MSF DRC: Children make up nearly 1 in 4 confirmed Ebola cases, yet left behind in the current outbreak response

While Ebola remains a deadly disease for all age groups, the youngest children face the highest risk of death. In North Kivu, children have been particularly affected by the current outbreak: 24% of confirmed cases are among children under five years of age, compared with 13% in Ituri, while infants under one year old account for 13% of cases, compared with 6% in Ituri. At the Ebola Treatment Centre (ETC) in Butembo, North Kivu, MSF teams have observed that the case fatality rate among children was particularly high. Between June and September 2026, 24 out of 30 children—most of whom under the age of five—died from the Bundibugyo virus in this ETC alone. The rapid progression of the disease in communities and limited access to specialised care at health facility level are contributing to such alarming high fatality rates. ​

“Primary health facilities often lack the specialized expertise, equipment, and infection prevention and control measures needed to identify and safely manage suspected cases,” explains Stéphanie Hoffmann, project coordinator for MSF in Butembo. “Most of the paediatric cases admitted in our ETC in Butembo, North Kivu, over the summer, had already been hospitalised for other illnesses in several facilities during the days or weeks before their admission. Their family members did not have Ebola themselves, and it is highly likely that these children contracted the disease inside healthcare facilities.” Strengthening infection prevention and control (IPC) measures in health facilities, ensuring the availability of personal protective equipment (PPE), and reinforcing the training of healthcare workers in non-Ebola health centres across at-risk areas are critical to maintaining essential services while preventing healthcare-associated transmission.

While efforts have been made to reduce the emotional toll of isolation on children in ETCs, including the creation of visibility areas where parents can see and communicate with their hospitalised children, being admitted to an Ebola Treatment Centre remains a deeply distressing experience for young patients. Children may be too young to understand their situation or meet their own basic needs. To help address this situation, MSF has recruited and trained caregivers who provide daily support and comfort to children inside several MSF-supported ETCs while wearing full personal protective equipment (PPE). These caregivers come from diverse backgrounds, including but not limited to Ebola survivors. Today, 13 caregivers are supporting children at Kitatumba Ebola Treatment Centre in Butembo. While far from a perfect solution, this initiative provides essential human contact and emotional support for children facing the outbreak.

"On top of enormous challenges caring for young patients, medical facilities are dealing with a lack of paediatric dosing guidance, and limited availability of child-friendly formulations of investigational medicines. A child-centred approach must be at the heart of medical care, operational planning, and research efforts", said Dr. Guyguy Manangama, epidemiologist and deputy director of operations at MSF.

Children have been disproportionately affected by the current outbreak, yet they are left behind when it comes to access to innovative medical tools. Historically, children are often excluded from clinical research or included only after significant delays, creating dangerous gaps in evidence and access to potentially life-saving interventions. ​

"Treatments, vaccines, and other preventive tools should be evaluated for use in children from the outset of research efforts and made available to them without delay. Yet in the current outbreak, children are still being left behind, with very limited access to vaccination trials and campaigns, as well as the latest therapeutic innovations despite bearing a significant burden of disease. Children cannot continue to wait for data generated in adults before benefiting from advances in Ebola care and prevention," added Dr. Guyguy Manangama. ​

MSF urges national authorities, research institutions, pharmaceutical developers, and international funders to prioritise the inclusion of children in all ongoing and future Bundibugyo virus studies. Ensuring equitable access to research and new medical tools, including vaccines, is essential to reducing preventable deaths and improving outcomes for one of the most vulnerable groups.

The impact of the outbreak on children extends beyond Ebola infection itself. Disruptions to essential health services can rapidly increase risks from vaccine-preventable diseases, malnutrition, and other common childhood illnesses. Preserving routine immunization, nutrition programmes, and access to primary healthcare must therefore be considered a core component of the outbreak response, not an afterthought. ​

Note to editors:

Treatment: One ongoing study, EBO-PEP, is evaluating an oral antiviral drug, obeldesivir, to prevent Ebola infection after high-risk exposure. If proven effective, the treatment could provide a practical way to protect people who have recently been in contact with an Ebola patient. While the trial is expected to expand eligibility to include some children, those under 20 kilograms remain excluded because an appropriate paediatric formulation is not yet available.

