Project Summary:

The provinces of North and South Kivu in eastern Democratic Republic of the Congo (DRC) have suffered from decades of war and humanitarian crises (Bompangue et al., 2009). On 1 August 2018 an outbreak of Ebola virus disease (EVD) was declared in North Kivu province (World Health Organization, 2018). By the end of the epidemic on 25 June 2020, there had been 3470 cases and 2287 deaths with over 300,000 people vaccinated using the rVSV-ZEBOV-GP vaccine (World Health Organization, 2020a). However, the outbreak response was complicated by violence and mistrust amongst the community (Moran, 2018, Center for Infectious Disease Research and Policy, 2019b). A Public Health Emergency of International Concern was declared on 17 July 2019 (World Health Organization, 2019a).


Research from the outbreak of EVD in Sierra Leone (2014-2016) suggested that compliance with public health interventions to prevent or cure EVD is influenced by public trust in the healthcare system and the understanding of the transmission risk of EVD in addition to the long-term effects of violence (Nuriddin et al., 2018, Betancourt et al., 2016). During the 2018-2020 EVD epidemic, it was thought that multiple factors contributed to the community mistrust in aid organisations,  including the rapid response to the outbreak in contrast to the long-term failure to protect civilians from conflict (Vinck et al., 2019), the limited assistance with access to basic healthcare, water and shelter and support for other ongoing outbreaks including measles and cholera (Arie, 2019). Research from Beni and Butembo showed that over a quarter of study participants did not believe that Ebola was real which resulted in a decreased likelihood of seeking formal healthcare or undertaking preventative measures including the acceptance of vaccines (Vinck et al., 2019). Two assessments of understanding of the epidemic in Goma and Beni, conducted by Translators without Borders found that women and older people in particular, did not fully understand the risk communication materials and community health workers faced difficulties in translating information on EVD to local languages (Translators without Borders, 2019a, 2019b).


In addition to the difficulties with mistrust, it is known that population movements can result in the spread of a pathogen to areas which were previously disease free (Kraemer et al., 2019). Travel across international borders and into cities may have played a role in the magnitude of the EVD outbreak in West Africa in 2014-2015 (World Health Organization, 2019b). Within eastern DRC, Ebola moved between different health zones over the course of the epidemic (World Health Organization, 2019c) and there is a high risk of cross-border spread from the DRC to neighbouring countries (Gostin et al., 2019) with recent cases in Uganda (World Health Organization, 2019d) and Goma, DRC which borders Rwanda (World Health Organization, 2019e).


The response faces significant challenges relating to effective health communication, surveillance (including identifying reasons for high rates of nosocomial transmission) and in reframing what has so far been a vertical response to consider (mis)trust in the wider health system (Vinck et al., 2019). Political instability exacerbates the challenge of engaging communities (Betancourt et al., 2016), highlighting the need to effectively map trusted sources of (formal and informal) authority. The intensity of the epidemic has increased and many people are no longer seeking care (International Federation of the Red Cross (IFRC), 2019) which is of particular concern due to porous borders between DRC and Uganda (Bedford, 2018, Storer and Pearson, 2019) and Rwanda (Lamarque et al., 2019).


As a result of these factors, Uganda has been undertaking activities to prepare for the importation of EVD since 7 November 2018. These include the set-up of Ebola Treatment Unit in the districts bordering North Kivu and Ituri, vaccination of health and frontline workers in areas at risk, community education and disease monitoring (World Health Organization, 2019d). However, there is a need to conduct research to better understand community trust in border districts in addition to movement patterns and risk of importation and potential geographical spread of the virus. This collaborative multi-site protocol was submitted under an emergency fund for Ebola by CDC to address these issues.