Ebola Watch: WHO warns children under five face higher risk in DRC Ebola outbreak

A doctor provides care to a patient with Ebola virus disease at the Rwampara Ebola Treatment Centre in Bunia, Ituri, on July 13, 2026. [AFP]

Children are accounting for a disproportionately large share of deaths in the Democratic Republic of Congo’s escalating Bundibugyo virus outbreak, with the youngest patients facing the highest risk of dying once infected.

The latest World Health Organisation data shows that children under five accounted for nearly one in three confirmed community deaths recorded during the most recent 21-day period.

Of 482 community deaths with age and sex information available between August 31 and September 20, 146 were children aged below five, 30.3 per cent of the total.

That is higher than the 24.7 per cent recorded among all 2,241 community deaths for which age and sex information was available during the outbreak.

WHO says the pattern warrants closer examination of how quickly young children are recognised as sick, referred and brought to appropriate care.

“The fatality rate in children under five years with the Bundibugyo virus continues to be higher than in older children and adults,” said Dr Daniel Youkee, WHO’s Ebola case management team lead.

“This is consistent with previous Ebola outbreaks, where evidence demonstrates that under-fives have a higher risk of mortality than other age groups,” he said.

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The warning is backed by the history of Ebola in the region.

During the 2018–2020 Ebola outbreak in eastern DRC, which infected 3,470 people and killed 2,287, children accounted for about 28 per cent of all cases. WHO analysis found that among children aged one to four, the case fatality ratio was 78 per cent, compared with 70 per cent among infants under one.

An earlier WHO analysis, based on data available in May 2019, found the case fatality rate among children under five at 77 per cent, compared with 57 per cent among people aged over five.

The same outbreak also demonstrated the enormous social cost of Ebola on children who survive infection but lose their caregivers.

By September 2020, UNICEF had recorded 2,571 children orphaned because of Ebola during the eastern DRC outbreak.

The toll on children was already visible early in that epidemic. In August 2018, UNICEF reported that two children had died, six children were being treated or investigated for Ebola, and 53 children had already been identified as having lost their parents to the disease. By September, 155 children had been identified as orphaned or left unaccompanied.

And the problem grew rapidly. By April 2019, UNICEF said 1,400 children had been orphaned or separated from their families by the outbreak.

The current outbreak is caused by Bundibugyo virus, a different Ebola species from the Zaire ebolavirus that caused the 2018–2020 epidemic.

But the virus itself has a history.

Bundibugyo virus was first identified during an outbreak in western Uganda in 2007. The outbreak recorded 131 reported cases and 42 deaths, according to the US Centres for Disease Control and Prevention. A subsequent 2012 outbreak in DRC recorded 56 laboratory-confirmed cases and 17 deaths.

WHO says the case fatality rates in the previous Bundibugyo outbreaks in Uganda and DRC ranged from about 30 to 50 per cent.

In the current DRC outbreak, however, children are again emerging as one of the groups requiring particular attention.

WHO's latest child-focused update says that while adults account for nearly two-thirds of confirmed Bundibugyo virus cases, children make up almost one in four cases but almost one in three deaths.

More than 60 per cent of confirmed cases among children under five have proved fatal, compared with fewer than 30 per cent among adults, according to WHO.

The reasons are partly biological and partly linked to the difficulties of providing care to very young patients.

“Young children have a lower physiological reserve and require constant attention and care,” Youkee said.

He added that they need trained staff, specialised equipment and medicines that are “sometimes not readily available”.

The clinical needs of a young Ebola patient can also change rapidly.

Dr Chaka Keita, a paediatrician with ALIMA, said the condition of paediatric Ebola patients can deteriorate “very rapidly”.

Children face the additional burden of being separated from their families while receiving treatment, with isolation potentially increasing fear, agitation and distress.

“Isolation is a major factor contributing to emotional stress, agitation and irritability,” Keita said.

He said treatment therefore needs to go beyond medical intervention, requiring emotional support, small frequent meals and the presence of a caregiver throughout the child's treatment journey.

“Wherever possible, the utmost should be done to keep children with their caregivers,” Youkee said.

WHO says treatment-centre designs are being adapted to allow healthcare workers to interact more closely with children and facilitate family visits.

But the challenge begins before a child reaches a treatment centre.

Of the 222 confirmed deaths recorded nationally during the week of September 14 to 20, 136 occurred in communities rather than treatment facilities.

