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On May 8, the Democratic Republic of Congo (DRC) notified the World Health Organization (WHO) of a confirmed outbreak of Ebola in Bikoro, on the shores of Lake Tumba in Équateur Province. Ebola in the DRC is not unexpected. The first-ever identified Ebola outbreak occurred in the DRC—then Zaire—in 1976. This is the ninth of DRC’s outbreaks, which until now have been confined mainly to rural areas. With high fatality rates, earlier outbreaks quickly burned out due to the natural firewall of remoteness.

Bikoro and a nearby village, Ikoko-Impenge, are rural, but on May 16, the WHO confirmed spread to Mbandaka, home to 1.2 million people. Peter Salama, MD, MPH, head of the WHO’s Emergencies Program, called urban spread a game changer that could spill over porous borders. Lake Tumba flows to the Congo River, connecting 2 capital cities (Kinshasa, DRC, and Brazzaville, Republic of the Congo) along the waterway. The WHO warned that 9 neighboring countries, including the Central African Republic, are at high risk.