu," he said.
A woman gets her temperature checked on July 16 at an Ebola screening station in Goma as she enters Congo from Rwanda. The first case of Ebola in Goma was recently confirmed, raising fears that the virus could make its way across the border into Rwanda.
Three people ride a motorcycle and carry a cross for a grave along the road linking Mangina to Beni on August 23. "This scene is something we see often," Wessels said. "Unfortunately it has become 'normal' to see pick-ups with multiple coffins and people carrying crosses to burials in and around the towns."
John Wessels is a South African photographer based in the Democratic Republic of Congo. He is a regular contributor to Agence France-Presse. Follow him on Facebook, Instagram and Twitter.
Ebola: How A Disease Is Prevented From Spreading
Marie Roseline Darnycka Belizaire (L) helps to lead WHO efforts to tackle Ebola in the Democratic Republic of Congo
For health workers on the frontlines of the battle against Ebola, time means everything.
Earlier this month, the World Health Organization (WHO) declared an international health emergency in the Democratic Republic of Congo (DRC) after an outbreak of Ebola. The second-deadliest Ebola epidemic in history, it has killed more than 1,600 people so far and the numbers are rising.
Haitian doctor Marie Roseline Darnycka Belizaire is helping lead the WHO's efforts to tackle the disease in the DRC, where additional challenges include armed conflict, tough terrain and widespread fear and suspicion.
Here, Marie Roseline talks us though the process of trying to contain Ebola.
Step one: The first case
One case of Ebola is an epidemic. When someone is suspected to have the virus, we must quickly get samples to check and confirm that.
The symptoms are very, very similar to lots of other diseases, like malaria for example. It can begin with abdominal aches, headaches, sore throats, fevers. After two days, there will be an exacerbation of these symptoms and others may be exposed. For example, you can have diarrhoea, you can also have a higher fever. After five to seven days, we can begin to see haemorrhagic symptoms. When we get into the last stages of symptoms, we have very pronounced asthenia, when the person becomes very weak.
Ebola patients look like any person who is sick. When you are very accustomed to seeing people with Ebola, you can distinguish an Ebola sufferer with the most severe symptoms. It's like someone who is very ill with a lot of pain in his body. He's looking at you with some anxiety, some fear of dying. We have found people who have escaped and have gone to hide themselves to die.
We have put in place what we call a surveillance system. Members of the community go between houses to detect if someone is sick. If this is the case, they will refer this person to a health centre where the health worker has to refer this person to the Ebola team if the symptoms are the same as those seen in Ebola. At that point, we will receive an alert.
To distinguish a case of Ebola we have to make a sample. When we suspect a case, only a laboratory can say it is or it is not.
The person is then transferred to an Ebola treatment centre for the sample to be collected and analysed. Throughout this time, the patient will be receiving psychological support. This is important because it is a deadly disease that can kill several family members at the same time, people are often stigmatised when they have it, and some people think they have Ebola because they have done something wrong.
Step 2: The diagnosis
If the sample is positive, we now know we have an Ebola case. At this point, we put all pillars of our response plan into action.
Ebola is not killing you spontaneously, there is time to go for help.
If you get to a treatment centre in the first two days of symptoms, you have a 95% chance of being healed. But if you go 10 days after symptoms begin, you have a 95% chance of dying.
One of the main difficulties we're having is when a doctor within the local health structure suspects someone of having Ebola they are not calling quickly. The problem that we have is that 90-95% of the health structure is private. So when they refer the patient quickly, they say that they are not earning anything. Sometimes they keep the patient and then the patient infects other people in the health structure.
After the patient is informed of a positive result, the team will go to the family to tell them and offer psychological support.
In the Ebola treatment centre, we make sure that every treatment is available to the patient. We make some laboratory analyses to see if the kidneys are OK, if the heart is OK. Once we check all the biological functions of the person, the committee dealing with the treatment meet and decide what the best option available is.
If the person comes early, if they come late, they are treated at the same level. All of the patients are receiving the treatment. All of those patients are receiving the vital support. All the patients are receiving psychological support, and all the patients have the right to have a family member there, although direct contact is not allowed.
