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The Ebola outbreak in the Democratic Republic of Congo

The 2018-2020 Ebola crisis in the Democratic Republic of Congo (DRC) was the worst recorded in the country, and the second largest known outbreak of Ebola virus disease in the world.

In July 2019, the World Health Organization declared the outbreak to be a public health emergency of international concern (PHEIC). Despite a huge international response to control the epidemic, it continued to spread throughout DRC’s Ituri and North Kivu provinces until April 2020. 

As of 25 June, the Ebola outbreak in the Democratic Republic of Congo has been declared over by Congolese authorities, with no new confirmed cases in the past 57 days.
During the outbreak, 3,470 cases were reported, with 2,287 deaths. 1,171 people survived.
More than 320,000 people were vaccinated during the response, including frontline workers, contacts of confirmed patients and vulnerable groups.
MSF lab technicians look through at two nurses in personal protection equipment in the high-risk zone of the laboratory in an MSF Ebola treatment centre, DRC, August 2018. © Carl Theunis / MSF

1 August 2018 to 25 June 2020: 2,287 people killed 

From the declaration of the Ebola outbreak in DRC on 1 August 2018, Ebola infected more than 3,470 people. As of 25 June, 2,287 of these people had died. There were 1,171 survivors. 

During the first eight months of the epidemic, until March 2019, more than 1,000 cases of Ebola were reported in the region. This number doubled between April and June 2019, with a further 1,000 new cases reported in three months, and remained high between early June and the beginning of August, averaging between 75 and 100 each week. Cases were found across 28 health zones in Ituri and North Kivu provinces, which share 47 health zones in total. A third province, South Kivu, also recorded cases in Mwenga health zone.

An MSF health worker in protective clothing carries a child suspected of having Ebola in an MSF ETC in Liberia on 5 October 2014. The girl and her mother, showing symptoms of the deadly disease, were awaiting test results for the virus. © John Moore / MSF

How did the Ebola outbreak in DRC start? 

On 30 July 2018, Médecins Sans Frontières (MSF) received an alert about suspected cases of Ebola near Mangina, a small town of 40,000 people in North Kivu province. An MSF team, along with local representatives of the Ministry of Health, arrived in Mangina the following day to investigate the alert.

The Ministry of Health officially declared the outbreak—the tenth Ebola epidemic to occur in the DRC—on 1 August 2018. Subsequent investigations have suggested the outbreak likely began months earlier.

The outbreak was confirmed to be of the Zaire Ebola virus, the deadliest strain of the Ebola disease and the same one that affected people in West Africa during the outbreak of 2014 to 2016. The strain is different to the smaller epidemic that broke out in the DRC’s Equateur province earlier in 2018, which killed 14 people.

Once the outbreak was declared, MSF immediately began responding alongside the Ministry of Health to care for sick people and prevent the virus from spreading.

Our teams opened an isolation centre, and then an Ebola treatment centre (ETC), in Mangina, and began offering therapeutic drugs to eligible patients in the treatment centre from 24 August 2018.

From Mangina, the epidemic moved south to the larger city of Beni, with a population of 400,000 people, then to the trading hub of Butembo. Later in 2018 the outbreak reached Katwa and Kanya, and spread north to neighbouring Ituri province. 

What is Ebola?
Ebola is a highly contagious viral disease with an incubation period of up to 21 days. The disease is transmitted from person to person via bodily fluids such as blood, sweat, saliva or tears. Those diagnosed with the Ebola virus suffer severe diarrhoea, vomiting and bleeding, which can lead to severe dehydration, and ultimately organ failure and death.

The difficulties in controlling Ebola 

Efforts to control this outbreak were hampered by the realities of fighting an epidemic in a conflict zone. The epicentre of the outbreak was located in North Kivu province, a region of around seven million inhabitants that has been affected by conflict for more than 25 years. Fighting between armed groups is common, and widespread violence has caused many people to flee their homes.

The displacement of many people, as well as trade, movement and human trafficking across the border with Uganda, means there is a high mobility of people in this region of the country – which adds to the ease with which Ebola can spread.

The insecurity prevented healthcare workers from accessing people in some regions. There were multiple attacks on health facilities during the Ebola outbreak, including incidents which threatened the lives of patients, their families and healthcare workers, and forced MSF teams to withdraw from providing care in some areas.

In July 2019, two non-MSF healthcare workers were killed by unidentified attackers in Beni. In September 2019, in Lwemba, Ituri province, a section of the health centre and around 30 houses were burnt to the ground after a local health worker died from Ebola.

