First Ebola death in Kenya raises fears of wider outbreak in Africa

Kenya has reported its first death from a dangerous Ebola strain that has been spreading widely, originating in the Democratic Republic of Congo earlier this year. The patient had lived in DR Congo for many years, fell ill there and was treated before travelling to Uganda and flying on to Nairobi.

According to the World Health Organization (WHO), the Bundibugyo Ebola strain (BDBV) was first identified in Uganda in 2007. The current outbreak in DR Congo has killed at least 4,148 of 8,300 cases. The virus also crossed the border into Uganda, with about 20 cases before that country declared itself Ebola-free in July.

However, the death in Kenya raises many questions: the patient travelled overland from DR Congo to Uganda before flying to Nairobi, fuelling doubts about Uganda's "Ebola-free" status, about Kenya's entry screening procedures and about whether the outbreak has spread further than previously believed.

What is Ebola?

It is a severe, potentially fatal viral illness spread through contact with the bodily fluids of infected people or wild animals, including fluid left on surfaces. People can also contract the disease by eating contaminated meat.

Central, West and East Africa have recorded numerous outbreaks. The 2014-2016 West Africa outbreak killed at least 11,300 of 28,600 cases and drove the development of vaccines. That was the Zaire strain, for which a vaccine now exists.

The strain behind the current outbreak is Bundibugyo, believed to have originated in a new animal-to-human transmission that then spread between people, rather than from variants linked to previous outbreaks. There is currently no vaccine for the Bundibugyo strain.

Symptoms can appear from two to 21 days after infection, beginning suddenly with flu-like signs such as high fever, fatigue and headache; the disease can lead to internal and external bleeding, liver failure, kidney failure and multiple organ failure.

How did the case reach Kenya?

Kenyan Health Minister Aden Duale said the patient (who has not been named) first fell ill a month ago in DR Congo, where the person had lived for many years, and was treated there. On 2 October, the patient travelled overland to Uganda's capital Kampala via Beni, then flew to Nairobi, arriving the following day.

At the Kenyan airport, the patient was taken to hospital by a relative and a friend, quickly isolated and tested positive. Despite receiving care, the patient died on Monday and was buried on Tuesday in line with the country's Ebola prevention procedures.

Kenyan health officials have so far identified 28 potential contacts, including relatives and health workers who cared for the patient. Authorities are also separately monitoring 23 passengers and four crew members, "with appropriate measures being taken to monitor and quarantine those assessed to be at risk", according to the WHO.

Why did the patient pass screening in both Uganda and Kenya?

Passengers arriving in, departing from or transiting Uganda and Kenya must undergo multiple temperature checks at airports and fill in at least two electronic forms designed to detect the risk of exposure to the virus in DR Congo. Yet the patient in this case was not detected.

Ugandan government spokesman Alan Kasujja said Kampala was not at fault for the Kenyan patient contracting the virus, writing on X: "Leave Uganda out of this story. We do not have Ebola here."

In a statement on Tuesday, Uganda's Health Ministry said the person had a "normal temperature" when screened at Entebbe airport before departure. Kenyan officials said the patient may have taken medication to mask symptoms when checked at Nairobi airport. Investigations are continuing.

Richard Mugahi, a senior Ugandan health official, told Reuters: "We are trying to retrieve the electronic form this person should have filled in at Entebbe airport during the temperature scan to see what was declared. The form includes questions about recent health issues and whether the passenger had recently been in DR Congo. We are also reviewing airport security cameras to identify the driver who brought this person to the airport, in order to trace all contacts there."

Professor Wolfgang Preiser, head of medical virology at Stellenbosch University in South Africa, said the tracing system "appears to have worked as it did in Uganda", with the diagnosis made quickly once the patient sought medical care in Kenya. He said tracing back the course of events at the stops along the journey would be very useful and that countries needed to learn lessons.

He cited an example from a previous Ebola outbreak in West Africa, when a British nurse contracted the disease on her way home and reported at a health checkpoint at Heathrow, but was still allowed to continue to her destination and was diagnosed with Ebola there. The lesson, he said, is that "even cooperative passengers and good systems can slip through the net".

Where has Ebola spread?

Since it began in Ituri province in northeastern DR Congo, this year's outbreak has spread to seven provinces in the north and east of the country. The outbreak was officially declared in DR Congo in May.

Weak health infrastructure, the remoteness of eastern DR Congo and conflict with armed groups near the borders with South Sudan, Uganda and Rwanda have hampered a rapid and effective response. The fight against the outbreak has been further complicated by strikes by unpaid health workers, misinformation and cultural practices, including open-casket funerals for some early victims of the virus, which increased the risk of infection.

The United Nations said last week that a camp affected by Ebola, which has a transit centre for infected patients, was burned by soldiers searching for weapons on the outskirts of Bunia, the capital of Ituri province and the epicentre of the outbreak. The incident forced 19,000 people to leave the camp.

The outbreak also spread to Uganda, where 20 people from DR Congo were treated before the country declared itself Ebola-free in July. More recently, controlling the outbreak within DR Congo's territory has become increasingly difficult.

On Monday, Médecins Sans Frontières (MSF) warned of an "alarming rise" in cases in North Kivu province in eastern DR Congo, which borders Uganda and now accounts for 40 percent of new cases. "It's like fighting a forest fire," said Stephanie Hoffmann, coordinator at MSF's Ebola treatment centre in the city of Butembo. "Multiple outbreaks are developing at the same time, with different intensity and in different locations."

According to MSF, about 2 million people live in and around Butembo but there are only four Ebola treatment centres, two of which opened recently. Patients often have to be transferred elsewhere, increasing the risk of infecting others.

What happens next?

The WHO is working with Kenyan authorities to trace contacts and step up checks on incoming passengers. Mohamed Janabi, the WHO's Africa regional director, said on Tuesday that "preparing for a health emergency gives us the advantage of staying ahead".

"Kenya has put in place important outbreak control measures. The priority now is to act quickly to detect any further cases before the virus has a chance to spread. We are supporting efforts to strengthen the response, and with fast, coordinated action we can stop the virus from taking hold and prevent a larger outbreak," Janabi said.

The agency also said it had shipped about 1,000 Ebola test kits and "1,000 personal protective equipment kits to high-risk counties in Kenya".

In June, Kenya's government allowed the United States to set up an Ebola quarantine facility at Laikipia Air Base, 193km from the capital Nairobi, to treat Americans infected in African countries before they travel to the US. The plan triggered a fierce backlash from local residents worried about infection, and a Kenyan court suspended it.

Overall, Professor Nachenga said strengthening border screening alone was not enough, and that there was also a need to "bolster the entire public health response system", including training frontline health workers, ensuring rapid diagnostic testing, promptly isolating suspected cases and tracing and monitoring contacts. "Kenya's detection of this case is an important opportunity to strengthen preparedness," he said.