Questions remain over Ebola patient who travelled across three nations undetected

A Kenyan businessman was able to spend time in one of the regions worst-affected by Ebola, then travel to two more countries before his illness was identified.

The 40-year-old – who was only diagnosed with the deadly infectious disease after arriving seriously ill at a Nairobi hospital – became Kenya’s first confirmed case. He died two days later on 5 October.

That his infection went undetected at multiple health facilities in the Democratic Republic of Congo and two airport health screenings in Uganda and Kenya has raised serious questions about these nations’ biosecurity during a significant outbreak.

More than 4,000 people have died from Ebola in DR Congo this year, in what is the second most deadly known outbreak to date.

Africa CDC, the continent’s leading public health agency, has now reconstructed the Kenyan patient’s movements across nearly six weeks, revealing several missed opportunities to detect his infection and potentially preventing dozens of people from coming into contact with the deadly virus.

DR Congo

The account, presented by the agency’s emergency director, Dr Wessam Mankoula, provides the clearest picture yet of how the businessman travelled thousands of kilometres while growing increasingly unwell.

The man, whose identity has not been made public, had lived in DR Congo for seven years and had travelled across three of its provinces on business.

Exactly when or where he contracted Ebola remains unclear – but it was present in all three provinces he went through by early October, according to the World Health Organization (WHO).

The man had spent much of late August and early September in the province of Bas-Uélé, visiting towns including Buta, Aketi and Likati.

The WHO confirmed an Ebola case in Buta in August, prior to his visit, though there is no evidence he contracted the virus there.

His symptoms first emerged around 15 September. He was given antibiotics and sent home.

Two days later, he was admitted to the Tongo Etandi Health Centre in Bondo, where he remained until 19 September.

Despite suffering from fever and a rash, he was diagnosed with a skin infection.

Without an Ebola test being taken at any point during his travels, it is hard to say exactly when he contracted the virus. Those symptoms are consistent with the early stages of the disease, but also other infections common to the region, such as malaria.

On 20 September, he flew to Kisangani, a city with a population of about 1.5 million people on the Congo River, where he spent more than 10 days seeking medical care.

We do not know which hospitals or clinics treated him there, nor what medications they gave him. Kisangani is the capital of Tshopo province which has only recorded 51 Ebola cases.

Uganda

However, on 1 October, more than two weeks after first becoming ill, the businessman boarded another domestic flight to Beni, before continuing his journey to Kasindi, a busy border town.

Both Beni and Kasindi are in North Kivu, which has recorded 1,755 Ebola infections and more than 1,000 deaths, making it one of the Congolese provinces worst-hit by the disease.

But he did not stay there long, crossing into Uganda later that day.

Uganda imposed restrictions on movement across its border with DR Congo shortly after the outbreak began in May.

The country has experience containing several Ebola outbreaks, including through surveillance, contact tracing and the isolation of suspected cases. It has had some cases this year – mostly among people travelling from DR Congo – but was declared free of the disease in August.

But the border between the two nations stretches for hundreds of kilometres through remote terrain, making it difficult to police.

It remains unclear whether the businessman passed through an official health checkpoint when he crossed the border.

Once he had, he travelled by road to the capital, Kampala, and then Entebbe International Airport, where he boarded a flight to Nairobi on 3 October.

Ugandan officials said his temperature was normal when he passed through airport screening. Health experts say his case highlights the limitations of relying on temperature checks and self-declarations.

Mankoula said investigators were examining whether the man’s medication could have suppressed his temperature. He may have also not had a fever when he passed through the checks.

Kenya

Similarly, he was not flagged as a suspected Ebola patient when he reached Nairobi’s Jomo Kenyatta International Airport, where a relative collected him and drove him directly to Nairobi Hospital, a private medical facility in the Kenyan capital.

By then, he was suffering from fever, chills, muscle pain, a sore throat and bleeding.

Laboratory tests confirmed that he had contracted the Bundibugyo species of Ebola – the same one responsible for the outbreak in DR Congo.

He was placed in isolation while his condition deteriorated. He died on 5 October and was buried the following day under strict infection-control measures.

The Kenyan government says it has now identified 66 people who may have been in contact with him after he arrived there. The WHO says the number is likely to rise as contact-tracing in Uganda and DR Congo continues.

The quarantine arrangements have also raised concerns among some healthcare workers, amid questions about how the patient was handled at Nairobi Hospital.

Kenya’s health ministry says more than 652,000 travellers have been screened and nearly 5,000 healthcare workers trained to deal with Ebola, with five facilities designated to handle cases.

Ebola spreads through direct contact with the bodily fluids of an infected person who has developed symptoms, or through contaminated materials.

Its incubation period ranges from two to 21 days, meaning someone exposed to the virus may not become ill until several weeks later.

CDC advice

Mankoula urged travellers experiencing symptoms of Ebola to report them, saying early medical attention could improve their chances of survival.

“When you reveal any Ebola-related symptoms early, you’re not only preventing the virus spreading to other countries but you’re also protecting yourself first,” he said.

The WHO has warned that stigma surrounding Ebola could discourage people from reporting symptoms or seeking medical care, potentially allowing the virus to spread undetected.

The agency says it is stepping up efforts to encourage this by reducing fear and misinformation about the disease – something that is a big problem in DR Congo, where some health workers have been attacked by people who claim Ebola doesn’t exist.