Partly feeding this violence was a lack of trust of the Ebola response within the local community. A local staff member with MSF describes the anger felt by much of the population:

“My husband was killed in a massacre in Beni. At that time, all I wanted was some organisation to come protect us from the killings, but no international organisation came. I have had three children die of malaria. No international organisation has ever come to work in this area to make sure we have access to health care or clean water. But now Ebola arrives, and all the organisations come because Ebola gives them money. If you cared about us, you would ask us our priorities. My priority is security and making sure my children don't die from malaria or diarrhoea. My priority is not Ebola, that is your priority”.  While mistrust remains, many people refuse to seek care at treatment centres when they are sick, and others refuse the vaccine. 

Medical facilities, personnel and patients continued to be the targets of violent attacks throughout the outbreak, with an increase in attacks and violence over November and December 2019 as anti-Ebola response sentiment resurfaced. There were more than 300 attacks on Ebola health workers recorded in 2019, leaving six dead and 70 wounded.

Kayugho outside her house in Masingira,DRC. © Caroline Frechard / MSF 

How was the Ebola outbreak controlled?

This Ebola outbreak was different to previous outbreaks, as we had access to new tools to contain the virus—including the vaccine, rVSV-ZEBOV, which has been indicated to be effective in protecting both people who are first and second-degree contacts of confirmed Ebola patients and workers on the frontline of the response.

Developmental treatments were also available for patients admitted to ETCs and confirmed to have the virus, and teams were able to provide a higher level of supportive care than previously. But the situation was still bleak—during the outbreak, there was a 67 per cent case fatality rate.

This outbreak saw many sick people who weren't coming to a health facility for care. ‘Community deaths’—deaths of people who died from the virus before being identified, diagnosed and admitted for treatment—represent over a third of the total number of identified cases of Ebola. 

Identification and follow-up of contacts was a challenge, with a delay of around six days between the onset of symptoms of Ebola and the admission of the person to an ETC. Only around half of the cases recorded were been known to be contacts of other confirmed or probable Ebola patients.  

What is the response to the Ebola outbreak in DRC? 

The DRC Ministry of Health led the outbreak response, with support from the United Nations World Health Organization (WHO). 

MSF worked alongside the Ministry of Health to respond to the outbreak since the declaration of the epidemic on 1 August 2018. As of October 2019, we had more than 820 staff working in the DRC responding to the Ebola outbreak. As the situation deteriorated, MSF identified a need to shift the response to the outbreak, with an aim to ensure affected communities are better involved in the response. 

MSF noted that the intervention needed to be better adapted to the expectations of the local communities, giving people more choices about their own healthcare, and with better integration of Ebola response activities into the local healthcare system. Thi integration would help identify suspected cases earlier on, and could encourage people to seek help more promptly at healthcare posts, clinics and hospitals that they knew and trusted.

Trish Newport, deputy manager of MSF’s Ebola programs in the DRC, notes: "We determined that we needed to work more closely with the communities, and that we needed to listen to and respond to the health priorities of the affected communities." 

MSF’s response to the Ebola outbreak in DRC

MSF restarted providing care for confirmed Ebola patients in areas of active transmission—in Mambasa, Ituri province—in collaboration with the Ministry of Health.

MSF also treated people from the city of Goma with confirmed and suspect cases of Ebola in a ETC in Munigi, Nyiragongo health zone. The ETC scaled up to its full 72-bed capacity. We provided care to suspected cases, and also managed Transit Centres for possible Ebola patients. MSF supporting existing health structures including treating common illnesses. We improved water and sanitation, built transit units within existing facilities, and implemented and strengthened triage and infection prevention and control activities.

In addition, our teams reinforced health promotion and community engagement in the areas where we worked. We also worked towards strengthening the disease surveillance system in our regular project areas, including in Goma.

MSF operated the following activities in the affected provinces: 

