Ebola virus disease - the Democratic Republic of the Congo: Outbreak at a glance

On 21 August 2022, the Ministry of Health (MoH) of the Democratic Republic of the Congo announced that a new laboratory-confirmed case of Ebola Virus Disease (EVD) had been detected in the Beni health zone in the province of North Kivu. In the case, a 46-year-old woman who had co-morbidities died on 15 August 2022 after being hospitalized for 23 days. Oropharyngeal secretion samples were taken after death on 15 August 2022 and tested positive for EVD. The body was buried before the EVD results were known. Field investigations are ongoing to identify hospital and community contacts. The last EVD outbreak in the Democratic Republic of the Congo was in Equateur province and was declared over on 4 July 2022.

Outbreak overview

On 21 August 2022, the Ministry of Health (MoH) of the Democratic Republic of the Congo announced that a new laboratory-confirmed case of Ebola Virus Disease (EVD) had been detected in a 46-year-old woman living in the city of Beni, in the province of North Kivu.

The case was hospitalized and treated for 23 consecutive days—from 23 July to 15 August 2022—for symptoms thought to be related to her known co-morbidities, including cough, headache, polyarthralgia (joint pain), and physical asthenia (general fatigue). The patient died in the hospital on 15 August 2022 and the body was returned to the family for burial. To date, there is no information on the Ebola vaccination status of the deceased case.

On 15 August 2022, a sample of the oropharyngeal secretions was taken from the body and tested positive by reverse transcription polymerase chain reaction (RT-PCR) at the National Institute for Biomedical Research (INRB), Beni. For quality control purposes, the sample was then tested at the Rodolphe Mérieux INRB Laboratory in Goma, which confirmed the results by RT-PCR on 16 August 2022. The body was returned to the family prior to receiving the laboratory results and subsequently buried on 16 August 2022.

A total of 134 hospital contacts (60 healthcare personnel and 74 co-patients) have been identified. As of 24 August, nine family contacts have also been identified. There are ongoing investigations by response teams in the health facility where the patient was being treated, as well as in the community.

The sequencing carried out at the Rodolphe Mérieux Laboratory of INRB in Goma confirmed this case is genetically linked to the 2018-2020 outbreak in North Kivu, Ituri and South Kivu provinces (Ebola Zaire strain) and not a new spillover event. (For more information on this outbreak, please see the Disease Outbreak News published on 26 June 2020). Samples were also sent to INRB-Kinshasa for genomic sequencing.

Epidemiology of Ebola virus disease

EVD is a rare but severe, often fatal illness in humans. It is a viral hemorrhagic fever caused by the Ebola virus which is often fatal if untreated. The virus is transmitted to people through close contact with the blood, secretions, organs, or other bodily fluids of infected animals such as fruit bats (thought to be the natural hosts). It spreads through human-to-human transmission via direct contact with the blood or body fluids of a person who is sick with or has died from Ebola, objects that have been contaminated with body fluids from a person sick with Ebola, or the body of a person who died from Ebola.

The average EVD case fatality ratio is around 50% and has varied from 25% to 90% in past outbreaks. Providing supportive care - rehydration with oral or intravenous fluids - and treatment of specific symptoms improves survival. The incubation period (time from infection to onset of symptoms) ranges from 2 to 21 days. A person infected with Ebola cannot spread the disease until they develop symptoms.

Public health response

The MoH of the Democratic Republic of the Congo, in collaboration with WHO and other partners, has launched response measures to control the outbreak and prevent its spread.

Investigations are underway, including identifying the source of contamination, contacts, contacts of contacts, defining the risks of exposure at the different departments of the hospital, and strengthening infection prevention and control (IPC) measures at the hospital.

