Democratic Republic of Congo (DRC) declared their tenth outbreak of Ebola in 40 years on 1 August 2018. The outbreak is centred in the northeast of the country. With the number of cases passing 1,000, it is now by far the country's largest-ever Ebola outbreak. It is also the second-biggest Ebola epidemic ever recorded, behind the West Africa outbreak of 2014-2016.
On 11 June 2019, Uganda announced that three people had been positively diagnosed with Ebola, the first cross-border cases since the outbreak began.
Latest figures - information as of 16 June 2019; figures provided by DRC Ministry of Health.
Retrospective investigations point to a possible start of the outbreak back in May 2018 – around the same time as the Equateur outbreak earlier in the year. There is no connection or link between the two outbreaks.
The delay in the alert and subsequent response can be attributed to several factors, including a breakdown of the surveillance system due to the security context (there are limitations on movement, and access is difficult) and a strike by the health workers of the area which began in May, due to non-payment of salaries.
A person died at home after presenting symptoms of haemorrhagic fever. Family members of that person developed the same symptoms and also died. A joint Ministry of Health/World Health Organization (WHO) investigation on site found six more suspect cases, of which four tested positive. This result led to the declaration of the outbreak.
The national laboratory (INRB) confirmed on 7 August that the current outbreak is of the Zaire Ebola virus, the most deadly strain and the same one that affected West Africa during the 2014-2016 outbreak. Zaire Ebola was also the virus found in the outbreak in Equateur province, in western DRC earlier in 2018, although a different strain than is affecting the current outbreak.
30 Jul 2018
MSF receives an alert about suspect cases of Ebola near Beni/Mangina, North Kivu.
31 Jul 2018
An MSF team from the nearby project of Lubero (roughly 3 hours away by car) goes on site to investigate.
01 Aug 2018
The Ministry of Health declares an Ebola outbreak in Mangina, North Kivu, north-eastern Democratic Republic of Congo
02 Aug 2018
MSF prepares to respond to the outbreak, within the response plan of the Ministry of Health
06 Aug 2018
MSF isolation unit opens in Mangina; teams undertake infection prevention and control
07 Aug 2018
Zaire Ebola virus is confirmed, although a different strain from Equateur outbreak
14 Aug 2018
30-bed MSF treatment centre opens in Mangina; rapidly expands to 68 beds
24 Aug 2018
MSF begins offering therapeutic drugs to eligible patients in the ETC in Mangina
02 Sep 2018
MSF team arrives in Butembo following a potential case, which is later confirmed
20 Sep 2018
MSF opens a 28-bed Ebola Treatment Centre in Butembo in partnership with the Ministry of Health.
24 Sep 2018
MSF sends a team to Tchomia, on Lake Albert in Ituri, to attend to 2 confirmed cases and later sets up a treatment centre.
17 Oct 2018
WHO announces that the situation does not constitute a Public Health Emergency of International Concern.
20 Oct 2018
An armed attack in Beni's Rwenzori area leaves 12 people dead; Ebola activities temporarily stop but restart a few days later.
09 Nov 2018
The current outbreak records its 319th case, making it the country's biggest-ever known Ebola outbreak.
15 Nov 2018
MSF opens a transit centre for suspect cases in Beni, to support the capacity of the ETC.
29 Nov 2018
The outbreak becomes the second-biggest ever recorded outbreak of the disease, behind the West Africa outbreak of 2014-2016
27 Dec 2018
Announcement of postponed elections in Beni and Butembo sparks unrest, causing Ebola activities in Beni to be temporarily suspended
04 Jan 2019
MSF opens a new ETC in Katwa, near Butembo, and a transit centre in Bwana Sura, in the Ituri province to the north
24 Feb 2019
ETC in Katwa, North Kivu, is attacked and partly burnt down; MSF forced to suspend activitiesRead more
27 Feb 2019
A second MSF-run ETC, this time in Butembo, is attacked; we are forced to evacuate staff and suspend activities in the areaRead more
30 Mar 2019
The outbreak passes 1,000 confirmed cases of Ebola.
