Ebola virus disease – Democratic Republic of the Congo

Outbreak at a glance:

The Ministry of Health of the Democratic Republic of the Congo declared an outbreak of Ebola virus disease (EVD) in the country after a case was confirmed from Mbandaka, Equateur province. The onset of symptoms was on 5 April. The case subsequently died on 21 April, and a safe and dignified burial was performed. The second case, a family member, was confirmed on 25 April. As of 27 April, 267 contacts have been identified; other measures, including contact tracing, further investigations, decontamination of households and health facilities, are ongoing.

This is the third EVD outbreak in Equateur province and the sixth in the country since 2018. Previous outbreaks in Equateur province occurred in 2020 and 2018, with 130 and 54 confirmed and probable cases recorded, respectively.

Outbreak overview:

On 23 April 2022, the Ministry of Health of the Democratic Republic of the Congo declared an outbreak of Ebola virus disease (EVD) after laboratory confirmation of a case, a 31-year-old male from Mbandaka, a city of approximately 1.2 million people in the north-western Equateur province. The case had symptoms onset on 5 April, with fever and headache, and was under home treatment with antimalarial drugs and antibiotics before being admitted to two health facilities between 16 and 21 April, where infection prevention and control (IPC) measures were inadequate. Given the persistence of symptoms and appearance of haemorrhagic signs on 21 April, he was admitted to the General Referral Hospital in Wangata. He died on 21 April after which a safe and dignified burial was conducted. A blood sample taken by the provincial laboratory in Mbandaka tested positive for Ebola virus by reverse transcriptase-polymerase chain reaction (RT-PCR) on 21 April, and an oral swab analysed on 22 April also tested positive for Ebola virus. For confirmation, blood samples and oral swabs were sent to the reference laboratory, the National Institute of Biomedical Research (INRB) in Kinshasa and tested positive for Ebola virus by RT-PCR.

On 25 April, health authorities confirmed a second EVD case, a 25-year-old woman from Mbandaka who was a family member of the first case. She developed symptoms on 13 April and was treated at home for five days. While symptomatic, she visited a prayer house, a health center, a pharmacy and a nurse’s home. She died on 25 April and a safe and dignified burial was performed on the same day.

Ebola virus disease is present in animal reservoirs in the Democratic Republic of the Congo and before this EVD outbreak, the country had reported 13 EVD outbreaks since 1976. The current outbreak is the third EVD outbreak in Equateur province and the sixth in the country since 2018. The last outbreak in the Equateur Province was declared over in November 2020, after 130 confirmed and probable cases were recorded and nearly six months after the first cases were reported (more details, published in Disease outbreak news on 18 November 2020).

Full genome sequencing was performed at the INRB in Kinshasa and results indicate that this outbreak represents a new spill-over from the animal population.

Public health response

The Ministry of Health (MoH), in coordination with WHO and other partners have initiated measures to control the outbreak and prevent further spread. The MoH has activated the national and provincial emergency management committees to coordinate the response. Multidisciplinary teams are being reassigned to manage this outbreak. Outbreak control interventions are being organized in the field and include case investigation, contact tracing, surveillance at points of entry and checkpoints, isolation of suspected cases, laboratory confirmation, IPC measures in health facilities as well as community engagement and social mobilization.

EVD response interventions include:

Strong engagement with communities focusing on EVD prevention, early recognition of symptoms and care seeking and vaccination.
Case investigations and contact tracing activities including on-going in-depth interventions around the two confirmed cases. To date 267 contacts have been identified of which two suspected cases have tested negative for EVD.
Alert system is being set-up in the affected areas.
Sixteen points of control have been activated in Mbandaka.
A functional laboratory is established in Mbandaka, and supplies have been delivered.
On 24 April, the International Coordinating Group on vaccine provision received and approved the use of 1307 doses of the Ervebo licensed vaccine stored in Goma. On 26 April, 200 doses of Ervebo vaccine and matching injection devices arrived in Mbandaka.  Ring vaccination started on 27 April. Further doses will be shipped as needed and as ultra-cold chain capacities are strengthened in Mbandaka.
On-going assessment and rehabilitation of Mbandaka Ebola Treatment Centre and strengthening of screening, triage and isolation capacities of other health facilities.
Twenty treatment courses of monoclonal antibodies were received in Mbandaka on 26 April.
Infection Prevention and Control (IPC) measures have been initiated and include decontamination of health facilities, assessment and support to health facilities and training of health care workers on implementation of IPC measures, and water and sanitation rehabilitation.

