On 8 May 2018, in accordance with the provisions of the International Health Regulations, the Ministry of Health of the Democratic Republic of the Congo has notified WHO of two suspected cases of Ebola virus disease (EVD) in the health zone of Bikoro in the province of Equateur. A rapid and immediate assessment of public health risks was conducted and it identified five active cases, two of which were hospitalized at Bikoro General Hospital and three at Ikoko Impenge Health Center. Samples were taken from the five cases and sent for analysis to the National Institute of Biomedical Research (INRB) of Kinshasa on Sunday, 6 May 2018. The reverse transcription polymerase chain reaction RT-PCR analysis revealed two samples positive for EVD serotype Zaire.
Since this declaration, two other health zones have reported cases (Iboko and Wangata in the city of Mbandaka), the affected areas border the neighboring Republic of Congo. This is the ninth Ebola outbreak in the Democratic Republic of the Congo, but the first in the separate province of Equateur. Having started in a rural area, the epidemic reached an urban area with the notification of the first cases in Mbandaka on 11 May 2018, and then the confirmation of a case dated 15 May 2018.
Up to the 25 May 2018, a total of 54 cases and 25 deaths have been reported since the official notification of the outbreak by the Ministry of Health in accordance with the International Health Regulations, the case fatality rate is 46.3%. Of these cases, 35 are confirmed, 13 are probable and 6 are suspect.
The affected area is remote, with limited communication and poor transport infrastructure. The Equateur Province has a population of approximately 2.5 million people spread over an area of approximately 103 902 km2. Mbandaka, the capital of the Equateur Province, is an important port city with over 1.5 million inhabitants.
Mbandaka is reachable by plane from Kinshasa. Onward ground travel to Bikoro requires at least three hours, on a motorbike, and 12 hours by car. Since 8 May, regular helicopter communication has been established between Mbandaka and Bikoro.
National and local authorities and partners have moved quickly to respond to the outbreak. Rapid response teams from the national and provincial levels have been deployed to Bikoro to carry out case investigation, trace contacts, put in place case management and other control measures. In addition, a roadmap regrouping certain emergency actions was elaborated. These include: the activation of the national coordinating committee for outbreak response; the official declaration of the outbreak by the Ministry of Health as a public health emergency (announced on 8 May 2018); the deployment of a multisectoral field team and a mobile field laboratory; the inventory of available intervention kits; exit screening and the development of a national response plan.
By 10 May 2018, Ministry of Health and partners have been deployed to Bikoro, Mbandaka and Kinshasa, and additional surge is rapidly scaling up. Operational hubs for the EVD response will be established in Mbandaka and the affected health zones with operational and technical support provided from Kinshasa.
Surveillance activities including contact tracing are in place in all affected areas and Ebola treatment centres are being established.
Infection prevention and control measures are strengthened in major hospitals and other health facilities and social mobilization activities are underway. Points of Entry (PoE) surveillance and other measures are being put in place at major airports, water and road routes.
RISK OF SPREAD
Information about the extent of the outbreak remains limited and investigations are ongoing. Currently, WHO considers the public health risk to be very high at the national level due to the serious nature of the disease, insufficient epidemiological information and the delay in the detection of initial cases, which makes it difficult to assess the magnitude and geographical extent of the outbreak.
The confirmed case in Mbandaka, a large urban centre located on major national and international river, with road and air transport axes increases the risk both of local propagation and further spread within the Democratic Republic of the Congo and to neighbouring countries. The risk at the regional level is therefore considered high. At the global level, the risk is currently considered low.
As further information becomes available, the risk assessment will be reviewed.
The IHR Emergency Committee met on Friday 18 May 2018, which concluded that the conditions for a Public Health Emergency of International Concern (PHEIC) had not been met.
The risk assessment will be re-evaluated by the three levels of WHO according to the evolution of the situation and the available information. If the outbreak expands significantly, or if there is international spread, the Emergency Committee will be reconvened Based on an initial assessment of the area there is an approximate movement of over 1000 people per day by river, road and air at the major points of entry connected to affected Bikoro health zone.
EVD is a serious, often fatal disease in humans. The virus is transmitted to humans from wild animals and spreads to populations through human-to-human transmission. The average case fatality rate is about 50%. During previous outbreaks, rates ranged from 25% to 90%.
The first Ebola outbreak was reported in the Democratic Republic of the Congo in Yambuku in Equateur Province in 1976. Another isolated case occurred in June 1977 in a 9-year-old girl living in Tandala, located 325 km from Yambuku. In 1995, the epidemic reappeared in the city of Kikwit and surrounding areas in Bandundu province. It was of a greater magnitude, characterized by high incidence and lethality, in a densely populated city where environmental conditions were conducive for sustained transmission. Since then, several other epidemics have occurred in the health zone of Mweka, in Kasai Oriental Province, the health zone of Isiro, in Orientale Province, and the health zone of Boende in the new province of Tshuapa (Ex-Equateur Province) as shown in the table below