The Ebola outbreak in Congo - the second-largest on record - has inflicted an unusually heavy toll on children. More than a quarter of the confirmed and probable cases identified as of early April were children under 15, compared to 18% in the last major outbreak in West Africa from 2013 to 2016, according to figures compiled by the World Health Organization (WHO).

The disease can progress rapidly, crippling the immune system and shutting down vital organs.

Young children and babies are especially vulnerable. Their small bodies are less well equipped to cope with extreme fluid loss brought on by common symptoms such as diarrhea, vomiting, fever and bleeding, said Daniel Bausch, an infectious disease specialist at the London School of Hygiene and Tropical Medicine.

More than two out of every three children infected in this outbreak have died compared with just over half the adults, the WHO said. As of May 26, the death toll stood at 1,281 people, including at least 541 who were under 18.

Fatality rates are highest for children under four who died at a rate of around 80% in West Africa, according to a study published in the New England Journal of Medicine in 2015. More than 11,000 people in all died in that outbreak.

The contents of the storage room at the Butembo treatment center attest to the age of many of the patients. Alongside blankets and spare clothes stand shelves full of baby formula and neon-colored plastic rattles in the shape of little bears.

In the city center, small coffins wrapped in flowery plastic were stacked outside a carpenter's shop. An employee lamented the frequency of orders.

Gloves and bodily fluids 

Ebola cases would typically be divided more or less equally between male and female patients. But in this outbreak, women and girls account for 58% of cases, down from a peak of 62% in December, the WHO said.

The reason more women and children have fallen sick remains a bit of a mystery. But experts suspect it may be because the Beni area, where the outbreak began in August, was also battling malaria at the time.

Malaria can cause severe complications in pregnant women and children, requiring treatment at medical facilities where they risk exposure to undiagnosed Ebola patients, said Mike Ryan, who heads the WHO's health emergencies program.

“Transmission within the healthcare setting has been a major factor driving this outbreak,” Ryan said. “Unfortunately, women and children have been the unwitting victims of that reality.

Healthcare standards in Congo vary widely due to lack of oversight over a system that includes many unregistered private clinics and traditional healers operating out of their homes.

The virus is transmitted through contact with infected bodily fluids. But health workers operating outside of government hospitals do not always follow guidelines to prevent cross-contamination, according to Congo's health ministry.

“It means at times they don't change gloves or don't use single-use ones or simply they don't use gloves at all,” said Jessica Ilunga, a ministry spokeswoman. “They don't sterilize their equipment, and they don't decontaminate beds, and they don't change sheets.”

Anselme Mungwayitheka said he and two other health workers at a private clinic in Beni caught Ebola from a woman and her newborn who were infected while in the care of a traditional healer.

 “We didn't have much equipment in this facility,” said Mungwayitheka, who now works at an Ebola treatment center in Beni he credits with saving his life. “When we received patients, we just had to put on protective gloves. After caring for them, we had to remove the gloves, but the patient had touched almost all the doors.”

A key part of the Ebola response effort involves decontaminating health facilities, educating health workers on how to protect themselves and their patients, and persuading residents to seek treatment at specialized centers. But these efforts have been hindered by outbreaks of violence and a deep mistrust of outsiders.

This is Congo's tenth Ebola outbreak, but it is the first in the densely populated provinces of North Kivu and Ituri, where militias carry out sporadic raids from hidden strongholds in the tropical forest. Women and children are often the first to be displaced by the bloodshed. 

(Cover photo: The city of Butembo is at the epicenter of the Ebola crisis, the death toll of the outbreak to date is over 1000 deaths, May 16, 2019, Congo. /VCG Photo)