For the youngest children, the current alternative involves a 10-day course of intravenous treatment, an approach that is particularly difficult to implement in outbreak settings and can be especially challenging for young patients and their caregivers. More information here: An urgent opportunity to ensure children's access to oral post-exposure prophylaxis trials for Bundibugyo virus disease - The Lancet Child & Adolescent Health

Vaccination: While the results of ongoing trials evaluating vaccines specifically designed for the Bundibugyo virus are not expected for several months, ERVEBO® is an immediately available option. Its safety profile is well established, it is approved for use in children aged one year and older, and health authorities in the DRC have extensive experience deploying it in outbreak settings. Emerging evidence also suggests that it may offer some protection against the Bundibugyo virus, although the degree of protection remains to be clarified. In areas at high risk of Ebola transmission, vaccinating contacts of confirmed cases, including children over one year of age, could help prevent severe illness and save lives.

Dr Rupa Narra, MSF Paediatrician - Ebola in the DRC: “Children are paying the price for gaps in the Ebola response”

Since the Ebola outbreak was declared in northeastern Democratic Republic of the Congo (DRC) on 15 May 2026, more than 4,000 people have died from the disease out of over 9,000 confirmed cases. MSF teams are responding in the affected areas of Ituri, North Kivu, and Haut-Uélé with eight Ebola treatment centres. Dr Rupa Narra, a paediatrician who has been working on MSF assignments for over fifteen years, spent six weeks in Butembo, North Kivu. She is concerned by the number of children affected and by the measures being implemented to protect them as the outbreak continues to spread.

I arrived in Butembo, a city in North Kivu, in mid-August 2026 for an assignment of nearly six weeks as a paediatrician with MSF. It was my twenty-fourth assignment with the organisation. In 2014, I worked as an epidemiologist for another organisation in Guéckédou, Guinea, at the epicentre of the Ebola outbreak that struck West Africa.

Until this year, I had never been involved in the paediatric care of children with Ebola in a treatment centre. Most importantly, I had never witnessed such high child mortality. It was the most difficult assignment I have ever undertaken.

At the Kitatumba Treatment Centre in Butembo, managed by the Ministry of Health and supported by MSF, around thirty children were admitted over the summer. Twenty-four of them died. Their average age was seventeen months, including several newborns. I was involved in the care of three seven-year-olds and one six-year-old. All the others were under the age of five.

One question has stayed with me since this assignment: are children paying the price for shortcomings in the Ebola response?

Once these children arrived at our facility, they were alone. Butembo operates under Ministry of Health protocols, and the Ministry determines what happens inside the treatment centre. When a patient tests positive, family members without symptoms are generally discouraged from accompanying them, in order to avoid exposing an entire household of six or seven children, a spouse, or grandparents. I understand that decision, and I had no authority to change it. But in practical terms, it meant leaving a 15-month-old baby or a two-and-a-half-year-old child alone in a room for long periods of time. This is almost impossible to comprehend and accept.

I remember hearing one sentence repeatedly during my assignment: “These children arrive very late; their parents should have brought them sooner.” Yet these children had already been hospitalised in several facilities during the days or weeks before their admission to the Ebola treatment centre.

I reviewed the investigation records of children who had previously been treated at the centre, as well as those I cared for myself. Among more than 82 per cent of children under five, nobody else in the family was sick. Not the parents, not the grandparents, not the older siblings who attended school. These were often large families with four, five or six children. Only the youngest child had Ebola.

Some colleagues suggested a possible explanation for these isolated cases within a family: perhaps the parents had been vaccinated during a previous outbreak in 2018 and have retained immunity ever since. But then why were the older brothers and sisters not infected either?