We are some times also called after a community death. In this case we arrange a safe and dignified burial.
Step 3: 'Mapping'
Once the psychological support is in place and the family is accepting of the result and understands what it means, our surveillance team will go deeper into an investigation we launched when we validated the case as suspected.
We do what we call "mapping". The mapping is to find where and with whom this person has been, not only in the period since symptoms began but also 21 days before this.
If someone has been in a church, we have to go to the church and try to find all the people that have been around this person. If this person went to prayer, then the pastor may have put his hand under the person. So then we have to find all the people that have been in the same room praying as this person.
How many people are affected completely depends on the movements of this person.
Marie Roseline Darnycka Belizaire says 'mapping' is a central part of the fight against Ebola
Sometimes we find that families are the main contacts, but we find also friends who are visiting, and in the community we find neighbours who have been visiting after hearing that this person has been sick in their house. When the person has been in hospital, this means all the co-patients are also contacts, workers in this hospital who have been dealing with the person are also contacts and people who have been visiting patients in the same room as the confirmed case are also contacts. You can understand how difficult it is after listing all those contacts to identify them and find them.
When we have identified each direct contact in the case one by one, we follow all of them for 21 days. While we are monitoring them, we also offer them vaccinations.
We also offer vaccinations to contacts of contacts. Those are people who have been in contact with someone who has been in direct contact with the confirmed case. Contacts of contacts of contacts are offered vaccines too.
We call these groups the first, second and third generation of contacts. There is a median number of contacts we have established of between 50 and 150 people, which helps to guide us when we are looking for them.
We have had a case that generated 356 contacts because he was a singer. It all depends on the mapping of the person.
Step 4: Vaccinations
The first, second and third generation of contacts are all offered the vaccine, but the vaccine is not mandatory.
Before offering them the vaccine, we explain why we are proposing it and why it would be good for them to take it. We also explain to them what will happen to them once they take it, because there are some symptoms they can have afterwards. After all this, they decide if they want it.
When they decide not to take the vaccine, we try to convince them. But in the end, it is a personal decision.
It is normally not so difficult to get people to take the vaccine but sometimes we have issues.
We have found people who don't want to take the vaccine because they don't want to put any external liquid in their body. We have those that have refused because they have a religion that doesn't want them to take vaccines. We have people who refuse just because they don't believe in Ebola. And we have people refuse because they think they are protected against all the bad things in the world. We have faced all of those things when people refuse them.
The vaccine has been invaluable for those who want to take it.
Some simple techniques can help prevent spread of Ebola.
We do not vaccinate everyone in the country because the vaccine is still under investigation, the number of vaccines that are available now is not enough, and by vaccinating the third ring of contacts, we create what we call community immunisation anyway. This means that the entire population is not in need of the vaccine.
We are working in very remote places, so sometimes we are carrying the vaccine on our heads. We had a team who had to walk more than five hours to a place because no cars, no motorcycles could get there so they had to go by foot.
With very remote places in the forest, we can also have insecurity because there are armed groups operating there.
Sometimes you think you might not survive. One of our colleagues has been killed and there are also people in the community who have been killed in their houses because they are working with us in the response.
Step 5: Cross-border co-ordination
We also support bordering countries with their preparedness and response plan.
When someone - a contact - is displaced to another place, we rapidly contact the other country. We have contacts who have travelled to Uganda but we have informed Uganda quickly and those contacts have been identified and come back to the DRC.
So far, the recommendation of WHO is not to close the borders. We should reinforce checks on the borders, screenings at the point of entry - this is the recommendation.
At the points of entry, if someone is sick and trying to get to another country, you can detect them there.
Step 6: Epidemic over
To declare that an epidemic is over, we have to have 42 days without any cases. Forty-two days is double the incubation period.
After the Ebola is declared finished, we begin with a surveillance phase. This is 90 days during which the team is still in the field. We train local people to try to make the system sustainable. We also actively search the community to find any cases that have been hiding somehow.
After an outbreak, we want to help local health systems to become more reliable.
This interview has been edited for length and clarity.
