Kenya prepared for Ebola. It still slipped through — a warning of wider cross-border spread

Kenya had spent months preparing for Ebola, one of the world’s deadliest viral diseases, screening hundreds of thousands of travelers and training nearly 5,000 health workers in case it crossed the borders.

Then Ebola arrived.

A man who had been ill for weeks and was later confirmed to have Ebola left eastern Democratic Republic of Congo (DRC), crossed by road into neighboring Uganda and flew to Nairobi, passing airport health screening in both countries without being flagged.

A relative and a friend drove him directly from the airport to the Nairobi Hospital, a private hospital in the Kenyan capital. By the time he arrived on October 3, he had a fever, chills, severe fatigue, muscle pain and bleeding beneath his skin, according to Kenya’s Ministry of Health. Doctors isolated him and tests later confirmed Bundibugyo virus, a form of Ebola. He died days later on Monday, and health officials have been trying to identify anyone who may have been exposed.

His journey shows how quickly an outbreak centered in the DRC can become a wider regional problem. The outbreak is now the largest Ebola outbreak ever recorded in the country. As of Wednesday, the World Health Organization (WHO) had recorded 8,728 confirmed cases and 4,205 deaths in the DRC. Cases have been recorded across seven provinces. WHO says transmission remains intense and assesses the risk to countries sharing land borders with the DRC as high.

The DRC is not the only country affected. Uganda recorded 20 cases before its health ministry declared the country Ebola-free on July 28, while France recorded a travel-related case with no additional cases reported. Kenya is now the fourth country to confirm Bundibugyo virus.

Oyewale Tomori, a former WHO regional virologist for Africa, told CNN that the Kenya case warns that more infections could cross borders while transmission remains high in the DRC.

“Africa is an open field divided into countries by poorly manned porous borders,” he said. “The Kenya case is a warning of more cases in the future.”

A security guard and staff members wearing face masks are seen at Nairobi Hospital on Wednesday.

Yang Guang/Xinhua/Getty Images

Why cross-border spread is hard to stop

The Kenyan man, who had lived in the DRC for seven years, moved through three countries in about two days.

On October 2, he traveled by road through Beni in eastern DRC’s North Kivu province to Kampala, Uganda’s capital, before flying to Nairobi the next day, according to Kenya’s Ministry of Health and WHO. Authorities have not said what screening, if any, he underwent at the DRC-Uganda land border.

WHO says it is unclear when he developed Ebola symptoms during the trip. The agency says his month-long illness suggests he was probably sick with something else at first and possibly later contracted Ebola while seeking care.

Uganda had temporarily restricted non-essential travel across its border with the DRC after most of its cases were imported from the country.

Uganda’s health ministry said the man spent fewer than 24 hours in the country and had a normal temperature when screened before departing Entebbe International Airport, near Kampala. The ministry said it was intensifying cross-border surveillance and information sharing following the case.

A health worker cleans PPE at the Mulago National Referral Hospital isolation unit in Kampala, Uganda, on July 8.

Badru Katumba/AFP/Getty Images

In Nairobi, Kenya’s health ministry says he underwent “normal public health screening” at Jomo Kenyatta International Airport. The ministry’s account indicates he was not flagged as a suspected Ebola case during the screening.

Kenya Airports Authority told CNN that Port Health Services, part of the Ministry of Health, handles passenger screening.

CNN has asked health authorities in Uganda and Kenya what checks he underwent and whether his recent travel from the DRC should have prompted further assessment.

The challenge goes beyond airports and official border crossings. The International Organization for Migration (IOM) told CNN that movement between Ebola-affected parts of eastern DRC and neighboring countries remains high, with people regularly crossing for work, trade and family reasons. Not all of that movement happens through official border posts.

IOM said some people use informal routes that are much harder to monitor, so airport and land-border screening will not catch every infected traveler, especially before symptoms appear. It said countries also need to watch for cases in communities, test quickly, trace contacts and share information across borders – just like the response in Kenya – so imported cases are found early and further spread can be contained.

Why health screening can miss cases

Tomori was skeptical that border screening alone could do much, comparing weaknesses in the system to “using a football goalpost net to catch a mosquito.”

Christian Happi, a professor of molecular biology and genomics at Redeemer’s University in Nigeria, whose laboratory helped confirm Nigeria’s first Ebola case in 2014, said temperature checks can miss an infected traveler who is not running a fever at that moment.

“If you don’t have a fever at the time you are passing the health post at the airport, how is the health care worker going to detect it?” he asked.

WHO’s current guidance for the DRC calls for exit screening at airports, ports and ground crossings, including at least a questionnaire about possible exposure and a temperature check. The agency says “suspected, probable and confirmed” cases, as well as contacts assessed as exposed, should not travel internationally except for medical evacuation.

Health workers conduct temperature screenings and health checks on travellers at the Kanyaruchinya checkpoint in Goma, Democratic Republic of Congo, on May 24.

Daniel Buuma/Getty Images

Happi argues that authorities should go further and require people flying from the DRC to show a negative Ebola test before boarding.

“Anybody without a negative Ebola test should not board a flight,” he said. He also said countries need the capacity to test travelers much more quickly at airports.

His proposal goes beyond WHO guidance, which does not call for negative Ebola tests for every traveler leaving an affected area. WHO also advises against broader travel or trade restrictions involving affected countries.

CNN has asked WHO and the Africa Centres for Disease Control and Prevention (Africa CDC) how likely the outbreak is to spread further across borders and what countries should do as cases continue in the DRC.

That is why the response doesn’t stop at the border: when screening misses a case, speed becomes critical.

The bigger test: stopping onward spread

In Kenya, health officials are now trying to identify anyone who may have been exposed and prevent further transmission. They have also intensified screening at Nairobi’s Jomo Kenyatta International Airport.

Preliminary tests on a separate 20-year-old patient who had traveled from the DRC through Uganda came back negative for Ebola on Thursday, according to Kenyan authorities.

Rapid detection is particularly important because there is no licensed vaccine or approved specific treatment for this form of Ebola, although possible vaccines and treatments are being tested.

Happi pointed to Nigeria’s experience during the 2014 West Africa Ebola epidemic, when an imported case in Lagos, one of Africa’s largest cities, led to 20 cases and eight deaths before transmission was stopped.

He said rapid detection and close coordination were key to containing the outbreak.

For Happi, Nigeria’s experience is the lesson for countries now watching the DRC outbreak.

“It won’t be easy to detect everybody crossing borders,” he said. “It is how quickly countries detect and then how quickly they can contain imported cases.”

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