Ebola virus disease in Democratic Republic of Congo

On October 8, 2021, the Ministry of Health of the Democratic Republic of the Congo (DRC) announced that a new laboratory confirmed case of Ebola virus disease (EVD) had been detected in Butsili Health Area, Beni Health Zone in North Kivu Province. Earlier this year, an EVD outbreak affected North Kivu Province which was declared over on May 3, 2021.  

The case was a 3-year-old male who, in early October, developed symptoms including physical weakness, loss of appetite, abdominal pain, breathing difficulty, dark stool and blood in their vomit. He died on October 6. 

On October 7, 2021, samples were tested at the National Institute of Biomedical Research (INRB) laboratory in Beni for molecular analysis. These were later sent to the Rodolphe Mérieux INRB Laboratory, Goma on October 8 and EVD was confirmed by reverse transcription polymerase chain reaction (RT-PCR) on the same day.

This follows a cluster of three deaths (two children and their father) who were neighbours of the case. These three patients died on September 14, 19 and 29 after developing symptoms consistent with Ebola, however, none were tested for the virus. 

The first of these cases, a child, was taken to a local health center for fever, physical weakness and headache between September 5-7, 2021 in the Butsili Health Area. Her condition improved and she returned home. However, on 12 September, she was re-admitted to the same health center with diarrhoea and vomiting and tested positive for malaria by Rapid Diagnostic Test (RDT). She died on the 14 September. 

The child’s father had onset of symptoms on 10 September. He consulted another health facility on 14 September and later was admitted to a hospital in Beni. He died on 19 September.

On September 27, the child’s sister developed similar symptoms. She was taken to a local health centre and later referred to another health facility where she tested positive for malaria by RDT and was treated for severe malaria. She died on September 29.  

The Beni Health Zone was informed about these three deaths on 30 September. A joint investigation team, comprising members of the Beni Health Zone and WHO, was deployed to further investigate and list the contacts. Two samples were collected to test for COVID-19 but no samples were taken for EVD testing.  No safe and dignified burials were conducted.  Severe malaria, EVD, measles and meningitis were retrospectively listed as potential causes.  

Butsili Health Area is close to Beni city, which was one of the epicentres of the 2018–2020 Ebola outbreak in the country with 736 probable and confirmed cases reported. It is about 50 km from Butembo city, which experienced a new Ebola outbreak earlier this year. It is not unusual for sporadic cases to occur following a major outbreak, but it is too early to say whether this case is related to the previous outbreaks. The city of Beni is a commercial hub with links to the neighbouring countries of Uganda and Rwanda. 

Public health response

The North Kivu Provincial health authorities are leading the current response. The Ministry of Health, with support from WHO and partners, is investigating the most recent case. During the previous outbreaks in North Kivu, WHO helped build the capacity of local laboratory technicians, contact tracers, vaccination teams, and reached out to community groups to raise Ebola awareness and engaged them in response interventions, as well as in establishing an Ebola survivor care programme. 

Among the WHO staff supporting the response is a focal point for the prevention of sexual exploitation and abuse.  In addition, WHO will ensure mandatory pre-deployment training and refresher training for any further deployments; reporting channels for alerts or complaints; prompt investigation of complaints; and monitoring.

As of 9 October, a total of 148 contacts have been identified and are under follow up by the response team.

WHO risk assessment

According to the available information, the three suspected cases and the confirmed case were admitted in several health facilities where infection prevention and control measures (IPC) might not have been optimal, which increases the risk of spread. In addition, they were buried without following safe and dignified burials protocols. Additionally, as mentioned above, the cases are from a health zone that is located within the densely populated city of Beni. Therefore, there is a risk of EVD spread to other health zones.

WHO is closely monitoring the situation and the risk assessment will be updated as more information becomes available.

The current resurgence is not unexpected given that EVD is enzootic (present in animal reservoirs) in the DRC including this region. The risk of re-emergence through exposure to an animal host or body fluids of Ebola survivors cannot be excluded. In addition, it is not unusual for sporadic cases to occur following a major outbreak.

Re-emergence of EVD is a major public health issue in the DRC and there are gaps in the country’s capacity to prepare for and respond to outbreaks. A confluence of environmental and socioeconomic factors including poverty, community mistrust, weak health systems, and political instability is accelerating the rate of the emergence of EVD in the DRC.

Another challenge stretching the limited resources is the concurrent COVID-19 outbreak. The first confirmed COVID-19 case was registered in DRC on 14 March 2020. As of 5 October 2021, DRC had reported 57 197 confirmed cases of COVID-19 and 1 087 deaths.

WHO considers that ongoing challenges in terms of access and security, epidemiological surveillance, coupled with the emergence of COVID-19, as well as cholera, meningitis, and measles outbreaks may jeopardize the country’s ability to rapidly detect and respond to the re-emergence of EVD cases.

WHO advice

WHO advises the following risk reduction measures as an effective way to reduce EVD transmission in humans:

• Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes and the consumption of their raw meat. Animals should be handled with gloves and other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked before consumption.
• Reducing the risk of human-to-human transmission from direct or close contact with people with EVD symptoms, particularly with their bodily fluids. Appropriate personal protective equipment (PPE) should be worn when taking care of ill patients. Regular hand washing is required after visiting patients in a hospital, as well as after touching or coming into contact with any body fluids.
• Reducing the risk of possible sexual transmission based on further analysis of ongoing research and consideration by the WHO Advisory Group on the Ebola Virus Disease Response, WHO recommends that male survivors of EVD practice safe sex for 12 months from onset of symptoms or until their semen tests negative twice for Ebola virus. Contact with body fluids should be avoided and hand washing with soap and water is recommended. WHO does not recommend isolation of male or female convalescent patients whose blood has been tested negative for the Ebola virus.
• Continue training and re-training of the health workforce for early detection, isolation, and treatment of EVD cases as well as re-training on safe and dignified burials and the IPC ring approach.
• Ensure availability of PPE and IPC supplies to manage ill patients and for decontamination.
• Conduct health facility assessments (“Scorecard”) of adherence to IPC measures in preparedness for managing Ebola patients (this includes WASH, waste management, PPE supplies, triage/screening capacity, etc) and continue to support facilities in developing and implementing action plans to address identified gaps.
• Prepare for ring vaccination of contacts and contacts of contacts of confirmed cases and of frontline workers.
• Engage with communities to reinforce safe and dignified burial practices.

Based on the current risk assessment and prior evidence on Ebola outbreaks, WHO advises against any restriction of travel and trade to the Democratic Republic of the Congo.