That means 61.3 per cent of confirmed deaths during the latest week occurred outside treatment centres.

WHO says community deaths may reflect several barriers along the pathway to care, including missed diagnosis at peripheral health facilities, self-medication, seeking care from traditional healers or religious institutions, refusal of referral and having no prior contact with the healthcare system.

The agency says the higher representation of children under five among recent community deaths suggests that the group may be particularly vulnerable to dying before receiving appropriate care.

It is calling for closer investigation of “care-seeking, detection and referral pathways among young children”.

The historical evidence points to why that matters.

In the 2018–2020 DRC outbreak, WHO found that children under five were reaching healthcare facilities sooner than older patients, an average of 2.4 days after symptom onset compared with 3.2 days, but many were not referred to Ebola treatment centres. Children under five visited an average of 1.5 healthcare facilities before reaching appropriate Ebola care.

The child mortality figures come as the wider outbreak continues to expand.

As of September 20, the DRC had recorded 7,733 confirmed Bundibugyo virus cases and 3,732 confirmed deaths, giving a crude case fatality ratio of 48.3 per cent.

The outbreak has affected seven provinces and 63 health zones.

Although confirmed cases fell by five per cent nationally during the latest 21-day period compared with the previous three weeks, the decline masks major differences between provinces.

In Ituri, cases fell by 25.8 per cent, from 1,255 to 931.

But in Nord-Kivu, cases increased by 72.7 per cent, from 341 to 589.

The outbreak has also moved into Dungu Health Zone in Haut-Uélé Province, which borders South Sudan.

And while health authorities struggle to keep patients alive, scientists are trying to establish whether existing Ebola tools can work against Bundibugyo virus — and whether new treatments can reduce deaths.

There is currently no licensed vaccine specifically for Bundibugyo virus disease.

WHO says research is underway on vaccines specifically designed against the virus, while researchers are also studying whether Ervebo, the licensed vaccine against Ebola virus, could offer protection.

In August, the DRC received an allocation of 70,000 Ervebo doses from the global Ebola vaccine stockpile.

Of these, 20,000 doses were allocated to a Phase 3 clinical trial examining the vaccine's potential effect against Bundibugyo virus, while other doses were allocated for healthcare and frontline workers under research protocols.

WHO cautions that it is not yet known whether Ervebo protects people against Bundibugyo virus.

“Early laboratory and animal data suggest it may provide some protection,” WHO said when announcing the vaccine allocation, adding that the clinical trial is expected to generate evidence needed to guide future policy.

WHO's current guidance is that Ervebo should only be used against Bundibugyo virus within a research protocol because evidence of protection in humans remains insufficient.

The vaccine research is not the only clinical research underway.

Children are eligible to participate in the ongoing clinical trial investigating a treatment for Bundibugyo virus disease, provided their parents give consent.

The treatment research is part of a wider effort to find medical tools for a virus for which existing Ebola interventions cannot simply be assumed to work.

The PARTNERS treatment trial had enrolled 515 participants across five treatment centres by September 20, according to the latest situation report.

Preliminary results are expected in approximately four to six weeks, once most participants have completed 28 days of follow-up.

Another study, EBO-PEP, is investigating post-exposure prophylaxis. It enrolled 299 participants, including people receiving obeldesivir or placebo and others receiving remdesivir.

The research comes at a critical point in the outbreak.

WHO says there are 1,535 treatment beds across 49 treatment centres and units, with 821 patients hospitalised or in isolation as of September 20.

But access to care remains uneven.

Nord-Kivu's standardised treatment structures were operating at 91.2 per cent occupancy, while WHO reported no available beds in Butembo and Katwa.

For these children, the challenge is even more specialised.

WHO says treatment centres need paediatric-sized equipment and medicines, while healthcare workers require training in managing conditions such as low blood sugar and shock in children.

The agency is also urging that routine childhood vaccination continue wherever it can be safely delivered during the outbreak, warning that interruptions could leave children vulnerable to other serious diseases.

The history of Ebola in DRC shows that the impact on children does not end when the virus is contained.

In previous outbreaks, children have survived the infection only to lose parents and caregivers, face separation from their families, disruption to schooling and the stigma that can follow Ebola.

For thousands of children affected by the 2018–2020 outbreak, UNICEF had to provide psychosocial support, food, school materials, fees and assistance with family reintegration.

The latest figures suggest that for children under five, time matters twice: getting them to specialised care early enough to survive, and protecting them from the family and social consequences that can follow the disease.