In DR Congo, the geographic spread of the Ebola epidemic appears to be unpredictable

Summary

Democratic Republic of Congo (DRC) declared their tenth outbreak of Ebola in 40 years on 1 August 2018. The outbreak is centred in the northeast of the country, in North Kivu and Ituri provinces, with cases also now appearing in South Kivu. With the number of cases having surpassed 3,000, it is now by far the country’s largest-ever Ebola outbreak. It is also the second-biggest Ebola epidemic ever recorded, behind the West Africa outbreak of 2014-2016.

During the first eight months of the epidemic, until March 2019, more than 1,000 cases of Ebola were reported in the affected region. However, between April and June 2019, this number doubled, with a further 1,000 new cases reported in just those three months. Between early June and the beginning of August, the number of new cases notified per week was high, and averaged between 75 and 100 each week; since August, this rate has been slowly declining, with just 70 cases identified throughout all of October.

Latest figures – information as of 25 December 2019; figures provided by DRC Ministry of Health via WHO.

3,371 TOTAL CASES
3,253 CONFIRMED CASES
2,228 TOTAL DEATHS

While there are positive signs that the number of cases is slowly reducing, the outbreak remains a serious public health concern, and it is unclear when it may end.

Although the proportion of new Ebola cases previously identified and monitored as contacts has increased in the last three months, the rate is still hovering at around one-third. However, 40 per cent of new Ebola cases were never registered as contacts, showing that identifying and following up contacts of people diagnosed with Ebola remains difficult. Reasons include the movement of people (such as in the case of motorbike taxi drivers), to downright fear in some communities which hinders engagement.

New Ebola patients are confirmed and isolated with an average delay of five days after showing symptoms, during which time they are both infectious to others and miss the benefit of receiving early treatments with a higher chance of survival.

On 11 June 2019, Uganda announced that three people had been positively diagnosed with Ebola, the first cross-border cases since the outbreak began. After several weeks with no recorded cases, the Ugandan government announced a new case on 29 August; the patient, a young girl, sadly died.

On 14 July 2019, the first case of Ebola was confirmed in Goma, the capital of North Kivu, and a city of one million people. The patient, who had travelled from Butembo to Goma, was admitted to the MSF-supported Ebola Treatment Centre in Goma. After confirmation of lab results, the Ministry of Health decided to transfer the patient to Butembo on 15 July, where the patient died the following day. On 30 July, a second person in Goma was diagnosed with Ebola; they died the next day and two more cases were announced.

No new cases have since been recorded in either Uganda or in Goma.

In reaction to the first case found in Goma, on 17 July 2019, the World Health Organization (WHO) announced that the current Ebola outbreak in DR Congo represents a public health emergency of international concern (PHEIC).

In mid-August, the epidemic spread to neighbouring South Kivu province – becoming the third province in DRC to record cases in this outbreak – when a number of people became sick in Mwenga, 100 kilometres from Bukavu, the capital of the province.

Given the ongoing challenges in responding to the outbreak, MSF believes that Ebola-related activities should be integrated into the existing healthcare system, in order to improve proximity of the services to the community and ensure that it remains functional during the outbreak.

Background of the epidemic

Retrospective investigations point to a possible start of the outbreak back in May 2018 – around the same time as the Equateur outbreak earlier in the year – although the outbreak wasn’t declared until August. There is no connection or link between the two outbreaks.

The delay in the alert and subsequent response can be attributed to several factors, including a breakdown of the surveillance system due to the security context (there are limitations on movement, and access is difficult), and a strike by the health workers of the area which began in May, due to non-payment of salaries.

A person died at home after presenting symptoms of haemorrhagic fever. Family members of that person developed the same symptoms and also died. A joint Ministry of Health/World Health Organization (WHO) investigation on site found six more suspect cases, of which four tested positive. This result led to the declaration of the outbreak.

The national laboratory (INRB) confirmed on 7 August 2018 that the current outbreak is of the Zaire Ebola virus, the most deadly strain and the same one that affected West Africa during the 2014-2016 outbreak. Zaire Ebola was also the virus found in the outbreak in Equateur province, in western DRC earlier in 2018, although a different strain than the one affecting the current outbreak.

First declared in Mangina, a small town of 40,000 people in northern North Kivu province, the epicentre of the outbreak appeared to progressively move towards the south, first to the larger city of Beni, with approximately 400,000 people and the administrative centre of the region. As population movements are very common, the epidemic continued south to the bigger city of Butembo, a trading hub. Nearby Katwa became a new hotspot near the end of 2018 and cases had been found further south, in the Kanya area. Meanwhile, sporadic cases also appeared in neighbouring Ituri province to the north.

Overall, the geographic spread of the epidemic appears to be unpredictable, with scattered small clusters potentially occurring anywhere in the region. This pattern, along with the lack of visibility on the epidemiological situation, and the risk of flareups in former hotspots, is both extremely worrying and makes ending the outbreak even more challenging.