12 Apr 2019
WHO finds once again that the outbreak does not constitute a Public Health Emergency of International Concern
03 May 2019
The epidemic passes 1,000 deaths
11 Jun 2019
Uganda announces confirmed cases of Ebola, the first cross-border cases in the outbreak
Located in northeastern DRC, the North Kivu province is a densely populated area with approximately 7 million people, of whom more than 1 million are in Goma, and about 800,000 in Butembo. Despite the rough topography and the bad roads in the region, the population is very mobile.
North Kivu shares a border with Uganda to the east (Beni and Butembo are approximately 100 kilometres from the border). This area sees a lot of trade, but also trafficking, including ‘illegal’ crossings. Some communities live on both sides of the border, meaning that it is quite common for people to cross the border to visit relatives or trade goods at the market on the other side.
The province is also well-known for being an area of conflict for over 25 years, with more than 100 armed groups estimated to be active. Criminal activity, such as kidnappings, are relatively common and skirmishes between armed groups occur regularly across the whole area. Widespread violence has caused population displacement and made some areas in the region quite difficult to access. While most of the urban areas are relatively less exposed to the conflict, attacks and explosions have nonetheless taken place in Beni, an administrative centre of the region, sometimes imposing limitations on our ability to run our operations.
North Kivu is also a very rich region with a lot of natural resources (a third of its territory is dedicated to mining exploitation) which is also a political challenge as the province has the reputation of being an area that favours the opposition. The last elections were controversial with the population, who represents 10 percent of the DRC electorate.
Background of the epidemic
First declared in Mangina, a small town of 40,000 people, the epicentre of the outbreak appeared to progressively move towards the south, first to the larger city of Beni, with approximately 400,000 people and the administrative centre of the region. As population movements are very common, the epidemic continued south to the bigger city of Butembo, a trading hub. Nearby Katwa became a new hotspot near the end of 2018 and cases have recently been found further south, in the Kanya area. Meanwhile, sporadic cases also appeared in the neighbouring Ituri province to the north, most recently in the Komanda health zone.
Overall, the geographic spread of the epidemic appears to be unpredictable, with scattered small clusters potentially occurring anywhere in the region. This pattern makes ending the outbreak even more challenging. Given the appearance of new confirmed cases ever further to the south, the risk of the epidemic reaching Goma, the capital of the province, is another cause for concern.
Existing MSF presence in the area
MSF has had projects in North Kivu since 2006. Today, we have regular projects along the Goma-Beni axe as follows:
- Lubero hospital: paediatric/nutrition care and treatment of sexual and gender-based violence.
- Bambu-Kiribizi: Two teams support local emergency room and paediatric and malnutrition in-patient departments, plus care and treatment of sexual and gender-based violence.
- Rutshuru hospital: MSF withdrew from the hospital at the end of 2017. However, in light of the volatile conditions in the region, we have returned to support emergency room, emergency surgery and paediatric nutrition programmes.
- Goma: HIV programme supporting four medical centres (including access to antiretroviral treatment).
More than 20 health zones across Ituri and North Kivu provinces have reported cases of Ebola.
We have new tools and improvements in the medical management of this epidemic, compared to previous Ebola epidemics, such as new developmental treatments; a vaccine that has given indications of being effective; Ebola treatment centres are more open and accessible for the families of patients; and provision of a higher level of supportive care.
However, ten months into the outbreak, the situation in the Ebola-affected areas of DRC is deteriorating and the number of Ebola cases continues to increase: more than 2,000 cases and more than 1,400 confirmed deaths have been reported to date.
The response has been marked by community mistrust towards the response; attacks on our Ebola Treatment Centres (ETCs) in Katwa and Butembo in February 2019 led us to withdraw from running these centres.
The mistrust and violent attacks against the Ebola response show no signs of abating; as recently as 25 May, a health worker was killed in Vusahiro while working to prevent the spread of Ebola. High levels of insecurity continue to hamper the efforts to control the epidemic and have a negative impact on its evolution: the violence further discourages people from seeking care in Ebola treatment centres, resulting in an increased likelihood of the virus spreading across the healthcare system.
Many people continue to die in the community – either at home or in general healthcare facilities – and significant numbers of new confirmed cases cannot be traced to an existing contact with Ebola.
