EBOLA

ETIOLOGY

Ebola is a disease caused by the Ebola virus, which belongs to the Filoviridae family. To date, six species of Ebola virus have been identified, of which four cause disease in humans: Zaire, Sudan, Bundibugyo, and Taï Forest Ebola virus, while the other two species, Reston and Bombali, do not cause disease in humans.

Although rare, the disease can lead to outbreaks with a high mortality rate, averaging around 50%.

GEOGRAPHICAL DISTRIBUTION

Ebola has been reported in Central and West Africa, near tropical rainforests.

Since 1976, more than 40 Ebola outbreaks have been recorded in Africa. The most affected countries include:
• Democratic Republic of the Congo (DR Congo)
• Uganda
• Guinea
• Liberia
• Sierra Leone
• Sudan

The largest outbreak occurred in West Africa (2014–2016), with more than 28,000 cases and over 11,000 deaths.

In recent years, Ebola outbreaks have again been reported in the Democratic Republic of the Congo and Uganda, including the major outbreak in eastern Congo in 2018, the Kasai outbreak (DR Congo) in 2025, and the ongoing outbreaks in DR Congo and Uganda in 2026.

RESERVOIR AND SOURCE OF INFECTION

A species of fruit bats is considered the natural reservoir of the Ebola virus, in which the virus may circulate without causing severe disease.

In addition to fruit bats, primates, antelopes, hedgehogs, and other wild animals may also serve as sources of infection.

MODES OF TRANSMISSION

The disease may occur in humans and other primates. The virus is transmitted to humans from wild animals during hunting, handling of meat from infected animals, and contact with their blood, tissues, organs, or bodily excretions during meat processing. The virus then spreads within the human population through direct contact with the blood, secretions, organs, or other bodily fluids of infected individuals, as well as indirectly through contact with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.

Animal-to-human transmission is very rare. Most cases occur due to contact with blood, secretions, tissues, organs, or other bodily fluids of living or deceased infected individuals when infectious secretions come into contact with the eyes, mouth, nose, or open wounds, for example during the care of a patient without protective equipment in household or healthcare settings, or during traditional burial rituals. Human-to-human transmission is the main mechanism and route of transmission during epidemic spread of the disease.

It is important to note that the disease may also be transmitted through unprotected sexual contact with individuals who have recovered from the disease. The virus persists much longer in semen in men (sometimes up to 15 months) compared to women, in whom it usually persists in vaginal secretions for up to 1 month. The virus may also persist for a prolonged period in the placenta and in breast milk.

CLINICAL PRESENTATION

Symptoms of the disease usually appear within 2 to 21 days after infection. During the initial stage – the first few days of illness – symptoms include fever, general malaise and weakness, muscle and joint pain, headache, and sore throat. In the second stage, anorexia, diarrhea, abdominal pain, vomiting, skin rash, redness of the eyes, neurological symptoms such as confusion, cough, chest pain, difficulty breathing, impaired kidney and liver function may occur. External and internal bleeding may also develop (bloody diarrhea, nosebleeds, vomiting blood, internal bleeding, and bruising).

In the final stage of the disease, patients die due to a combination of multi-organ failure and hypovolemic shock caused by severe blood loss.

A person infected with Ebola cannot spread the disease until symptoms develop.

The risk of infection is considered low if infection prevention and control measures are followed.

LABORATORY DIAGNOSIS

Samples used for diagnosis include whole blood, oral swabs, or tissue specimens obtained during autopsy. Other types of secretions and excretions may also be used; however, they are generally not commonly utilized due to the higher biological risk associated with handling them and the unstable concentration of the virus in such specimens.

Laboratory methods used for diagnosis include RT-PCR, rapid antigen tests, and ELISA.

In the event of clinical suspicion of a person infected with Ebola in the Republic of North Macedonia, the Institute of Public Health organizes transport of the specimen to an appropriate reference laboratory in Europe, in accordance with the WHO guidelines for handling and transport of Category A infectious substances.

THERAPY

Approved specific therapy exists only for the Zaire Ebola virus and includes treatment with monoclonal antibodies mAb114 (Ansuvimab™) or REGN-EB3 (Inmazeb™), while for other Ebola viruses the treatment is non-specific and supportive.

