Intended for healthcare professionals


Ebola: new outbreak appears in Congo a week after epidemic was declared over

BMJ 2018; 362 doi: (Published 07 August 2018) Cite this as: BMJ 2018;362:k3421
  1. Owen Dyer
  1. Montreal

The Ebola virus has reappeared in the eastern Democratic Republic of the Congo only a week after an outbreak in the western part of the country was declared over.1 Already 33 deaths are suspected of being from the virus, said the World Health Organization. An additional 43 suspected cases have been reported, of which 13 have so far been confirmed by laboratory analysis.

The new outbreak is about 1000 km to the east of the previous one and is believed not to be related but to stem from a new wildlife contact, which could be due to consumption of bush meat or contact with a fruit bat. It is the 10th outbreak in the country, which is 10 times the area of the UK, since the virus was identified in 1976.

The “signal event” was the death and unsafe burial of a 65 year old woman in the small town of Mangina on 25 July: soon afterwards seven members of her immediate family died. The health ministry in the capital, Kinshasa, learnt of these events two days after it had declared the western outbreak over.

Many of the resources that were mobilised to counter the previous epidemic, including 3000 doses of an experimental vaccine by Merck, are already in the country, which should enable a rapid response. But, while the last outbreak took place in the peaceful Equateur province, the new outbreak is in North Kivu province, a region where over 100 armed groups are believed to operate. Cases are also suspected in the neighbouring Ituri province.

The earlier western outbreak had many difficult features and logistical constraints, said WHO’s head of emergencies, Peter Salama, at a briefing in Geneva, Switzerland, on 5 August. “Health workers were infected early on, there were multiple locations, the area abutted the rainforest, and [it] had proximity to borders, major cities, and riverine routes,” he said.

This outbreak has all of those complicating factors—two health workers have already died, and Beni, the largest town with suspected cases, is 50 km from the border with Uganda—“but this time we also have the security issue,” said Salama. “In the western epidemic, many of our workers were able to travel unaccompanied hundreds of kilometres on motorcycles tracing contacts—and contact tracing is the absolute foundation of our response.

“We’re responding to this high threat pathogen with one of the highest mortalities of any infectious disease in the context of a war zone. It’s at the top of the difficulty scale.”

The North Kivu outbreak, like the one in Equateur, is “extremely likely” to be the Zaire strain of Ebola virus, said Salama.

“The bad news is that this is the deadliest variant, with a case fatality rate of over 50%,” he said. “The good news is we do have a safe effective vaccine, though still experimental. But in Equateur we had access to contacts for our ring vaccination strategy. You can imagine the difficulty of pursuing an intricate web of contacts with the access issues we face across a war zone.”

About a million of North Kivu’s eight million inhabitants are internally displaced by war, and it has constant outflows of refugees to Uganda, Rwanda, Burundi, and Tanzania.

WHO, which is already trying to negotiate a ceasefire to mount a cholera vaccination campaign in Yemen, will base its Congo response in Goma, where 20 000 UN peacekeepers are headquartered about 200 km to the south of the outbreak’s epicentre. Health workers from WHO, Congo’s health ministry, Unicef, Médecins Sans Frontières, and the Congolese and international Red Cross will try to gain access through a mixed approach of negotiations and armed escorts.