Ebola kills 2,128 in Congo as outbreak reaches a sixth province

Congo's Ebola outbreak has spread to a sixth province, the head of the Africa Centres for Disease Control and Prevention said on August 13, after a man died in Bas-Uele, a northeastern province that had recorded no cases until this week. Jean Kaseya said the man had traveled to Buta, the provincial capital, from Isiro in neighboring Haut-Uele before he died.

If we do not stop this outbreak, it will last more than a year and will be the largest in the world.

The outbreak has killed 2,128 people out of roughly 4,566 confirmed cases in the Democratic Republic of the Congo, according to a government situation update published August 12 with data through August 11. That report counted 570 patients hospitalized in isolation and a rise of 117 deaths from the previous day's report. As of July 30, the WHO said, at least 654 patients had recovered.

How the virus reached Bas-Uele

The index patient in Bas-Uele was a motorcycle-taxi driver who sought care at several hospitals before he died in Buta, said Jean-Jacques Muyembe, head of Congo's National Institute for Biomedical Research. His movements through multiple facilities raised concerns that medical staff and other patients across those sites may have been exposed to the virus, which spreads through contact with blood, vomit, semen and other bodily fluids as well as contaminated surfaces.

His colleagues then tried to forcibly take his body, prompting police to intervene, Muyembe said. Disputes over the bodies of the dead have repeatedly heightened the risk of transmission during the outbreak, because corpses remain highly infectious and traditional burial customs bring mourners into close contact with them.

• Ituri, the northeastern province where the outbreak began and where about 90 percent of cases and 80 percent of deaths were concentrated as of August 12
• North Kivu, where an infected woman traveled to Goma in the outbreak's early weeks
• South Kivu, which recorded a case imported from Tshopo
• Haut-Uele, where the patient who died in Bas-Uele had set out from Isiro
• Tshopo, one of the provinces where case contacts are still being followed
• Bas-Uele, added Thursday after the motorcycle-taxi driver died in Buta

Six of Congo's 26 provinces have now recorded cases, though the official tallies still say five. Bas-Uele will not be added until a case of local transmission is confirmed there. It is a vast, hard-to-reach province bordering the Central African Republic, where armed violence has driven thousands to seek refuge, and its poor roads, patchy communications and constant movement tied to gold mining and displacement make surveillance harder still. Mercy Corps warned this week that infections had reached a major travel route about 35 kilometres from the border with South Sudan.

The response is losing track of the virus

Health authorities can no longer see much of where the virus is going. Between 60 percent and 70 percent of new cases are being recorded outside the contacts that monitors follow, an indication that the disease is spreading largely beyond official surveillance. A government update released August 12 listed 53 of 140 health zones affected across the five provinces that were reporting cases before Bas-Uele was added, with 82.4 percent of identified contacts still under follow-up.

Kaseya was blunter about the collapse of surveillance, saying on August 13 that 'the concept of contact tracing in DRC has become useless.' In the epicenter, Medecins Sans Frontieres said on August 5 that roughly nine in 10 patients admitted to its treatment center in Bunia had never appeared on any list of monitored contacts.

The outbreak was declared on May 15, but the WHO now says genetic sequencing showed it had begun months earlier, in February, in the Mongbwalu health zone of Ituri, where the epidemic was initially confined before spreading. That undetected start helps explain why case counts have climbed faster than in any earlier Ebola outbreak on record, and it has left responders chasing chains of transmission they cannot fully see.

The week of July 20 to 26 brought the highest weekly totals of the outbreak so far, 567 cases and 296 deaths. The crude case fatality ratio stood at 44 percent at the end of the month.

Strikes, rebels and mistrust hamper the response

The response is unfolding in some of the most difficult conditions imaginable. Dozens of armed groups operate in the east, rebel threats have shadowed treatment sites, and communities scarred by earlier crises have met outside responders with anger and with misinformation claiming that Ebola is not real.

Unpaid health workers have staged repeated strikes. Staff at the Nizi Treatment Center in Ituri walked out on August 13, forcing the site to close temporarily, after saying they had not been paid in three months. Workers at the Rwampara treatment center struck on July 13 and agreed to return the next day if paid within 72 hours, and staff at Bunia General Hospital walked off the job on July 15.

