Community engagement and vaccinations during the Ebola outbreak in Democratic Republic of Congo

This blog is also available in French.

The 10th Ebola outbreak in the Democratic Republic of Congo (DRC), the second largest outbreak in the world, was declared on August 1, 2018. This outbreak was challenging, occurring in an active conflict area and determined to be a Public Health Emergency of International Concern by the World Health Organization.

Frequent attacks from multiple armed groups affected communities for years, and often halted critical response interventions. The years of armed conflict and political instability created an environment of mistrust towards responders.

Over the course of the 22-month outbreak, two different vaccines were administered to more than 300,000 people.

Understanding community perceptions

The Social Sciences Analysis Cell (CASS) was set up by UNICEF in support of the government-led Ebola response. It is an integrated platform of multidisciplinary actors providing real-time rapid social sciences analyses to inform response interventions. CASS worked alongside the WHO-supported Epidemiological Analysis Cell, conducting regular studies to understand community and health care worker perceptions, and health care seeking behavior, to adapt and improve response strategies including vaccinations. This was the first time that integrated epidemiological and social sciences evidence were analyzed together during an outbreak to provide an understanding of trends and their potential causes and effects. CASS works with local researchers to ensure that research is collected in local languages and that results are shared with communities.

The results of a meta-analysis on community perception in November 2019 helped to adapt and develop strategies for community engagement around vaccinations, psychosocial impact, risk communication and surveillance interventions.  

In June 2020, CASS followed up with household and health care worker surveys coinciding with the start of the 11^th Ebola outbreak in Equateur province.

The consistent collection of data from communities throughout the 10^th and 11^th Ebola outbreaks provide important insights into community perceptions regarding vaccinations , and are helpful to inform future engagements. These are the main findings:

• Misunderstanding and misinformation on the vaccine can lead to distrust and hesitancy. This was linked to a misunderstanding of side-effects, and to limited information on the vaccine and vaccine strategy. For example, 23% of respondents in Bunia and 46% of respondents in Butembo-Katwa said they refused vaccination due to a lack of information on the vaccine and eligibility criteria, such as ring vaccination (where all people who have come into contact with someone with a confirmed case of Ebola are given the vaccine).
• Knowledge does not equal trust. In the 2020 survey conducted in the Equateur region, up to 92% of community respondents reported having heard of the Ebola vaccine. However, nearly half refused the vaccine due to a lack of trust in the vaccine (47%), belief that Ebola was not a risk (up to 42%), fear that the vaccine would infect them (24%), and lack of trust in health care workers (14%). 

• Mistrust of Ebola response actors and authorities had a negative effect on the consent and commitment of the community, leading to a refusal of the vaccine. Factors such as non-local health care workers administering the vaccine, unusual locations for vaccination (outside of health care facilities), and the presence of police at some vaccination locations led to mistrust. 

• Lack of consent forms in appropriate or local languages and lack of engagement of local influencers such as women, youth, and leaders had a detrimental impact on vaccine awareness.

• Limited trust of health care workers was due to their lack of training and vaccine awareness. Approximately 42% of health care workers in Mabalako and 55% in Mandima said they needed more information on vaccinations. In Beni, only 21% of health care workers reported having received vaccinations training .  

• Health care workers refused the vaccine due to lack of information and fear of side-effects. 49% of health care workers had not been vaccinated for Ebola because they feared side effects (46%) or lacked information on where to get vaccinated. 

• Distrust and fear of the Ebola vaccine was also found to impact routine vaccinations. For example, 47% of respondents in Beni and 62% in Mambasa reported they feared other vaccinations since the Ebola outbreak (believing them all to be Ebola vaccines).  

Lessons learned for COVID-19 

Key lessons learned during the Ebola outbreaks in the DRC can provide guidance for the distribution of COVID-19 vaccines.  They highlight the importance of building trust, working with health care workers and communities to understand how the vaccine works, where to get it and what the side effects are, rather than simply communicating the vaccine’s existence. Targeted risk communications and community engagement will be key for a successful COVID-19 vaccination campaign.  

These lessons include:    

1. Development of an integrated communication strategy with the vaccination strategy. Communication must be led by trusted actors and steer away from acceptance to focus instead on understanding. This includes information on eligibility, explaining trail phases, understanding side effects, using known and trusted health care workers to administer vaccines, and initiating community level communication campaigns early, using local languages and media.
2. Engagement of community leaders and political leaders to inform and engage the community with harmonized messages to avoid conflicting information or misinformation.  
3. Training for health care workers to ensure they have access to key resources and can answer questions. Use short videos on phones to support communication. 
4. Provide vaccines at routine health care facilities or locations close by.
5. Provide consent forms and communication materials (including videos) in local languages and clearly explain the trial, eligibility, and side-effects. 
6. Integration of social science, epidemiology, and data on service utilization to understand perception dynamics and to inform immunization strategies, communications, and community outreach. 

Lessons learned from the Ebola outbreaks in DRC have shown that risk communications and community engagement are critical and should be prioritized for COVID-19 vaccination strategies.