The Ebola outbreak has been confined to West Africa: Sierra Leone, Liberia, Nigeria, and Guinea. Now a fifth country — the Democratic Republic of the Congo in Central Africa — appears to be battling the virus.

The DRC health minister, Dr. Felix Kabange Numbi, says two people have just died from Ebola during a deadly hemorrhagic fever outbreak in a remote, northwestern region of the country. According to reports, there were 13 deaths in total.

Numbi says the outbreak in his country has "nothing to do with the one in West Africa," according to the Associated Press. But the World Health Organization says it is waiting to confirm the DRC's findings. In its own labs, it will test to find out which of the five strains of the Ebola virus afflicted the Congolese and whether they match the strain circulating in West Africa, known as Zaire ebolavirus.

A WHO spokesperson said confirmation about whether this is a separate outbreak will likely arrive on Monday and cautioned that the notice about the two DRC deaths has not come from the WHO.

(The Ebola outbreak 2014, courtesy of Health Map.)

Until this year, all previous Ebola outbreaks have occurred in Central Africa, and the DRC has been afflicted numerous times in the past. The first known outbreak occurred there in 1976, in the same area where the current Ebola cases were detected.

Where will the Ebola outbreak move next?

To date, there have been suspected Ebola cases in Europe, Asia, and North America but none have tested positive. Public health officials are relatively unconcerned about Ebola becoming a big problem in the developed world. That's because outbreaks persist in countries with poor sanitation and a shortage of resources to contain them, not in resource-rich places like the US.

For this reason, continued spread in Africa is really what public health officials are worried about. "Our first concern is that this is going to go into adjacent areas through people traveling in the region," said Daniel Bausch, associate professor at the Tulane University School of Public Health and Tropical Medicine, who is working with the WHO and Médecins Sans Frontières on the outbreak. "In the short term, the main vector is the traveler: local people traveling from one village to the next. On a more regional scale, plane travelers." Travel from Sierra Leone, Guinea, and Liberia within the African continent is much more prevalent than travel elsewhere.

All countries in West Africa are already on alert. National authorities in Ghana, Nigeria, Togo, and Côte d'Ivoire are working with the WHO on prevention efforts and monitoring potential cases.

To do this, contact tracing is essential, said Bausch. "With Ebola outbreaks, most of the time there's one or very few introductions of the virus from the wild into humans, and all the transmission after that is human-to-human transmission. So people who are traveling locally as well as on planes and other modes of transport, that's the way this would get around."

The worst-case scenario

Even if the outbreak didn't move across any other country border, intensification within the already affected areas is the most immediate health threat. As of Aug. 22, there have been 1,082 cases and 624 deaths reported. This is the largest-ever Ebola outbreak, and the WHO said that it is preparing for the outbreak to last for months.

"The worst-case scenario is that the disease will continue to bubble on, like a persistent bushfire, never quite doused out," said Derek Gatherer, a Lancaster University bioinformatician who has studied the evolution of this Ebola outbreak. "It may start to approach endemic status in some of the worst affected regions. This would have very debilitating effects on the economies of the affected countries and West Africa in general."

"Ebola may start to approach endemic status in some of the worst affected regions."

This dire situation could come about because of a "persistent failure of current efforts," he added. "Previous successful eradications of Ebola outbreaks have been via swamping the areas with medical staff and essentially cutting the transmission chains. Doing that here is going to be very difficult and expensive. We have little option other than to pump in resources and engage with the problem using the tried-and-tested strategy—but on a scale previously unused."

Resources are already extremely constrained in most of the countries affected right now. As Dr. Bausch said, "If you're in a hospital in Sierra Leone or Guinea, it might not be unusual to say, 'I need gloves to examine this patient,' and have someone tell you, 'We don't have gloves in the hospital today,' or 'We're out of clean needles,' — all the sorts of things you need to protect against Ebola."

In these situations, local health-care workers — the ones most impacted by the disease — start to get scared and walk off the job. And the situation worsens.

When Bausch was in Sierra Leone in July, he said all the nurses went on strike in one of the hospitals where he was working. "There were 55 people in the Ebola ward," he said, "and myself and one other doctor."

He'd walk into the hospital in the morning and find patients on the floor in pools of vomit, blood, and stool. They had fallen out of their beds during the night, and they were delirious. "What should happen is that a nursing staff or sanitation officer would come and decontaminate the area," he said. "But when you don't have that support, obviously it gets more dangerous." So the disease spreads.

http://www.vox.com/2014/8/24/6063027/ebola-virus-found-in-the-democratic-republic-of-the-congo