The unrest, such as fighting between the army and armed groups in early May and the killing of a WHO doctor in April in Butembo, have brought many outbreak response activities to a standstill. Vaccination of contacts, contacts of contacts and frontline workers in Butembo and Katwa (the epicentre of the outbreak) is sometimes temporarily suspended because of threats to the safety of vaccination teams.
Ebola in Uganda
On 11 June, the Ugandan Ministry of Health and WHO confirmed three people from the same family had tested positive for Ebola in the Kasese district, western Uganda, which borders DRC. The family had travelled over the border into Uganda from DRC. They are the first cross-border cases in the current outbreak.
Two of the people sadly died, while the third person and two other members of the family, showing symptoms consistent with the disease, were repatriated to DRC.
An MSF medical and logistical team is currently in Kasese district. The MSF team is supporting the Ugandan health authorities for the management of people who have been in contact with the confirmed Ebola patients and people showing symptoms compatible with the disease, for which close monitoring is needed while waiting to confirm whether they are infected or not.
We are also ready to support the management of any eventual new cases, in an eight-bed Ebola Treatment Unit which we assisted to set-up in Bwera hospital in August 2018 Four suspect cases are currently hospitalised in this ETU. We have previously provided training to Ministry of Health staff in managing haemorrhagic fevers, such as Ebola, including during the response to a Marburg fever outbreak in Uganda between October and December 2017.
Finally, MSF will collaborate with the Ministry of Health to improve the hygiene and infection prevention and control measures in Kagando and Bwera hospitals, where the confirmed Ebola cases were first admitted. We are also ready to support the safe provision of care for medical needs unrelated to Ebola in these facilities, should the need arise.
The response to the current outbreak
The DRC Ministry of Health (MoH) is leading the outbreak response, with support from WHO. The MoH team sent to coordinate the response in Beni was dispatched from Kinshasa and is the same team that coordinated the response in Equateur province. The WHO emergency pool was mobilised in the area upon the declaration of the outbreak.
We believe it will not be possible to end this outbreak if there is no trust built between the response and the affected people. Response authorities and workers must listen to the needs of communities, restore people’s choice when it comes to managing their health, and involve the community in every aspect of the Ebola response. This includes integrating Ebola care in the overall provision of healthcare in the region.
In order to respond to people’s needs, earn their trust and improve our early detection of new cases, those responding to the outbreak need to support local health centres through training to identify suspected cases and manage isolation while people are waiting for their Ebola test results.
MSF has been involved in the outbreak response, working with the Ministry of Health, since the declaration of the epidemic on 1 August 2018.
Since our withdrawal from Katwa and Butembo following the attacks on our ETCs in February 2019, MSF is no longer running ETCs and is currently not providing care to confirmed Ebola patients.
We continue to undertake prevention and treatment activities of suspect cases, managing Transit Centres for suspected Ebola patients, and supporting health structures. Our activities include helping the healthcare system to provide support in general healthcare (beyond Ebola) such as treating common illnesses and improving water and sanitation, and implementing and strengthening triage and infection prevention and control activities (IPC).
In addition, our teams are reinforcing health promotion and community engagement in the areas where we are working. We are also working towards strengthening the disease surveillance system in our regular project areas, including in Goma.
MSF is currently running the following activities in the affected North-Kivu and Ituri provinces:
- In the city of Goma, MSF has been supporting emergency preparedness by reinforcing the surveillance system and ensuring there is adequate capacity to isolate suspected cases, including the construction of an ETC. We also have health promotion and community engagement activities in Goma and the surrounds.
- In the area surrounding Bunia, we are undertaking infection prevention and control measures in several health centres and transit centres in Komanda, Bunia, and Rwampara. We are also conducting health promotion and other awareness activities in partnership with communities.
- We are treating suspect cases in Bunia transit centre, with a 16-bed capacity.
- In Biakato, MSF teams are undertaking infection prevention and control and water and sanitation activities, plus identifying and treating suspect cases and providing treatment to people with non-Ebola illnesses.
- Across Lubero, Kayna and Beni, teams are undertaking triage and isolation of suspected Ebola cases, while providing infection prevention and control, and health promotion activities in hospitals and health centres.
- MSF teams are supporting the treatment of both non-Ebola illnesses and care to suspect cases at Lubero general hospital and five surrounding health centres, Kayna general hospital and five health centres in Beni.