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The success of the new Ebola vaccine will hinge on trust

The vaccine rollout in the DRC has to do more than fight the infection; it needs public acceptance.

The first Ebola vaccination session in Mbandaka, the Democratic Republic of Congo. It's the first time the vaccine is being given out outside of the context of a clinical trial.

The quest to convince people not to fear a lifesaving vaccine is underway in the Democratic Republic of Congo, where an ongoing outbreak of the Ebola virus has transfixed the global health community.

For the first time ever in an Ebola outbreak, health care workers have a vaccine to offer people at risk of infection. The experimental shot has had a remarkable rate of success in clinical trials, and it could be a game changer in the DRC outbreak, which has already infected 58 people, including 27 deaths.

But success hinges on one major obstacle: People in the country need to trust and accept the new vaccine, and it’s not a given they will.

The vaccine campaign launched this week, and the DRC ministry of health is bracing for a backlash. “The basic Ebola treatment is not accepted by the population,” Jessica Ilunga, the lead spokesperson for the ministry, told Vox. “You need to isolate people — measures that contradict traditional practices.” When people are sick, family members swarm to care for them. So it is no surprise that there have already been reports of Ebola three patients escaping from treatment centers with their families after refusing to follow health care workers’ instructions. (Two of them later died.)

Ilunga says she's also heard about Ebola responders who were refused entry into a home where they were supposed to test a probable Ebola infection in a person who died. And when a DRC ministry of health team showed up in Bikoro, where this outbreak originated, to launch a public health campaign, they were met by locals who had heard the international community was pouring millions into the Ebola response. “'We don’t really believe you because you are just here to make money,'” she recalls them saying. The locals asked for the money and said they could manage the response by themselves.

This wariness of Ebola health care workers is nothing new. In the 2013-’16 epidemic in West Africa, Ebola responders faced attacks and struggled to convince people to follow safe burial practices (because funerals can act as Ebola super-spreaders since families prepare, touch, and kiss corpses as part of traditional burial rituals). And though there are some parallels with the anti-vaccine movement in the US and Europe — a general mistrust of government and the medical establishment — the bigger issue for health care workers in the DRC may simply be that they are outsiders working in remote communities.

To prevent vaccine pushback, the head of the Africa Centers for Disease Control said anthropologists will be dispatched to the DRC in the coming weeks to support the vaccine efforts. “If we do not handle communication well,” John Nkengasong, head of Africa CDC, told reporters in Geneva this week, “the vaccination program may suffer.”

And he’s right: It’s not an overstatement to say the task of earning the trust of locals could make or break the Ebola vaccine’s debut.

Explaining the Ebola vaccine to locals could prove more difficult than distributing it

Ebola in the DRC, 1976 to 2018.

It's still early days, but the World Health Organization and the vaccine maker Merck have reportedly done a good job on the logistics of the vaccine rollout. Some 7,500 doses of the Ebola have already arrived in the DRC and are being given out by the DRC’s health ministry, with the help of Doctors Without Borders, the WHO, UNICEF, and the vaccine public-private partnership Gavi. Another 8,000 doses will be arriving in the coming days. Yet even with the logistics in place, the rollout is uniquely challenging from a communications perspective.

Before we get into why, let’s talk about some Ebola basics. The virus is spread through direct contact with the bodily fluids, like vomit, urine, or blood, of someone who is already sick and has symptoms. The sicker people get, and the closer to the death, the more infectious they become. (That's why funerals are so dangerous.)

When the disease strikes, it’s like the worst and most humiliating flu you could imagine. People get the sweats, along with body aches and pains. Then they start vomiting and having uncontrollable diarrhea. They experience dehydration. These symptoms can appear anywhere between two and 21 days after exposure to the virus. Sometimes patients go into shock. Rarely, they bleed.

In every Ebola outbreak, public health officials need to figure out how to mount vigorous public health awareness campaigns — to remind people to wash their hands, that touching and kissing friends and neighbors is a potential health risk, and that burial practices need to be modified to minimize the risk of Ebola spread at funerals.

They also employ a strategy called “contact tracing”: isolating those related to the sick before they have had a chance to infect anyone else, and thus interrupting the human chain of transmission. This practice is pretty cruel from a human perspective, since it means tearing people away from their loved ones in their dying days.

This time, health workers have an additional challenge: They’ll need to convince those contacts to take the vaccine, which is still considered experimental since it hasn't yet been approved for market.