Ebola: Your questions answered
Ebola outbreak in five graphics
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Ebola Outbreak In Five Graphics
More than 1,800 people have died and more than 2,700 have been infected in the latest outbreak of Ebola in central Africa.
The World Health Organization (WHO) has declared the crisis a public health emergency of international concern.
The outbreak is the second-largest in the history of the virus. It follows the 2013-16 epidemic in West Africa that killed more than 11,300 people.
1. Ebola cases are on the rise
So far, more than 1,800 people have died in the Democratic Republic of Congo in the latest outbreak, which began in August last year.
The death of a priest from the disease in the eastern city of Goma, a major transport hub on the DR Congo-Rwanda border, could be a "game-changer" given the city has a large population, the WHO said.
He had travelled 200km (125 miles) by bus from Butembo - one of the towns hardest hit by Ebola - where he had mixed with worshippers sick with the disease.
The DR Congo health ministry said the driver of the bus he was travelling on and the other 18 passengers were being vaccinated.
However, the case has heightened concerns the outbreak could spread to Rwanda.
The country's authorities have ruled out closing the border saying the priest's death was not sufficient reason to shut the frontier.
2. North Kivu and Ituri provinces are affected
The current 12-month epidemic began in the eastern region of Kivu in the DR Congo and cases have since been reported in neighbouring Ituri.
The latest case in the border transport hub of Goma is of particular concern to health authorities, as it is far harder to isolate patients and trace contacts in major cities, where highly-mobile, large populations are living in close proximity.
Goma adjoins the city of Gisenyi on the Rwandan side, and people travel between the two places every day.
Rwanda has stepped up border monitoring and has urged its citizens to avoid "unnecessary" travel to DR Congo. Some 2,600 health workers had also been vaccinated.
Ugandan health officials are also screening travellers at the border to check their temperature and disinfect their hands.
Three Ebola cases that originated in DR Congo were confirmed in the country last month, but no new cases have been registered there.
The country's health minister, Jane Ruth Aceng, said the challenge was to stop people crossing at "unofficial entry points" between the two countries.
3. The virus can spread quickly
Ebola infects humans through close contact with infected animals, including chimpanzees, fruit bats and forest antelope.
It can then spread rapidly, through contact with even small amounts of bodily fluid of those infected - or indirectly through contact with contaminated environments.
Even funerals of Ebola victims can be a risk, if mourners have direct contact with the body of the deceased.
Subsequent stages can bring vomiting, diarrhoea and - in some cases - both internal and external bleeding.
Patients tend to die from dehydration and multiple organ failure.
There are normally fewer than 500 cases reported each year, and no cases were reported at all between 1979 and 1994.
The current outbreak is the worst on record after an epidemic that struck Liberia, Guinea and Sierra Leone between 2013-16, leaving more than 11,300 people dead.
It killed five times more than all other known Ebola outbreaks combined.
4. The virus can be fatal, but there are treatments
The fatality rate from Ebola is high - up to 90%, according to the WHO, and there is no proven cure as yet.
However, rehydration with oral or intravenous fluids and the treatment of specific symptoms can improve survival - especially if the virus is caught early.
Ebola patients are channelled into specialist treatment centres, where those of high-risk are separated from those of low-risk.
Although medics currently treat Ebola's symptoms rather than offer a cure, a range of new drugs, blood products and immune therapies are currently being tested.
A multiple drug trial is currently under way in DR Congo to fully evaluate effectiveness, according to the WHO.
An experimental vaccine, which proved highly protective in a major trial in Guinea in 2015, has now been given to more than 130,000 people in DR Congo.
Thousands of health workers across the region have also been vaccinated.
5. With the right action, the spread can be stopped
The key to containing and controlling an outbreak is good communication with affected communities, the WHO says.
It is crucial to trace those who may have been in contact with infected people, ensuring they get tested and receive treatment, but people also need to know how to reduce the risk of passing on the virus.
The WHO and its partners are communicating advice to affected communities. Recommendations include:
In Uganda, mass gatherings including market days and prayers have been cancelled.
By Dominic Bailey, Lucy Rodgers and Wesley Stephenson
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