Ebola Lessons from DRC’s Past Outbreak Tested by New Strain

The epicentre of an Ebola outbreak often smells of chlorine. At hospitals and government buildings in Butembo, in North Kivu province of the Democratic Republic of the Congo (DRC), surfaces are sprayed with chlorine and hands washed in a 0.05% solution that can kill the virus in 60 seconds. Hand-held infrared thermometers check temperatures at airports and border crossings; any sign of fever halts travel. Contact tracing teams fan out across the countryside.

From 2018 to 2020, Butembo was the scene of the largest Ebola outbreak ever seen in the DRC. The crisis was not limited to the virus’s devastation but was amplified by the social, political and economic pressures of a region in conflict.

Now, as global health officials confront a serious new Ebola outbreak in the DRC—one that has surprised the World Health Organization (WHO) with its speed and scale—the question is what lessons have been learned from previous epidemics.

Ebola, unlike Covid, is not an efficient spreader. Because it does not travel through the air, it requires physical contact with bodily fluids, including blood and vomit, to transmit. That makes the virus especially dangerous for health workers, who need full-body personal protective equipment (PPE) and rigorous disinfection procedures. Social practices such as physical contact with the dead and dying in impoverished rural communities accelerated spread in eastern Kivu and Ituri province.

A second crucial factor that hampered the response six years ago was the historical political tension between the central government in Kinshasa and the Nande ethnic group in eastern Kivu, set against the backdrop of an insurgency. The epidemic was exploited by forces in political elections who claimed Ebola did not exist or was brought in by outsiders. This led to armed attacks—some deadly—on health workers and Ebola clinics, including an incident in Butembo witnessed by a Guardian reporter.

While a new vaccination programme was available in that outbreak, there is currently no vaccine for the virus strain in the current Ituri outbreak, which is caused by the Bundibugyo variant of Ebola. This is the least known of the three forms of the disease, having caused only two previous outbreaks in 2007 and 2012, with a fatality rate of about 30% of those infected.

Another reason for concern in the current outbreak is the possibility that cases may have been missed early on, allowing silent transmission. A key difference from previous large outbreaks in West and Central Africa is the speed with which the WHO this time declared a Public Health Emergency of International Concern (PHEIC). In 2018, the WHO was criticised for delaying four months before declaring a PHEIC. In the current outbreak, a PHEIC was declared within 48 hours, and WHO chief Tedros Adhanom Ghebreyesus said he was so concerned he decided to act without a meeting of the emergency committee.

Nevertheless, Daniela Manno, a clinical epidemiologist at the London School of Hygiene and Tropical Medicine, warns the current Ituri outbreak shares several complicating factors with the 2018–2020 epidemic. First, the number of suspected cases reported before confirmation suggests transmission may have been occurring for several weeks before the outbreak was officially identified. Second, the outbreak is occurring in an area affected by insecurity, population displacement and high population mobility, complicating surveillance, contact tracing and health service delivery. A previous Ebola outbreak affecting North Kivu and Ituri provinces lasted almost two years, with insecurity and community mistrust constantly disrupting tracing, vaccination and response activities.

Anne Cori, associate professor of infectious disease modelling at Imperial College London, said the spread of the disease across international borders may have influenced the decision to declare a public health emergency of international concern quickly. The final PHEIC for an Ebola outbreak was declared in July 2019 during the 2018–2020 epidemic in DRC’s North Kivu province, a year after the outbreak began, after it spread to the urban area of Goma, threatening international spread to neighbouring Rwanda. The current outbreak has confirmed cases in both the DRC and Uganda, which likely influenced the PHEIC declaration, as its focus is the international nature of the threat.

However, Daniela Manno also stressed that the DRC has extensive experience in responding to Ebola outbreaks, and its epidemic response capacity is now significantly stronger than a decade ago.