“People have heard it's an experimental vaccine and they think we are going to test weird drugs on them,” said Ilunga. “That's why people are afraid, so we have been explaining that the efficacy of the vaccine has already been proven; it is just that it’s not being put on the market. And that is something important for people to understand.”

What's more, instead of vaccinating the entire population, health workers are deploying the shots through a “ring vaccination” strategy, which involves immunizing the contacts — friends, family, housemates, neighbors — of people who have fallen ill to create a protective ring around them to stop transmission. In the DRC, health workers and other Ebola responders are also being vaccinated.

This approach, while effective, could also stoke skepticism. ”What people are used to is a vaccine campaign of routine immunization for everybody,” said Seth Berkley, the CEO of Gavi. “The idea that you go into a community and just vaccinate a subset of the population requires education so the whole population [understands] that.”

So not only will Ebola responders need to track down contacts, they’ll also need to educate them about why they are getting vaccinated while some of their friends aren’t. What’s more, by definition, the people getting vaccinated — the friends, family, and acquaintances of Ebola victims — are also the most likely to contract Ebola.

The first step — simply finding all the contacts — will be daunting enough, said Berkley. As of May 21, the WHO reported that more than 600 contacts had been identified. Berkley pointed out that every Ebola case has somewhere between 100 and 150 contacts. “If you have 58 cases, that’s [at least] 5,800 contacts,” he said. “So if that it’s correct — 600 cases have been found so far — that is a very small percentage of the total number of contacts that need to be on the list.”

Fighting off the rumor mill

Failing to understand how the vaccine works could also hinder trust in the shots. It takes 10 days for the body to mount an immune response to Ebola after getting vaccinated. That means people need to be aware that they should continue taking precautions — washing their hands, avoiding body contact with others, employing safe burial practices — during that period in order to avoid contracting Ebola.

If people get Ebola in that window, it also opens the door to rumors about the vaccine not working, said Ron Klain, the White House “Ebola czar” during the West African outbreak.

“‘My neighbor got the shot and got very very sick.’ ’My neighbor got the shot, they wound up with Ebola.’ [Health officials will] need to deal with the whisper networks,” said Klain. “How to combat that is really going to be critical — it’s a danger spot.”

“We have come a long way since the [2013-’16] West Africa Ebola outbreak in terms of having vaccine candidates that have shown to be effective,” said Heidi Larson, the director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine, in a statement. “But they are still very new and we need to build trust.”

Rolling out the Ebola vaccine in the DRC has some parallels to convincing vaccine-skeptical parents in the US

In West Africa, the Ebola response focused on connecting with social leaders and people who had authority in communities to help win trust and spread the word about avoiding Ebola.

But those efforts didn’t always work. “There was a widespread rumor campaign that the foreign health care workers were bringing Ebola rather than helping to arrest the epidemic,” Klain said.

“In the context of uncertainty, fear, a known deadly virus, and an unknown foreign vaccine, it is not surprising that some particularly remote or marginalized communities might turn to their faith-based groups and religious leaders,” Larson said.

That means, Klain said, “finding those people in society who have trust, confidence, and the authority to be believed” could be key to helping spread positive messages about the vaccine.

Illunga said the DRC health ministry is already trying to do that: “We are working with community leaders, especially traditional and religious leaders, to help us spread the right messages and help the population better understand what we are doing, why we are doing it, and why it's important that they respect the advice from health workers.”

A survey gauging community reactions to an Ebola vaccine in Guinea also has some clues about how to ensure trust in the vaccine. The researchers found Ebola vaccine interest and acceptability were higher among people who were most at risk of getting Ebola or knew people who had ben infected.

“This suggests that fear of an imminent infection that causes an obvious, severe disease, warrants specialized treatment, and has a high fatality rate may have stimulated interest in potentially beneficial vaccines,” the researchers wrote. The findings also suggest one way to enhance vaccine trust: “framing vaccination as a proactive choice that prevents dramatic, life-threatening disease and engaging survivors to champion Ebola vaccination.”

In many ways, Klain reflected, that’s no different from a vaccine campaign anywhere else. “Trying to persuade people in Orange County [California] that they should give their kids vaccinations and persuading people in a village in West Africa that foreign health care workers are in fact their friends and not their enemies,” he said. “It’s a hard problem here in our own country.” In the case of Ebola in the DRC, however, the health threat is a particularly lethal one.

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