WHO risk assessment

Preliminary information indicates that the first confirmed case was treated at home from the onset of symptoms before being admitted to two health facilities between 16 to 21 April. Since the case was isolated after the onset of haemorrhagic signs, there is a risk of EVD spread in the province. Additionally, due to inadequate IPC measures in place at the health facilities there is also the risk of spread among health workers and co-patients of the two facilities which the patient visited prior to the confirmation of EVD.

The exposure of the first case remains unknown, and therefore, it is difficult to assess the extent of the outbreak at this stage.

The current resurgence is not unexpected given that EVD is endemic in the Democratic Republic of the Congo and the Ebola virus is present in animal reservoirs in the region. A confluence of environmental and socioeconomic factors such as poverty, community mistrust, weak health systems, and political instability may be accelerating the rate of the emergence of EVD in the Democratic Republic of the Congo.

Although Mbandaka has experienced two EVD outbreaks in 2020 and 2018, some of the improvements achieved by establishing capacities such as IPC measures in health facilities during previous outbreaks have not been maintained over time to tackle the current outbreak. There is a need to support the province’s health professionals to conduct an effective response. In addition, logistical support is needed to reactivate the health infrastructure that was put in place during previous epidemics.

The risk of regional and international spread of this epidemic is not precluded as the city of Mbandaka borders the Congo River and has river and land connections with the capital Kinshasa, the Republic of Congo, the Central African Republic, and Angola. Mbandaka also has air connections with Sud Ubangi province bordering Central African Republic and the Republic of Congo and the capital Democratic Republic of the Congo – Kinshasa.

The risk associated with EVD in the Democratic Republic of the Congo is high due to the presence of animal reservoirs or intermediate hosts implicated in previous spill-over events, the high frequency of these outbreaks, environmental and anthropogenic factors1 , and reduced capacity of the public health sector due to other ongoing outbreaks of cholera, measles, monkeypox, and COVID-19 pandemic in the context of  a protracted humanitarian crisis due to ongoing violence and conflict.

The risk at regional and global level is assessed to be moderate and low respectively. WHO is closely monitoring the situation and the risk assessment will be updated as more information becomes available.

WHO advice

WHO advises the following risk reduction measures as an effective way to reduce Ebola virus disease 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 Ebola symptoms, particularly with their bodily fluids. Urgently refer any suspected cases to health care facility where patient should be screened, triaged and isolated accordingly. Appropriate personal protective equipment (PPE) should be worn when taking care of patients suspected or confirmed with EVD. Regular hand washing is required after visiting patients in 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 washing with soap and water is recommended. WHO does not recommend isolation of male or female convalescent patients whose blood has tested negative for Ebola virus.
All EVD control intervention should be grounded into strong community engagement, aiming at building trust with affected populations and supporting them to implement preventive measures and adhere to response interventions.
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 assess IPC capacities (including WASH and waste management) in all healthcare settings to manage ill patients and for decontamination.

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.

International travel or trade:

WHO does not recommend any restriction on travel or trade to Democratic Republic of the Congo based on the current situation.

Further information

Ebola virus disease fact sheet
Optimized Supportive Care for Ebola Virus Disease. Clinical management standard operating procedures. WHO. 2019
WHO Health topics: Ebola virus disease
Sequencing results from Ebola virus disease case in Equateur Province, DRC, represents a new spillover event, April 2022

[1] relating to, or resulting from the influence of human beings on nature

Citable reference: World Health Organization (27 April 2022). Disease Outbreak News; Ebola virus disease- Democratic Republic of the Congo. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON377
Distributed by APO Group on behalf of World Health Organization (WHO).Media files