Ebola Spreads to Third Congo Province as U.S. Expands Airport Screening Beyond Dulles

The World Health Organization’s Emergency Committee issued its first formal set of temporary recommendations Friday as the Bundibugyo Ebola outbreak confirmed its first case in Sud-Kivu Province, extending the outbreak to a third Congolese province in under two weeks. Simultaneously, the U.S. Centers for Disease Control and Prevention expanded mandatory entry health screenings to Hartsfield-Jackson Atlanta International Airport, the world’s busiest airport by passenger volume, effective late Friday night.

As of May 22, the WHO Secretariat had tallied 85 laboratory-confirmed cases — including two in Uganda — and 744 suspected cases across both countries, with 176 suspected deaths. Among confirmed cases, 10 deaths have been recorded. The WHO assessed the risk as very high at the national level in the Democratic Republic of the Congo, high at the regional level across East and Central Africa, and low at the global level.

The Sud-Kivu confirmation marks a qualitative shift. For the first six days after the DRC’s Ministry of Health confirmed the Bundibugyo strain on May 15, the outbreak was concentrated in Ituri Province in northeastern Congo. The WHO declared a global health emergency on May 17 — the first time any WHO Director-General invoked a public health emergency of international concern before convening an emergency committee — citing rapid spread across Ituri’s health zones. By May 21, confirmed cases had appeared in Nord-Kivu Province, driven in part by the presence of M23 rebel forces controlling portions of the province, which constrain the movement of response teams and health workers. Sud-Kivu, which borders Nord-Kivu to the south and shares a frontier with Rwanda and Burundi, reported its first confirmed case Friday.

Three Provinces, One Outbreak

The geographic expansion from Ituri to Nord-Kivu to Sud-Kivu follows the road corridors and displacement patterns of eastern Congo. Ituri Province, where the outbreak originated and is concentrated, is a commercial and migratory hub bordered by Uganda and South Sudan. Nord-Kivu lies immediately south of Ituri and has been among the most conflict-affected parts of the DRC for more than a decade; M23’s territorial control of portions of the province, including significant areas around Goma, has complicated epidemic response since the earliest days of the outbreak. Humanitarian agencies have reported more than 100,000 new displacements in the Ituri-North Kivu corridor in the two months preceding the outbreak.

The WHO’s temporary recommendations issued Friday include: enhanced surveillance at all points of entry in DRC, Uganda, and neighboring countries; risk communication campaigns aimed at reducing unsafe burial practices, which have historically amplified Ebola transmission; reinforcement of contact-tracing capacity in all active health zones; and continued coordination with the Africa CDC on cross-border measures.

The committee stopped short of recommending a travel or trade ban. That pattern reflects a deliberate posture: during the 2018–2020 DRC Ebola epidemic, the WHO’s emergency committee found that travel bans increased the risk of concealed transmission by incentivizing travelers to avoid declaring their origins, while doing little to slow actual spread. The U.S. restrictions announced on May 18 — which bar certain non-U.S. nationals who have been in DRC, Uganda, or South Sudan within the preceding 21 days from entering the United States — operate under a separate legal authority, the CDC’s Title 42 public health order, and were not recommended by the WHO committee.

Airport Screening Expands

The U.S. approach has been to channel rather than ban. Under the May 18 CDC order, U.S. citizens and nationals who have been in DRC, Uganda, or South Sudan within the past 21 days are not barred from returning, but they are required to enter the country through one of a small number of designated airports where CDC health officers conduct enhanced screenings. Lawful permanent residents who have been in those countries are barred from entry temporarily while the CDC completes a risk assessment.

Washington-Dulles International Airport in Loudoun County, Virginia, was the initial designated screening airport, beginning at 11:59 p.m. on May 20. The CDC announced Wednesday that Hartsfield-Jackson Atlanta International Airport would be added to the list, effective at 11:59 p.m. Friday, May 22. U.S. Customs and Border Protection announced that George Bush Intercontinental Airport in Houston would be added next, with an effective date of the following Tuesday.

Hartsfield-Jackson processes approximately 100 million passengers per year and handles the largest volume of connecting traffic in the Western Hemisphere. It was one of the five airports that received enhanced Ebola screening during the 2014 West Africa epidemic, which was caused by the Zaire strain. Adding it to the current network is the largest single expansion of the screening system since it was activated last week.

Travelers arriving at these three airports who have been in DRC, Uganda, or South Sudan in the previous 21 days are escorted to a dedicated screening area where they answer a questionnaire about their travel history and symptoms, undergo a non-contact temperature check, and receive a monitoring information packet for the following 21 days. Travelers without symptoms are permitted to continue to their final destinations. Those with symptoms consistent with Ebola — fever above 38.6°C, unexplained bleeding, vomiting, or diarrhea — are assessed by a federal health officer and may be transferred to a designated medical facility.

