As Ebola rages in DRC, survey highlights wide mistrust

The Ebola total in the Democratic Republic of the Congo (DRC) grew by 14 today, amid a fragile security situation in an outbreak region that is still experiencing sporadic violence and pockets of mistrust, according to the latest updates.

In a new research development, a survey of residents of Beni and Butembo that was conducted 1 month after the outbreak was declared found a link between mistrust of institutions and misinformation and fewer efforts to protect against the disease, including accepting vaccination.

In addition, a quarter of respondents questioned whether the disease even exists.

New Katwa cases include health workers

In its latest update today, the DRC's health ministry said 6 of the newly confirmed cases are in Katwa and four in Vuhovi.

Of the new cases in Katwa, two involve health workers who cared for patients in a facility in the Muchanga health area where several confirmed patients have died since Mar 10. In its report yesterday, the ministry said possible nosocomial spread had occurred at the facility, but decontamination—a key step for curbing the spread of the virus—couldn't be carried out due to community refusal.

Four other locations each have one new case: Beni, Lubero, Oicha, and Mandima. Officials added one more probable case, that of a nurse who died in early March after caring for a confirmed case-patient. Those new cases increase the number of health worker infections to 80, of which 27 were fatal.

The new illnesses boost the overall outbreak total to 1,044, which includes 978 confirmed and 66 probable cases. Also, outbreak responders are investigating 218 suspected Ebola cases.

Nine more people died from the virus, four of them in community settings in Vuhovi and Mandima, and five in Ebola treatment centers in Butembo and Mabalako. So far, 652 people have died from their infections.

WHO details challenges, signs of progress

Though no major security incidents have occurred over the last 10 days, Ebola response teams sometimes still face security challenges, the World Health Organization (WHO) said in an update today on the outbreak. Timely identification and investigation of cases is occurring against a backdrop of sporadic violence from armed groups and mistrust in some affected communities.

Despite the challenges, however, Ebola responders have made progress in emerging clusters in Mandima, Masereka, and Vuhovi, as they gradually regain access as well as community acceptance of steps known to break transmission chains, the WHO said.

A limited number of cases are occurring in other areas, but all of the cases are linked to transmission chains in hotspot areas, with some onward local spread within family networks and health centers where patients received care before they were diagnosed as having Ebola. For example, in today's health ministry update, officials said most cases in Beni recurred after a person from Mandima was moved there for treatment, with one linked to attending a funeral in Butembo.

The WHO referenced community engagement efforts that the health ministry has recently detailed, noting that, over the past week, community health workers and Red Cross volunteers have visited 4,171 households in Butembo and Katwa.

In another developments, international teams are in Beni training ophthalmologists and establishing eye care clinics for Ebola survivors, and so far 145 have been screened in the clinics and 293 have been enrolled in survivor programs.

Survey probes mistrust, misinformation

Meanwhile, a team led by Harvard University researchers yesterday published findings from an Ebola perceptions survey of people in Beni and Butembo in The Lancet Infectious Diseases. The group's goal was to tease out the role of trust and misinformation on infection prevention behaviors, given the outbreak's location in an area that has experienced regular violence over the past 20 years, alongside political instability—complex factors fueling many of the problems outbreak responders face.

The study included 961 randomly selected adults who were surveyed from Sep 1 to Sep 16, about a month after the DRC declared the current outbreak, which has become the world's second largest.

The investigators found that only 31.9% trusted that local authorities represent their best interest and that belief in misinformation was widespread, with 25.5% believing that Ebola isn't real.

They found that low institutional trust and belief in misinformation were associated with a decreased likelihood of adopting prevention measures and seeking healthcare.

Though in general, confidence in vaccines was high, levels were reduced for the Ebola vaccine, which might relate to fear of contamination, misperceptions about cost, or because it is new, the team wrote. And though they found a link between low trust, misbelief, and reduced adherence to steps to prevent Ebola, overall adherence was high, which the group said probably reflects the impact of local engagement efforts.

"Until trust building is effectively translated into response strategies and communication protocols, the basic principles of intensive risk communication by trusted sources in a transparent, sincere, and consistent manner should be the cornerstone of the social mobilisation and community engagement efforts," the team wrote.

Solutions to mistrust elusive

In a related commentary, Joe Trapido, PhD, with the department of anthropology and sociology at the School of Oriental and African Studies at the London School of Economics, wrote that as the authors of the study found, people in the DRC have learned to distrust authority in ways that make it difficult for public health interventions to gain traction.

However, he notes that solutions to trust problems are much more difficult than identifying them. He urged health responders not to mistake local gatekeepers with community in a "violently divided" society like the DRC. Trapido said the strength of the survey is the attention given to ordinary people.

He urged experts to consider replacing the term misinformation with rumor, which reflect a more complex social phenomena. There is much that outbreak responders can learn from local views, which guide how people respond to health interventions, he wrote. "And it is only by listening and understanding, free of the kind of prior judgements that the term misinformation implies, that interventions can be made more effective."

See also:

Mar 27 DRC update

Mar 28 DRC update

Mar 28 WHO Ebola update

Mar 27 Lancet Infect Dis abstract

Mar 27 Lancet Infect Dis commentary

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