Ebola virus disease – Democratic Republic of the Congo

On 25 June 2020, the Minister of Health of the Democratic Republic of the Congo declared the end of the Ebola Virus Disease (EVD) outbreak in North Kivu, Ituri and South Kivu Provinces . In accordance with WHO recommendations, the declaration was made more than 42 days after the last person who contracted EVD in this outbreak tested negative twice and was discharged from care.

The outbreak was declared on 1 August 2018 following investigations and laboratory confirmation of a cluster of EVD cases in North Kivu Province. Further investigations identified cases in Ituri and North Kivu Provinces with dates of symptom onset from May to August 2018. In 2019, the outbreak subsequently spread to South Kivu Province, and on 17 July 2019, the WHO Director-General declared the outbreak a Public Health Emergency of International Concern. In the Democratic Republic of the Congo, 11 outbreaks have been recorded since the first recognized outbreak in 1976. The 10th EVD outbreak in North Kivu, Ituri and South Kivu Provinces was the country’s longest EVD outbreak and the second largest in the world after the 2014–2016 EVD outbreak in West Africa.

The response to the outbreak was led by the Ministry of Health with support from WHO and partners in the areas of surveillance, contact tracing, laboratory services, infection prevention and control (IPC), clinical management, community engagement, safe and dignified burials, response coordination and preparedness activities in neighbouring provinces. The engagement of local leaders, communities and survivors in EVD survivor care programmes and community messaging played a central role in curtailing the outbreak. Challenges in establishing trust with affected communities, reticence for admission to Ebola treatment facilities, a high level of insecurity due to the presence of armed groups in the affected areas, as well as a series of attacks against health workers contributed to the difficulty of containing this outbreak.

Despite these challenges, no new confirmed cases have been reported since April 2020, and North Kivu, Ituri and South Kivu Provinces were declared Ebola-free 23 months after the first cases were reported. June 2020 marks the beginning of the handover of outbreak response and surveillance activities from the central government and international partners to the Provincial Health Divisions.

From 17 to 23 June 2020, an average of 2790 alerts were reported per day and investigated. Of these, over 99% were investigated within 24 hours, and an average of 428 alerts were validated as suspected cases each day, requiring specialized care and laboratory testing to rule out EVD. Sustained numbers of alerts have been reported daily since April 2020 due to strengthened capacity to detect emergent cases and continuous support of provincial health divisions and the Ministry of Health. The timely testing of suspected cases was achieved by a network of eight laboratories. From 15 to 21 June 2020, a total of 3219 samples were tested including 2665 blood samples from alive, suspected cases; 323 swabs from community deaths; and 344 samples from re-tested patients. Overall, the number of samples tested by the laboratories increased by 4% compared to the previous week.

From 1 August 2018 to 25 June 2020, a total of 3470 EVD cases were reported from 29 health zones including 3317 confirmed cases and 153 probable cases. Of the total confirmed and probable cases, 57% (n=1974) were female, 29% (n=1006) were children aged less than 18 years and 5% (n=171) were health care workers. There were 2287 deaths recorded (overall case fatality ratio 66%), 33% (1152/3470) of cases died outside of Ebola treatment centres, and 1171 cases recovered from EVD. Over the course of the outbreak, more than 250 000 contacts of cases were registered in North Kivu, Ituri and South Kivu Provinces.

On 25 June 2020, the Democratic Republic of the Congo entered a 90-day period of heightened surveillance. Although human-to-human transmission of Ebola virus has ended in North Kivu, Ituri and South Kivu Provinces and the outbreak has officially been declared over, the risk of re-emergence still exists. Therefore, there is a critical need to maintain response operations to rapidly detect and respond to any new cases and to prioritize ongoing support and care for people who recovered from EVD.

Ebola virus can persist in some body fluids of survivors for several months, and in rare cases may result in secondary transmission or in relapse, as seen in this outbreak. In addition, Ebola virus is present in animal reservoirs in the region, so there is continued risk of zoonotic spillover. Given that cases may continue to occur from time to time in the Democratic Republic of the Congo, maintaining a robust surveillance system and response operations to rapidly detect, isolate, test and treat new suspected cases are essential.

Figure 1: Confirmed and probable Ebola virus disease cases by week of illness onset by health zone. Data as of 25 June 2020*

*Excludes n=71/3470 cases for whom onset dates not reported. Data in recent weeks are subject to delays in case confirmation and reporting, as well as ongoing data cleaning. ‘Other zones’ indicate health zones other than Kalunguta, Mandima, Mabalako, Beni, Butembo & Katwa Health Zones which have been affected by EVD.

