The current outbreak in Congo is now the second biggest in history and has so far infected at least 450 people and killed at least 270 of them, according to WHO and Congo health officials. Responding to the Ebola virus disease (EVD) outbreak in north-eastern parts of the Democratic Republic of the Congo continues to be a multifaceted challenge. By utilising proven public health measures (contact tracing, engaging communities) as well as new tools at hand (vaccine and therapeutics), WHO remains confident the outbreak can be contained and brought to an end.
During the reporting period (28 November – 4 December 2018), 35 new cases were reported from nine health zones in North Kivu and Ituri provinces: Beni (8), Komanda (eight), Katwa (eight), Vuhovi (three), Kalunguta (two), Butembo (two), Mabalako (two), Masereka (one), and Mutwanga (one). Recent cases in Komanda and Mabalako health zones follow an extended period (exceeding two incubation periods) without detection of new cases; highlighting the risk of reintroduction of the virus, and the need to maintain enhanced surveillance. Cases in the Komanda originated from an infection of a mother and her children in Beni. While insecurity in Komanda will challenge the response activities, control measures including contact tracing and vaccination were initiated soon after the detection of cases.
Public and private health centres with inadequate infection prevention and control (IPC) practices continue to be major source of amplification of the outbreak. During the reporting period, two new infections were reported in health workers, and at least one new case likely acquired EVD from an infected health worker during a routine visit. Altogether, 44 health workers (41 nurses and three doctors) have been infected to date, of which 59% (26) were female. As of the reporting period, 21 additional survivors were discharged from Ebola treatment centres (ETCs) in Beni (12) and Butembo (nine) and reintegrated into their communities. A total of 142 patients have recovered to date.
As of 4 December, 458 EVD cases (410 confirmed and 48 probable), including 271 deaths, have been reported in 11 health zones in North Kivu Province and three health zones in Ituri Province (Figure 1). The epidemiological curve (Figure 2) of the outbreak shows two distinct phases. The first phase was centred in Mangina and was largely brought under control within a month. The second wave, dispersed across many areas, has continued for over two months with approximately five new cases per day. Given the expected delays in case detection and reporting in the recent weeks, overall trends in weekly case incidence must be interpreted cautiously.
The risk of the outbreak spreading to other provinces in the Democratic Republic of the Congo, as well as to neighbouring countries, remains very high. Over the course of the past week, alerts have been reported from several provinces within the Democratic Republic of the Congo, South Sudan and Uganda; EVD has been ruled out for all alerts to date. Ebola virus disease in women and children
Concerns have been raised regarding the disproportionate number of women and children infected during this outbreak (Figure 3). To date, females accounted for 62% (280/450) of overall cases where sex was reported. Of all female cases, 83% (230/277) were aged ≥15 years. Of these women, at least 18 were pregnant, and an additional seven were breastfeeding or recently delivered at the time of infection. There have been 27 cases among infants less than one year of age, with 70% (19) of these being boys, and 21 fatalities (age-specific case fatality of 78%). There were also nine cases in infants aged less than one month. Children less than 15 years of age accounted for 24% (106/447) of cases.
There are likely a multitude of factors contributing towards this disproportionate disease burden observed in women and children. These include: exposure within formal and informal health facilities, involvement in traditional burial practices, transmission within family groups (including transmission between mothers caring for children), differences in health seeking behaviour, as well as the impact of ongoing conflict on the underlying population structure in affected areas. Among those with available information, commonly identified risk factors reported by cases include: having contact to a known case (224/320, 70%), having attended funerals (121/299, 40%) and having visited/admitted to a health facility before onset of EVD (46/139, 33%). Of note, 46% of female cases (84/181) reported having attended funerals, in contrast to 31% of male cases (37/118).
A concurrent increase in cases of malaria and the inadequate accompanying IPC in health settings are also likely to be contributory to the high rates of EVD among children. The recent conclusion of a four-day malaria control campaign in Beni on 2 December aimed at preventing further malaria deaths, as well as lessen the burden on health centres in order to address this potential source of transmission. The MoH, WHO, are actively working with UNICEF and other partners to address the increased risks observed in women (including pregnant or breastfeeding women) and young children, and further strengthen measures to prevent and manage infections in these groups.