• At least 151 health workers had been infected and 44 had died as of July 30, a fatality ratio of 29 percent among staff
• A treatment center in Bunia was attacked in mid-July
• Some back pay reached workers in the week ending August 6, though many said the amounts did not match the risks they face
• Health workers in Ituri were photographed disinfecting graves and washing protective boots at Bunia General Hospital on August 11 and 12

Aid groups describe a virus that is outpacing them. Mercy Corps field teams find it increasingly difficult to reach communities safely, consistently and early enough, said Onesphore Bangenza, who leads the group's Ebola response in Bunia. 'There is no doubt that the virus is moving faster than we can contain it,' he said.

Caritas reached a similar conclusion. 'The disease has now settled in the community,' Angele Gapio, the charity's head of emergencies in Bunia, told Reuters. Many residents still turn to traditional healers rather than Ebola treatment centers, which deepens the reach of the virus and the difficulty of tracking it. Trust in outside responders has been thin since long before this outbreak, worn down by years of conflict and repeated health emergencies in the east.

A strain with no approved vaccine or treatment

The current outbreak is caused by the Bundibugyo virus, a rarer species of Ebola than the Zaire strain behind most previous epidemics. There are no approved vaccines or treatments for it, a gap that has complicated the response because existing tools were built for a different strain. The disease is rare but highly contagious, and it can be caught from contaminated surfaces and materials such as bedding and clothing as well as from bodily fluids.

Kaseya said the Africa CDC supports using Ervebo, a vaccine authorized against the Zaire strain, in provinces hit by the Bundibugyo virus, citing studies that suggest some cross-protection. 'We are in a gray area,' he said. 'And when you are in a gray area, you have to make strong decisions to stop seeing people dying.'

The outbreak is now the largest in Congo

The epidemic is already the largest ever recorded in the Democratic Republic of the Congo. It passed the 2018 to 2020 outbreak, which the WHO counts at 3,317 confirmed cases, at the end of July, and the WHO said on August 12 that it is on track to surpass the deadliest outbreak in history, the West African epidemic that killed more than 11,000 people over a decade ago.

It is the 17th Ebola outbreak in Congo since the virus was identified in 1976, declared on May 15, barely five months after the last one in Kasai was declared over. Sequencing has since placed the real start in February. The WHO called a public health emergency of international concern on May 17, two days after the health ministry confirmed the first cases in Ituri, where 246 suspected cases and 80 deaths had already been reported.

Cases have already reached three other countries

Beyond Congo, the WHO's July tally counted 20 cases in Uganda, most among visitors from Congo, and one in France, in a doctor who had returned from a humanitarian mission. Two patients diagnosed in Congo were later treated in Germany, and a U.S. citizen working for a humanitarian organization in Congo tested positive in July and was medically evacuated to Germany on July 13.

For now the risk to countries outside the region remains low, health agencies say. The U.S. Centers for Disease Control and Prevention judged the chance of spread to the United States to be low and issued a Level 3 travel notice for Congo and a Level 1 notice for Uganda in May. The European Centre for Disease Prevention and Control likewise called the likelihood of infection in the EU and EEA very low, while cautioning that wide gaps remain in surveillance and epidemiology.

Treatment trials began in Ituri in July, with patient enrolment starting on July 2, and two vaccines developed specifically for the Bundibugyo virus are being tested in people for the first time, according to the WHO. Results could shape how responders confront a strain that current tools were not built to fight.

The WHO said it hopes to reverse the spread within three months, while warning that the outbreak will not end in that time. Kaseya said failing to stop it would raise the danger of the virus crossing into neighboring countries.

Surveillance gaps still hide the true scale

The true scope of the outbreak remains unknown. With most new cases turning up outside monitored contacts and tracing all but abandoned in some areas, officials cannot yet say whether the epidemic has peaked or when existing tools might contain it. Kaseya's warning framed the stakes plainly. Without a halt, he said, the outbreak could last more than a year and become the largest the world has seen. Aid groups say they need safe, sustained access before that can change.