The screening system does not require travelers to disclose prior exposure to confirmed cases, and it does not capture travelers who have been in South Sudan or Uganda without having been in DRC — a gap that will become more relevant if the outbreak produces additional cross-border cases in countries not yet included in the restriction order.

The Vaccine Gap

The central challenge of this outbreak is one that did not exist for the two previous major DRC Ebola crises. The 2018–2020 epidemic, which killed more than 2,200 people in eastern Congo, was caused by the Zaire strain of ebolavirus. That epidemic drove the accelerated development and deployment of rVSV-ZEBOV, marketed as Ervebo, the first FDA-approved Ebola vaccine. Ervebo was deployed in ring vaccination campaigns — vaccinating all known contacts and contacts of contacts — and contributed significantly to ending the epidemic.

Ervebo does not protect against the Bundibugyo species. The Bundibugyo virus is genetically distinct enough from the Zaire virus that the antibody response generated by the Zaire vaccine does not cross-neutralize. There are no FDA-approved or WHO Emergency Use Listed vaccines or therapeutics for Bundibugyo. Antibody cocktails that have shown efficacy against Zaire, including mAb114 and REGN-EB3, were not developed with Bundibugyo as a target.

Two vaccine candidates in early-stage development have shown promise in animal models against the Bundibugyo species. The more advanced of the two, per NBC News reporting citing researchers familiar with the development timeline, would require at minimum six to nine months of preparatory manufacturing before Phase I human trials could begin. That timeline means no Bundibugyo-specific vaccine is available during this outbreak. Response teams are relying instead on isolation protocols, personal protective equipment, contact tracing, and supportive care to manage the case fatality rate.

The historical case fatality rate for Bundibugyo — from the only two prior documented outbreaks, in Uganda in 2007 and in DRC in 2012 — ranged from 30 to 50 percent of confirmed cases, substantially lower than untreated Zaire Ebola but high enough to make containment a medical and logistical emergency. Dr. Peter Stafford, the first American confirmed infected in the current outbreak, was evacuated to a high-containment hospital in Germany on May 19, where he and at least five other American medical workers from Nyankunde Hospital in Bunia are undergoing treatment or monitoring.

What the Committee Asked For

The IHR Emergency Committee’s temporary recommendations are formally directed at state parties to the International Health Regulations — that is, at governments, not at WHO itself. The most operationally significant recommendation addressed the outbreak’s conflict-zone dimension directly: states were asked to ensure that humanitarian and health response teams have safe access to affected communities, and that security conditions do not prevent contact-tracing or isolation operations.

That recommendation is aimed principally at the DRC government and at MONUSCO, the UN peacekeeping mission currently present in Nord-Kivu and South Kivu. M23’s control of territory in North Kivu has already forced response teams to operate with armed escorts, lengthening response times and reducing the frequency of site visits in communities outside Bunia. The committee’s language does not mandate any specific military or political action, but it places the access question formally on the record.

The committee also recommended that neighboring countries — Rwanda, Burundi, Uganda, Tanzania, South Sudan, and the Republic of the Congo — accelerate their national preparedness plans, including stockpiling personal protective equipment and establishing designated treatment centers. Uganda’s Ministry of Health has confirmed two imported cases from DRC and has activated its existing Ebola response infrastructure, which has been refined through multiple prior outbreak responses. Rwanda and Burundi have not confirmed cases but have elevated surveillance levels at border posts.

One additional dimension noted in Friday’s WHO briefing: the agency’s Director-General simultaneously addressed member states on both the Ebola and hantavirus outbreaks currently active in different regions. Eighteen Americans were placed under federal quarantine in Nebraska in April following a hantavirus cluster aboard the cruise ship MV Hondius, a separate and unrelated outbreak but one that has kept the CDC’s border health units operating under sustained pressure across multiple simultaneous responses.

What Happens Next

The WHO Emergency Committee will reconvene within 90 days under standard IHR procedures, or sooner if the outbreak trajectory deteriorates. The threshold for deterioration, based on prior committee language, would include: sustained community transmission in a new country, a confirmed case in a major regional hub city beyond Kampala, or evidence that case fatality rates are rising beyond the historical Bundibugyo range.

The CDC’s designation of airports for screening is reviewed on a rolling basis. The current 30-day restriction order will be reassessed before it expires. If the outbreak is brought under control in Ituri Province — the original center of transmission — the CDC’s risk assessment could allow an easing of restrictions. If it continues to spread into additional provinces or into Uganda’s interior, additional designated airports, expanded testing protocols, or strengthened entry requirements could follow.

The next 14-day contact-tracing cycle from the Sud-Kivu confirmation will be the first indicator of whether that province’s single confirmed case is an isolated import or the beginning of local community transmission. The difference between those two outcomes will shape the next month of the response.