PREVENTION

Two vaccines have been approved for use in many countries for protection against Zaire Ebola virus; however, there are no available vaccines against the other Ebola viruses.

To prevent infection, the following measures are recommended:

❖ Avoid:

·         habitats where Ebola viruses may be present

·         consumption of bushmeat

·         close contact with wild animals in areas where Ebola viruses may be present

·         unnecessary travel to regions affected by outbreaks

·         contact with suspected or infected individuals

❖ Maintain personal hygiene, especially hand hygiene

❖ Practice safe burial procedures

Preventive measures in healthcare facilities include:

❖ Early recognition and isolation

❖ A specifically designated and limited number of staff in contact with the patient

❖ Personal protective equipment (PPE):

·         double gloves

·         waterproof protective coverall

·         mask (FFP2/FFP3 or PAPR system)

·         eye protection/face shield

·         boots and apron

·         strict adherence to proper donning and doffing procedures

·         hygiene and disinfection with chlorine-based solutions

·         strict hand hygiene before and after contact

·         safe handling of medical equipment

❖ Safe collection and processing of samples:

·         minimum number of necessary laboratory tests

·         use of closed systems whenever possible

·         triple protective packaging of collected samples

·         transport according to biological safety Category A requirements

❖ Proper handling of medical waste:

·         treatment as high-risk infectious waste

·         autoclaving or incineration

·         safe disposal of needles and sharp objects

❖ Adequate training of healthcare personnel:

·         infection prevention and control measures

·         restricted access to isolation wards

·         monitoring exposure among healthcare workers

·         incident reporting system

The most important measures for Ebola prevention are early detection, contact tracing, strict isolation (quarantine), and consistent use of personal protective equipment, especially in healthcare settings.

CURRENT EPIDEMIOLOGICAL SITUATION

On 15 May 2026, an Ebola outbreak was declared in the Democratic Republic of the Congo (DR Congo) – Ituri administrative region. This represents the seventeenth outbreak in the country. The number of cases is rapidly changing as this is an active outbreak.

This outbreak is caused by the Bundibugyo Ebola virus, a rare form of the disease for which there is no approved specific treatment, no widely available vaccine, and which is more difficult to control, particularly in poor and conflict-affected regions such as Ituri. This region is unstable, with hundreds of thousands of displaced people, and healthcare teams face significant access challenges, resulting in slower case detection and contact tracing.

Reported regions with confirmed cases

DR Congo:

• Mongbwalu
• Rwampara
• Bunia
• North Kivu including Goma

Uganda:

• Kampala

Spread has been observed in urban areas – larger cities (e.g., Kampala) – which increases the risk of regional dissemination. The two cases in Uganda have a history of recent travel to DR Congo.

Healthcare workers have been infected, and deaths among medical personnel have been reported, indicating gaps in the implementation of preventive measures.

On 17 May 2026, the World Health Organization (WHO) declared a Public Health Emergency of International Concern (PHEIC), indicating a risk of international spread, although the current situation does not meet the criteria for a pandemic emergency.

Due to the recent declaration of the outbreak and uncertainties related to epidemiological data, the outbreak may be significantly larger than currently reported, not only in terms of the number of affected cases but also regarding its geographic extent.

RISK ASSESSMENT AND MONITORING – EU/EEA

According to the latest assessments by the European Centre for Disease Prevention and Control (ECDC), the risk of Ebola in the EU/EEA is very low. The likelihood of infection among people from the EU/EEA who live in or travel to Ituri is considered low. For people residing in the EU/EEA, the probability of infection is assessed as very low, given the extremely low risk of importation and secondary transmission.

Risk assessments will be updated as additional information becomes available.

ECDC considers that screening travelers returning from affected areas (DR Congo, Uganda) would not be an effective measure to prevent importation into Europe. This conclusion is based on lessons learned from the large Ebola outbreak in West Africa between 2013 and 2016, which involved tens of thousands of cases. Passenger screening consumes significant time and resources and does not efficiently identify infected individuals. Experience and evidence suggest that exit screening from affected areas may be a more effective measure to help limit disease spread.

The World Health Organization (WHO) and ECDC continuously monitor the current outbreak and provide timely updates.

The Institute of Public Health remains in constant communication with international health networks for early warning and response, continuously monitors the situation, and will promptly inform the public of any new findings, risk assessments, and potential recommendations.