Public health response

In response to this EVD outbreak, from 1 August 2018 to 25 June 2020:

• 11 field laboratories were set up to test up to 4200 samples a week, using GeneXpert polymerase chain reaction (PCR). Overall, more than 220 000 samples were tested;
• 11 Ebola Treatment Centres were set up to care for people with Ebola and provided supportive care and life-saving therapeutics to 2198 confirmed cases;
• 25 decentralized and centralized transit centres were set up to care for suspect cases;
• An Ebola vaccine was licensed, and two treatments, regeneron (REGN-EB3) and mAb114, were found to be highly effective. 305 841 people were identified as eligible for vaccination, of whom 99% (n=303 905) were vaccinated;
• Since November 2018, a national care programme for EVD survivors has been set up to provide dedicated clinical and psychological care and biological follow-up of body fluids. Every month, more than 90% of people who recovered from EVD attend the monthly follow-up, showing good acceptance and usefulness of the programme;
• More than 29 000 death alerts resulted in more than 26 000 safe and dignified burials performed (88% success throughout the outbreak);
• IPC supportive supervision and mentorship were provided to more than 3000 health facilities;
• More than 2100 healthcare workers were trained on IPC;
• More than 1000 metric tons of supplies were delivered through 750 international cargos; and
• Over 180 million screenings were conducted for Ebola symptoms at borders or other points of control.

For further information about public health response actions by the Ministry of Health, WHO, and partners, please refer to the latest situation reports published by the WHO Regional Office for Africa:

WHO risk assessment – North Kivu, Ituri and South Kivu Provinces

The latest WHO assessment concluded that the current EVD outbreak has been contained, considering that more than 42 days (two incubation periods) have elapsed since the date of the second consecutive negative test of the last case confirmed case on 13 May 2020. On 26 June 2020, WHO maintained the risk assessment for this event as Moderate at the national and regional levels, and the risk level remained Low at the global level.

Under the Consolidation and Stabilization Strategic Plan adopted by the Ministry of Health, enhanced surveillance, a long-term programme for Ebola survivor care, and other response mechanisms remain in place following the end of the outbreak declaration to maintain increased vigilance and contribute to strengthening and resilience of the local health systems.

Given that EVD is likely to persist in an animal reservoir in the Democratic Republic of the Congo, a new zoonotic spillover event may occur. Moreover, an EVD cluster may also occur from exposure to body fluids of survivors, although the probability of this will reduce over time.

WHO considers ongoing challenges in access and security, community trust in authorities, fragile health systems, coupled with the emergence of coronavirus 2019 (COVID-19), cholera, measles and the EVD outbreak recently reported in Équateur Province, as factors that might jeopardize the country’s ability to rapidly detect and respond to the re-emergence of EVD cases in North Kivu, Ituri and South Kivu Provinces.

As per the advice of the International Health Regulations (2005) Emergency Committee, which was convened on 26 June 2020, the WHO Director-General declared that the EVD outbreak in North Kivu, Ituri and South Kivu Provinces no longer constitutes a Public Health Emergency of International Concern. For further information, please see the Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 26 June 2020

WHO advice

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

• Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or non-human primates 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.
• Reducing the risk of human-to-human transmission from direct or close contact with people with EVD symptoms, particularly with their bodily fluids. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients. Regular hand washing is required after visiting patients in a hospital, as well as after taking care of patients at home.
• Strengthen infection prevention and control practices in healthcare facilities: standard precautions should be applied to all patients cared for in a health care facility irrespective of their infection status. A particular focus is required for traditional practitioners.
• Reducing the risk of possible sexual transmission, based on further analysis of ongoing research and consideration by the WHO Advisory Group on the Ebola Virus Disease Response, WHO recommends that male survivors of EVD practice safe sex and hygiene for 12 months from onset of symptoms or until their semen tests negative twice for Ebola virus. Contact with body fluids should be avoided and washing with soap and water is recommended. WHO does not recommend isolation of male or female convalescent patients whose blood has tested negative for the Ebola virus.
• Continue training and re-training of health workers on infection prevention and control measures, early detection, isolation and treatment of EVD suspected cases.

WHO continues to advise against any restriction of travel and trade to the Democratic Republic of the Congo in relation to this event based on the currently available information. Further information is available in the WHO recommendations for international traffic related to the Ebola Virus Disease outbreak in the Democratic Republic of the Congo.

For more information, please see: