Ebola virus disease – Democratic Republic of the Congo

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On 16 December 2021, the Ministry of Health (MoH) of the Democratic Republic of the Congo (DRC) declared the end of the Ebola virus disease (EVD) outbreak that affected Beni Health Zone (HZ) in North Kivu Province, DRC. The declaration was made in accordance with WHO recommendations , 42-days after the second negative test of the last confirmed case.

Between 8 October to 16 December, a total of 11 cases (eight confirmed, three probable) including nine deaths and two survivors have been reported from Beni HZ. Of the nine deaths, seven were in the community and two occurred at the Ebola Treatment Centre (ETC). The overall case fatality ratio (CFR) is 82% (9/11) among total cases while 75% (6/8) among confirmed cases.

This outbreak was declared on 8 October 2021 when the index case; a 3-year-old boy developed symptoms including physical weakness, loss of appetite, abdominal pain, breathing difficulty, dark stool and blood in their vomit and later died on 6 October (for more details, please see the Disease Outbreak News published on 10 October 2021).

On 7 October, samples were tested using reverse transcription polymerase chain reaction (RT-PCR) at the National Institute of Biomedical Research (INRB) laboratory in Beni. These were later sent to the Rodolphe Mérieux INRB Laboratory, Goma on 8 October and EVD was confirmed by RT-PCR on the same day. This event followed a cluster of three deaths (two children and their father) who were neighbours of the index case. These three patients died on 14, 19 and 29 September after developing symptoms consistent with Ebola, however, none were tested for the virus. Full genome sequencing, performed by the INRB in Kinshasa city, from the initial confirmed case indicates that this outbreak was not the result of a new zoonosis from an animal reservoir but was linked to a persistent Ebola virus infection.

During the outbreak period (8 October to 16 December 2021), three (16%) of the 19 health areas in Beni HZ reported confirmed cases, namely, Butsili (six cases), Bundji (one case) and Ngilinga (one case). Children under the age of five years accounted for 50% (4/8) of all confirmed cases. To date, all contacts completed their 21-day follow-up period and were discharged from active follow-up.

Additionally, from 8 October to 13 December, a total of 21 916 alerts were reported from nine health zones including 15 642 from Beni, 21 558 (98%) of which were investigated and 1709 were validated as suspected cases of EVD.

Public health response

The Ministry of Health (MoH), together with WHO and other partners, initiated measures to control the outbreak and prevent its further spread. The MoH activated the national and district emergency management committees to coordinate the response. Multidisciplinary teams were deployed to the field to actively search and provide care for cases; identify, reach and follow-up contacts; and sensitize communities on the outbreak prevention and control interventions.

In addition, the following public health measures were taken in response to the EVD outbreak;

• Continued use of alert monitoring for active case finding in health facilities as well as during passive surveillance.
• For the first time ever, licensed doses of ERVEBO vaccine (4,800) have been delivered in response to an EVD outbreak, through the International Coordinating Group (ICG) in vaccine provision mechanism. Vaccination with ERVEBO started on 25 November and as of 14 December, a total of 1193 frontline workers have been vaccinated with Ervebo.
• Vaccination activities with investigational doses were initiated on 13 October. As of 22 November, 656 people have been vaccinated with investigational doses, including 98 high risk contacts, 300 contacts of contacts and 258 probable contacts; of these 81 are frontline workers.
• As of 14 December, a total 1 827 samples including 834 swabs have been tested; of which eight were confirmed EVD cases at INRB field laboratories in Beni, Butembo, Mangina and Goma.
• Establishment of an ETC and other health facilities with capacity to care for suspected cases. Three alive confirmed patients received approved monoclonal antibodies at Beni ETC, two of them have since recovered from EVD.
• Strengthening of Infection Prevention and Control (IPC) capacities at 83 priority health facilities through IPC kit donations, training, supportive supervision, evaluation and other activities. Additional support was provided to 221 other health facilities through kit donations and briefing of health providers.
• From the declaration of the outbreak on 8 October to 12 December, a total of 14 points of entry were set up which screened 4 745 892 people and validated 216 alerts. None were confirmed.
• 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 IPC activities were conducted.
• Multiple community groups conducted risk communication and community sensitisation activities, using a wide range of communication channels (community dialogues, community radio, social media etc), to raise awareness of Ebola throughout the course of this outbreak. The communities were also engaged in response interventions. Additionally, a joint feedback mechanism was set-up across eight partners to record rumours, questions, and comments from communities. This has allowed for targeted communication and timely dialogue with communities.
• Psychosocial support has been offered to affected individuals and families including psychological support to confirmed and suspected patients, their close family and children as needed. In the communities, psychosocial sessions were regularly organized on different aspects of the EVD response.
• An integrated outbreak analytics (IOA) cell was set up in Beni, under the MoH’s leadership and in collaboration with the Global Outbreak Alert and Response Network (GOARN) partners. The IOA cell provided five ad hoc surveys and analyses to answer operational and strategic questions (lessons learned from Beni 2018-2020; EVD risks in children; alert performance evaluation; perception and behaviours among health workers; health seeking behaviours) and contributed to the co-development of evidence-based strategic and operational recommendations.
• The International Federation of the Red Cross and Red Crescent supported the national Congolese Red Cross in delivering safe and dignified burials throughout the outbreak.
• WHO continued to support the DRC MOH in implementing the EVD survivor care programme. The two people who recovered are entitled to an 18-month medical and psychological follow-up along with biological testing.

WHO risk assessment

The current re-emergence of EVD is the fifth outbreak in less than three years. The last EVD outbreak was reported in North Kivu Province earlier this year in February and was declared over on 3 May 2021 (for more details please see the Disease Outbreak News  published on 4 May 2021)

All probable and confirmed EVD cases were identified in three health areas of Beni HZ, within the densely populated city of Beni.  WHO continues to monitor the situation and the risk assessment will be updated as more information is available.

WHO has noted that although the current resurgence is undesirable, it is not unexpected given the fact that EVD is enzootic in the DRC and the Ebola virus is present in animal reservoirs in the region; it means that the risk of re-emergence through exposure to an animal host cannot be excluded. In addition, it is not unusual for sporadic cases to occur following a major outbreak. The Ebola virus can persist in certain body fluids of EVD survivors. In a limited number of cases, secondary transmissions resulting from exposure to survivors' body fluids have occurred. Therefore, maintaining collaborative relationships with survivor associations while monitoring survivors is a priority to mitigate any potential risk.

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.

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

WHO advice

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

• To reduce 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.
• To reduce the risk of human-to-human transmission from direct or close contact with people with Ebola symptoms, particularly with their bodily fluids. Appropriate personal protective equipment should be worn when taking care of ill patients. Regular hand washing is required after visiting patients in hospital, as well as after touching or coming into contact with any body fluids.
• To reduce the risk of possible transmission from virus persistence in some body fluids of survivors, WHO recommends providing medical care, psychological support and biological testing (until two consecutive negative tests) through an EVD survivors care programme. WHO does not recommend isolation of male or female convalescent patients whose blood has been tested negative for Ebola virus.
• Continue training and re-training of 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.)
• 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.

Distributed by APO Group on behalf of World Health Organization (WHO).