The only common factor I found was that all of these children had been admitted to two or three healthcare facilities, and sometimes more, before arriving at our centre. A health post, then a clinic, then a hospital, for example. They were usually being treated for what appeared to be malaria, pneumonia, diarrhoea, or vomiting, common illnesses in infants or in this region.

At the same time, we were receiving healthcare workers infected with Ebola who had come from these very same facilities. I know that many of these places do not always have gloves available, or even water and soap for staff to wash their hands between consultations.

This is not a scientific study, of course. I worked in only one Ebola treatment centre, Kitatumba in Butembo, and I am speaking only about the children who reached us. Community transmission is widespread and must be tackled, because that is how chains of transmission are broken. Many children are probably dying at home alongside sick relatives. But for the children I treated, no other explanation made sense. I believe they were infected in healthcare facilities, just like the healthcare workers employed there.

Until health facilities at every level have stronger infection prevention and control measures for both patients and staff, Ebola will continue to spread within them.

We were sometimes advised to entrust children to adult patients, but most adults were too ill even to sit up or drink unassisted and could not care for an energetic toddler. Only one survivor, a woman in her thirties who had no connection to the children or their families, agreed to enter the ward. She cared for a newborn for two weeks, then for a fifteen-month-old child for four days before leaving.

For the Zaire ebolavirus, which affected the DRC between 2018 and 2020, we had extensive data on survivors. With the Bundibugyo ebolavirus, however, we do not know whether someone who has recovered and is later heavily exposed can become sick again. The team explained this uncertainty honestly to the survivor who agreed to care for the children.

It was extremely difficult to stay with the children because, for safety reasons, healthcare workers cannot wear protective equipment for more than one hour at a time. There were occasions when I had to wait an hour before being able to enter, and then another thirty to forty-five minutes to remove my protective gear because there was only one designated area for doing so.

During my final two weeks, the treatment centre was operating at almost 100 per cent capacity. To ensure that someone could remain continuously with the children, we would have needed at least twenty-four staff members per day able to enter the high-risk zone.

Many children died alone. That is why it is essential to take their needs into account when considering the next steps, whether in treatment development, clinical trials, or any other initiative involving children. Too often, children and pregnant women are excluded from vaccine trials. Like many others, I refer to them as “therapeutic orphans.”

Throughout my career with MSF, palliative care has always been one of my priorities. In Butembo, however, it was almost impossible to provide.

Health centres have been burned down in other towns, and I was told this often happened after children had died. Rumours circulated that healthcare workers were being paid to kill patients. Some colleagues even requested that their names be removed from their protective suits. Instead, labels such as “Nurse 1,” “Nurse 2,” and “Doctor 1” were written on them because they feared reprisals.

In such an atmosphere, telling parents who already struggle to believe Ebola exists, “We are going to relieve your child’s suffering,” can sound as though we are giving up on their child. In many cases, I did not even raise the subject. When possible, I would simply say: “I need to prepare you, and I am deeply sorry, but your child is unlikely to survive the night. Please call as many relatives as you can.”

The Congolese healthcare workers I worked alongside were highly skilled, but most of them had little experience in paediatrics. They treated children like small adults, and that was not their fault. Either they weren't trained to care for children, or they didn't have the appropriate treatments available. Also, they are often not paid on time. And they risk their lives every day.

I focused on three simple but critical practices. First, using paediatric intravenous infusion sets, because an adult infusion set can deliver twenty to eighty times too much fluid to a child. Second, treating hypoglycaemia with 10 per cent glucose rather than 50 per cent, which can damage veins. Third, administering oxygen properly. It took nearly three weeks to earn their trust.

There are very few organisations capable of managing Ebola patients in North Kivu. Over time, local communities came to trust us more and brought us their sick relatives, both adults and children. We isolate patients, one of the most important measures for stopping an outbreak. We train healthcare workers. A mental health team operates inside the high-risk zone. And we provide our Congolese colleagues with the protective equipment they need.

Despite all these efforts, mortality has declined, but not yet to a significant extent.