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Congo confirms first urban Ebola case, raising possibility of ‘explosive increase in cases’

Health workers don protective equipment as they prepare to treat suspected Ebola patients in Bikoro — the epicenter of the latest Ebola outbreak in Congo — last week. (Mark Naftalin/AFP/Getty Images/UNICEF)

NAIROBI — Congo has confirmed a case of Ebola in Mbandaka, a city of 1.2 million, marking the first urban case in the latest outbreak, which is now the most serious since the epidemic that raged across West Africa between 2014 and 2016.

Ebola is much harder to contain in urban areas, so this development compounds the risk of contagion. The World Health Organization’s lead response official called the new confirmed case “a game changer.”

Previously, confirmed cases had been limited to a remote area more than 100 miles south of Mbandaka, in the rain forest of Congo’s Equateur province. The new, urban case was among 14 confirmed cases of the current outbreak, according to Congo Health Ministry figures reported by the Associated Press; 21 others were probable and 10 others were suspected, bringing the total of potential cases to 45. The death toll stood at 25. 

Here's how the virus spreads and how contact tracing works to stop outbreaks. (Video: Gillian Brockell/The Washington Post)

“This is a major development in the outbreak,” said Peter Salama, the WHO’s deputy director general of emergency preparedness and response. “We have urban Ebola, which is a very different animal from rural Ebola. The potential for an explosive increase in cases is now there.”

Given the signs of a worsening outbreak, the Centers for Disease Control and Prevention in Atlanta has assembled a team that is ready to deploy to Congo once the WHO finishes assessing its needs and the logistical challenges of transporting experts into the remote outbreak locations.

“Depending on the need, we may be preparing for a longer term,” said CDC epidemiologist Pierre Rollin, an Ebola expert who was in West Africa during the 2014 epidemic. The agency has multiple teams preparing, with each shift in the Congo expected to last four to six weeks.

The densely populated port city of Mbandaka lies on the eastern bank of the Congo River, Africa’s second-longest after the Nile. Tens of millions of people live along the river, and the capitals of Congo, the Central African Republic and Congo Republic lie along it and its tributaries. Health officials are increasingly worried that the virus could be conveyed quickly over long distances by boat between the towns that dot the river’s banks. 

Ebola is notoriously hard to contain, though recent outbreaks in Congo have been managed swiftly by the WHO and Congolese health officials, gaining the government there a reputation as one of the continent’s most prepared. Ebola is endemic in Congo, and this is the ninth outbreak of the disease there since the 1970s. Last May, a small outbreak resulted in five confirmed cases and four deaths in a province neighboring Equateur. 

New Ebola outbreak declared in Congo

The outbreak in West Africa that started in 2014 was the worst ever recorded. It reached epidemic proportions, infecting more than 28,000 and killing more than 11,000. A concurrent but much smaller and unrelated Ebola outbreak took place in Congo in 2014 as well. The WHO was accused of responding slowly in 2014, and the organization has taken pains to ensure it is acting more quickly — and seen as doing so — this time. The organization’s head, Tedros Ghebreyesus, visited the affected area earlier this week. 

The disease causes internal bleeding and spreads rapidly through contact with small amounts of bodily fluid. Its early symptoms are not obvious, and the worst effects may take weeks to show. It is often transmitted to humans through the consumption of contaminated meat, but it can also be acquired through any kind of close contact with an infected animal. 

The international response to the current Congo outbreak has been substantial and is expected to grow in size and urgency after the announcement of a confirmed urban case. On Wednesday, the WHO delivered 4,000 injections of an experimental vaccine with proven efficacy in recent trials, and more batches are expected soon. 

Persistent rain and lack of roads has hampered the effort to contain the outbreak. Before Thursday, cases had been confirmed only in Bikoro, a small town whose health clinic has “limited functionality,” according to the WHO. Helicopter and motorcycle are the only ways to reach Bikoro from Mbandaka, but an airstrip has been rapidly cleared for small planes to land with supplies. 

Part of the difficulty in deploying the vaccine is that it must be transported and stored at between minus-60 and minus-80 degrees Fahrenheit, which requires powerful refrigerators. The vaccine, produced by the pharmaceutical giant Merck, is not yet licensed, although the WHO has cleared it for “compassionate use.” Its deployment is being financed by Gavi, the Vaccine Alliance, based in Geneva.

“The remote location of the outbreak hampers both the information about the outbreak and interventions to control it,” said Cyrus Shahpar, director of epidemic prevention at Resolve to Save Lives, a New York-based organization. “This is evidenced by the fact that the current outbreak probably started in early April, but it was not officially declared until May 8.”

The only way to stop the outbreak is to seek out all the contacts of the infected person, known as contact tracing, then isolate the infected individuals and provide proper burial for those who die, the CDC’s Rollin said. Much of the transmission during the West Africa epidemic was from unsafe burial practices. The rituals around traditional burial practices are an issue that “always draws a lot of attention and reticence and complication,” he said.

When someone dies of Ebola, they are enormously infectious after death because their bodies are full of a huge number of virus particles.

The International Federation of the Red Cross and Red Crescent Societies (IFRC) said the first suspected victim was a police officer who died in a health center in the village of Ikoki-Impenge, near Bikoro. After his funeral, 11 family members got sick and seven died. All seven had attended the funeral or cared for the man while he was sick. 

More than 110 Red Cross volunteers in Bikoro and Mbandaka are working to alert surrounding communities and disinfect houses where cases have been suspected. An IFRC spokeswoman said the organization is “kick-starting its response” using stocks of medicine, disinfectant and informational posters left over from last year’s outbreak.

A total of 514 people who may have been in contact with infected people have been notified by national health authorities and are being monitored and may be candidates for the first round of vaccines. Vaccines can only slow the disease’s spread, not stop it. Rapid detection of symptoms, immediate isolation of suspected cases and safe burial for those who succumb to the disease are paramount in ending an outbreak.

Several tons of supplies were en route to the region, according to a statement from Doctors Without Borders, including “protection and disinfection kits containing isolation items such as protective clothing, gloves and boots; logistical and hygiene kits containing items such as plastic sheets, chlorine spray kits and water treatment kits; and palliative drugs to treat Ebola symptoms, such as strong painkillers, anti-anxiety drugs and antibiotics.”

Lena H. Sun in Washington contributed to this report.

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