Building on local capacities at the health zone level, outbreak control interventions are being organized in the field and include case investigation, contact tracing, strengthening of the surveillance system, isolation of suspected cases and providing care, 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, active case search, and contact tracing activities;
• Re-activation of the alert system;
• Activation of points of control at key border crossings;
• Strengthening, as needed, the functional laboratory in Beni;
• Preparation for ring vaccination using the Ervebo licensed vaccine and targeting contacts of the confirmed case and their contacts along with frontline workers. The International Coordinating Group for Vaccine Provision approved the use of the remaining doses available in the country. Vaccines are being shipped to Goma and Beni and the ultra-cold chain is being assessed and set up as needed.  
• A treatment course of monoclonal antibodies is available in the country;
• On-going assessment and rehabilitation of Beni Ebola Treatment Centre and strengthening of screening, triage, and isolation capacities of other health facilities;
• 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;
• Capacities for safe and dignified burials are being assessed.

WHO risk assessment

Preliminary information indicates that the first case was hospitalized at the health facility for 23 days without being diagnosed with EVD and died before EVD was confirmed by the laboratory. There is a risk of spread of EVD in the Province, and infection among health workers and co-patients in the health facility where the case was admitted.

The current resurgence is not unexpected given that EVD is endemic in the country and the Ebola virus is present in animal reservoirs in the region. The virus can persist in some bodily fluids of EVD survivors.  In a limited number of cases, secondary transmissions resulting from exposure to the body fluids of EVD survivors have been documented. Relapses in EVD survivors have been reported.  Moreover, the frequent detection of outbreaks in recent years can also be explained by new developments in Ebola control, such as the use of GeneXpert machines, as well as the strengthening of surveillance and detection following successive epidemics and the scaling up of Integrated Disease Surveillance and Response (IDSR).

The re-emergence of EVD is a major public health concern in the Democratic Republic of the Congo and there are still gaps in the country's capacity to recover, prepare and respond to outbreaks.

The Beni area is also affected by insecurity from armed groups. There have been more frequent protests against the security measures put in place by the authorities and against the United Nations Organization Stabilization Mission in the Democratic Republic of the Congo (MONUSCO), which further increases the risk of refusal of outbreak control measures and therefore the possibility of spread of the disease. The concurrent outbreaks in the country (COVID-19, cholera, measles, polio, yellow fever, monkeypox, etc) as well as the protracted humanitarian situation in the province of North Kivu, have put increasing pressure on the health system and the available resources.

The risk at the national level is assessed as high. The risk at the regional and global levels is assessed as moderate and low, respectively. WHO is closely monitoring the situation and the risk assessment will be updated as new information becomes available.

WHO advice

WHO recommends the following risk reduction measures as an effective way to reduce transmission of Ebola virus disease in humans:

• Reduce the risk of wildlife-to-human transmission through contact with infected fruit bats or monkeys/great apes and 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.
• Reduce the risk of human-to-human transmission through direct or close contact with people showing symptoms of Ebola, especially with their bodily fluids. Appropriate personal protective equipment should be worn when caring for sick patients. Regular hand washing is necessary after visiting patients in a hospital, as well as after touching or coming into contact with bodily fluids.
• Reduce the risk of possible sexual transmission, based on further analysis of ongoing research and review by the WHO Advisory Group on the Ebola Virus Disease Response. WHO recommends that male EVD survivors practice safer sex for 12 months from the onset of symptoms or until their semen tests negative twice for the Ebola virus. Contact with body fluids should be avoided and washing with soap and water is recommended. WHO does not recommend the isolation of male or female convalescent patients whose blood has tested negative for the Ebola virus.
• Engage with communities to support the implementation of preventive behavior and to foster acceptance of outbreak response measures.
• Continue training and retraining of health personnel for early detection, isolation, and treatment of EVD cases as well as retraining on safe and dignified burials.
• Ensure availability of PPE and IPC supplies to manage sick patients and for decontamination.
• Prepare for vaccination of health workers, contacts, and contacts-of-contacts using the Ervebo licensed vaccine.
• For those who have already been vaccinated for more than six months, the Strategic Advisory Group of Experts (SAGE) on vaccination recommends that they be revaccinated if they are among the contacts or contacts-of-contacts of the confirmed case of EVD.
• Provide access to Ebola-specific monoclonal antibodies to treat confirmed cases, as per the latest guidelines.
• Collaborate with communities to strengthen safe and dignified burial practices.

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