Goma – North Kivu province
  • Provided medical care to suspected and confirmed cases in a 10-bed ETC.
  • Vaccinated participants who consented to take part in a clinical trial of a second investigative vaccine, Ad26.ZEBOV/MVA-BN-Filo from Johnson&Johnson.
  • Built a multi-epidemic 20-bed isolation and treatment centre (including ETC) at the Hospital Provincial du Nord-Kivu (HPNK). 
  • Supported access to primary/maternal healthcare to two health centres on the outskirts of Goma. The Ebola treatment centre of Munigi was converted into an isolation and treatment centre for suspect and confirmed COVID-19 patients.
  • Undertook health promotion and community engagement activities in Goma and the surrounds. 
  • Provided free primary healthcare for non-Ebola needs, including treating malaria, measles, diarrhoea and respiratory and urinary tract infections.
Beni – North Kivu province
  • Handed over to the Ministry of Health the management of a 20 bed Ebola treatment centre in Beni
  • Supported three health care facilitird on the axis to Kisangani including maternal and in patient care.
  • Supported access to free non-Ebola healthcare in multiple hospitals and health centres; providing primary and secondary healthcare (including emergencies and laboratory needs)
  • Improved water and sanitation needs.
  • Engaged in community and health promotion activities.
  • Performed sensitisation and capacity building on traditional practitioners on contagious diseases, including Ebola, in nine health centres.
Lubero – North Kivu province
  • Provided basic healthcare across three health centres.
  • Provided infection prevention and control measures in healthcare facilities.
  • Undertook community involvement and engagement in activities.
Mambasa – Ituri province
  • Provided support to three health facilities which provide primary and secondary care, maternal care and IPC
  • Undertook health promotion and community engagement activities in the communities. 
  • Provided support to seven health structures and facilities across Mambasa.
  • Managed the 8-bed ITC in the health centre of Binase and 11-bed ITC in the health centre of Salama, as well as primary health care support and IPC activities.
  • Managed the surveillance system in the Binase and Salama health zone.

Ebola: Control, Vaccination and Prevention 

During the outbreak in West Africa in 2014-2016, all that could be done for Ebola prevention was to isolate patients, provide supportive care, and administer patients largely ineffective drugs. At the time, there was no Ebola vaccination available that had proven effective in humans and was registered for use in patients.

With the vaccines and experimental drugs available to us in 2019, MSF teams were able to offer people the chance to protect themselves individually as well as access to promising treatments.

There are now two vaccines against Ebola, which are in clinical study phases and are not licenced. One, the rVSV-ZEBOV vaccine produced by Merck, has been used in a 'ring' vaccination strategy since the beginning of 2019 (read more about this below). As of 7 March 2020, more than 300,300 people have been given this vaccine.

A second vaccine produced by Johnson&Johnson Ad26.ZEBOV/MVA-BN-Filo, began to be used by MSF teams in mid-November, following an announcement by the Ministry of Health. 

While vaccination is a good measure designed to prevent the disease from spreading further, treatments alone won't end any Ebola outbreak. Responders still need to urgently find a way to cut transmission.

 

What is ‘ring’ vaccination? 

Ring vaccination entails vaccinating anyone who has been in contact with someone infected with Ebola (first-degree contacts) as well as all their contacts (second-degree contacts, or ‘contacts of contacts’).

Implementing this method is time-consuming and challenging, as there are problems with identifying each and every person’s individual contacts, and it’s not adapted to the insecurity affecting DRC. In addition, the number of people vaccinated is too small to contain the spread of the epidemic.

MSF's vaccination strategy incorporated more geographical targeting of areas of high transmission and facilitating access to vaccination for more people, including all those at the highest risk. There were nonetheless challenges posed by transporting vaccines that must be stored at a constant temperature of -60°C across large geographical areas.  

How MSF prevents the spread of Ebola

There are several key approaches that MSF emphasises to prevent Ebola transmission in communities and in health facilities.

Aside from vaccination of people at the highest risk of contracting the disease (including contacts of patients and healthcare workers), MSF is supporting local health centres and general hospitals to identify cases early, to prevent infected people from passing on the disease and to increase patients’ chance of survival. Preventing nosocomial infection (or facility-acquired cases) is also highly important, through effective hygiene and infection control. 

All health workers in ETCs and affected areas need to use Personal Protective Equipment or PPE, which has to be meticulously applied and removed in the correct order. Each layer removed must be decontaminated with chlorine spray. MSF also employs a no-touch policy and provides multiple handwashing points in its facilities with soap, water and chlorine.  

MSF’s role in the West Africa 2014-2016 Ebola outbreak 

MSF was the first organisation on the ground to care for patients during the 2014-2016 West Africa Ebola outbreak, and by the end of the outbreak MSF had treated one third of all confirmed Ebola cases.

From the very beginning of the epidemic, MSF responded in the worst affected countries – GuineaLiberia and Sierra Leone - through setting up ETCs as well as providing services such as psychological support, health promotion activities, surveillance and contact tracing. 

At its peak, MSF employed nearly 4,000 national staff and over 325 international staff to combat the epidemic across the three countries. The organisation admitted a total of 10,376 patients to its ETCs, of whom 5,226 turned out to be confirmed Ebola cases. In January 2016, Liberia celebrated 42 days without any new Ebola infections – effectively marking the end of the Ebola outbreak in West Africa.  

 

Read our Ebola Accountability Report about our response to the West African outbreak: