2018 Équateur province Democratic Republic of the Congo Ebola virus outbreak

2018 Équateur province Democratic Republic of the Congo Ebola outbreak
Initial case: 8 May 2018[1][2]
Declared over: 24 July 2018[3]
Location of the Province of Équateur in the Democratic Republic of the Congo
Location of the Democratic Republic of the Congo in Africa
Confirmed cases 38[4]
Probable cases 16[5]
Deaths 33[5]

The 2018 Équateur province Democratic Republic of the Congo Ebola virus outbreak occurred in the north-west of the Democratic Republic of the Congo (DRC) from May to July 2018. It was the largest outbreak of Ebola virus disease (EVD) since the West African epidemic of 2013–16,[6] but never spread beyond Équateur province. It was also the first time the rVSV-ZEBOV Ebola vaccine had been used to stop an outbreak, with a total of 3,481 people vaccinated.[7][8][9] It was the ninth recorded Ebola outbreak in the DRC.[7]

The outbreak began when on 8 May 2018, when it was reported that 17 people were suspected of having died from EVD near the town of Bikoro in the Province of Équateur.[10] The World Health Organization declared the outbreak after two people were confirmed as having the disease.[1][11] On 17 May, the virus was confirmed to have spread to the inland port city of Mbandaka, causing the WHO to raise its assessment of the national risk level to "very high",[12][13] but not yet to constitute an international public health emergency.[14] The WHO declared the outbreak over on July 24.[15][16][3]

Subsequent to this, another Ebola virus outbreak was confirmed in Kivu province in the eastern region of the country, on 1 August 2018.[17]

Epidemiology

Early cases

Location of suspected cases reported

The earliest cases are believed to have occurred in early April 2018.[18] The suspected index case was a police officer, who died in a health center in the village of Ikoko-Impenge, near the market town of Bikoro in Équateur province, according to the International Federation of the Red Cross and Red Crescent Societies.[6]

After his funeral, eleven family members became ill, and seven of them died. All of the seven deceased had attended the man's funeral or cared for him while he was sick.[6] The identification of this individual as the index case has not yet been confirmed.[19]

Équateur province's Provincial Health Division reported 21 cases with symptoms consistent with Ebola virus disease, of whom 17 had died, on 3 May 2018.[20] Of these, eight cases have subsequently been shown not to have been Ebola-related.[21] The outbreak was declared on 8 May after samples from two of five patients in Bikoro tested positive for the Zaire strain of the Ebola virus.[1][20][10]

On 10 May, the World Health Organization (WHO) stated that the Democratic Republic of the Congo had a total of 32 cases of EVD,[2] and a further two suspected cases were announced on the following day, bringing the total cases to 34, all located in the Bikoro area of DRC.[22]


Timeline of reported cases and deaths[23]
DateCasesDeathsCFRContacts
ConfirmedProbableSuspectedTotal
2018-05-11[24]21814341852.9%75
2018-05-14[25]22217412048.8%432
2018-05-18[20]142110452555.6%532
2018-05-20[19]28212512752.9%628
2018-05-23[21]311385222*42.3%>600[26]
2018-05-27[27]35136542546.3%906
2018-05-30[28]3713050*2550%>900[29]
2018-06-03[30]37136562544.6%880
2018-06-06[31]381410622743.6%619
2018-06-10[32]3814355*2850.9%634
2018-06-17[33]381410622845.1%289
2018-06-20[15]3814961*2845.9%179
2018-06-24[34]3814355*2851%179
2018-06-29[35]3815053*2954.7%0
2018-07-09[36]38150532954.7%0
2018-07-24[7]38160543361%0

* numbers are subject to revision both up, when new cases are discovered, and down, when tests show cases were not Ebola-related.

Spread to Mbandaka

In the eight previous Ebola outbreaks in DRC since 1976, the virus had never before reached a major city. In May 2018, for the first time, four cases were confirmed in the city of Mbandaka.[37][21]

On 14 May, suspected cases were reported in the Iboko and Wangata areas in Équateur province, in addition to Bikoro. The WHO reported on 17 May 2018 that the first case of this outbreak in an urban area[6] had been confirmed in the Wangata district of Mbandaka city, the capital of Équateur province, about 100 miles north of Bikoro.[6][25][12] Mbandaka is a busy, densely populated port on the Congo River with a population of 1.2 million,[38] so there would be a high risk of contagion.[20][6] The following day, the WHO raised the health risk in DRC to "very high" due to the presence of the virus in an urban area.[13]

The DRC government was particularly concerned about the virus spreading by boat transport along the Congo between Mbandaka and the capital, Kinshasa.[39] The WHO also considered that there was a high risk of the outbreak spreading to nine other countries in the region,[20] including the bordering Republic of the Congo and Central African Republic.[39][38]

As of 23 May 2018, the focus of the outbreak was split between Bikoro and Iboko; Iboko had 55% of the confirmed cases of EVD[21] and Bikoro had 81.5% of the fatalities.[19] The cases in the Bikoro health zone were located in Ikoko Impenge (12), Bikoro (6), Momboyo (1) and Moheli (1); those in the Iboko health zone were located in Itipo (13), Mpangi (2), Wenga (1) and Loongo (1).[21]

According to the fifth situation report released by the WHO, the case fatality rate (CFR) was 42.3%.[21] Demographics had been reported for 44 cases as of 22 May; there were 26 cases of EVD in men and 18 in women; 7 cases were in children 14 years and under, and 9 were in those over 60 years.[21] By 23 May, there had been 5 reported cases in health-care workers, including two who died.[21] Contact tracing was being employed to identify contacts with infected individuals.[19][40] On 29 May, it was reported that 800 contacts had been identified in the city of Mbandaka;[41] the next day it was reported that 500 people in the city had been vaccinated.[42]

Cases and deaths by health zone
As of 24 July 2018[7]
Health
zone		CasesDeathsCFR
ConfirmedProbableSuspectedTotal
Bikoro10110211885.7%
Iboko2450291241.3%
Wangata4004375%
Ingende[33]00000-
Total38160543361%

On 29 May, the WHO indicated that nine neighbouring countries had been alerted for being at high risk of spread of EVD,[43] On 4 June, it was reported that Angola had closed its border with the DRC due to the outbreak.[44]

End of the outbreak

This outbreak in the Democratic Republic of the Congo was declared over on 24 July 2018 after 42 days passed without any new confirmed cases.[45][16][37] However, it is noted that a new outbreak occurred only one week later in the eastern region of Kivu, and it has not established whether they are linked.[17]

Containment challenges

The Bikoro area has three hospitals, but the area's health services were described by WHO as predominantly having "limited functionality";[20] they received supplies from international bodies but experienced frequent shortages. More than half of the Bikoro area cases were in Ikoko-Impenge, a village not connected to the road system.[20][21] Bikoro lies in dense rain forest,[6] and the area's remoteness and inadequate infrastructure were hindering treatment of EVD patients, as well as surveillance and vaccination efforts.[38]

Adherence was another challenge: on 20–21 May, three individuals with EVD in an isolation ward of a treatment center in Mbandaka fled; two later died after attending a prayer meeting, at which they may have exposed 50 other attendees to the virus.[46][47][48][49] Bushmeat is believed to be one vector of infection, but bushmeat vendors at the Mbandaka market told reporters that they did not believe Ebola was real or serious.[50]

Hostility towards health workers trying to offer medical assistance was also reported.[51] On 29 May, the WHO forecast somewhere between 100-300 cases before the end of July.[52]

Virology

Ebola virus virion

Zaire ebolavirus, which has been identified in this outbreak,[20] is included in genus Ebolavirus, family Filoviridae,[53] which are negative-sense single-stranded RNA viruses.[54]

The virus was named for the Ebola River, which runs as a tributary of the Congo River in the Democratic Republic of the Congo; the Zaire strain was first identified in 1976 in Yambuku.[55][56]

Response

Médecins Sans Frontières (MSF) has established treatment centers in Bikoro, Ikoko and Wangata.[21] WHO sent an expert team to Bikoro on 8 May,[1] and on 13 May, WHO Director-General Tedros Adhanom Ghebreyesus visited the town.[57] As of 24 May 2018, WHO had sent 138 technical personnel to the three affected areas; the Red Cross has sent more than 150 people, and UNICEF personnel are also active.[21] Other international agencies sending teams include the UK Public Health Rapid Support Team[58] and the Africa Centres for Disease Control and Prevention.[59] The Wellcome Trust has donated £2 million towards the DRC outbreak.[60] Merck is donating its experimental vaccine and Gavi, the Vaccine Alliance is helping to support vaccination operations.[61] Several tons of supplies have been shipped to the DRC, including protection and disinfection kits and palliative drugs.[6] After the virus spread to the city of Mbandaka, DRC health minister Oly Ilunga Kalenga announced that healthcare would be provided free for those affected.[62][63]

On 18 May, the WHO IHR committee met and decided against declaring a Public Health Emergency of International Concern; if the outbreak expands or spreads internationally, the committee will reassess the situation.[38]

US President Donald Trump has advocated rescinding Ebola funding and most financing for State Department emergency responses. National Security Advisor John Bolton removed the National Security Council’s health security chief on the day that the Ebola outbreak was declared, shutting down the entire epidemic prevention office.[64]

The U.S. Centers for Disease Control and Prevention says “about five” of its staff advise the Congolese government. CDC presence appears to be smaller than West African countries'. The U.S. Agency for International Development promised $1 million to WHO for Ebola efforts. Germany has promised $5.8 million.[64]

Surveillance

Surveillance of travelers at Mbandaka's port and airport is ongoing.[20] The DRC Ministry of Public Health has identified 115 areas where movement of people increases the risk of virus transmission, including 83 river ports, nine airports and seven bus stations, as well as 16 markets.[19] José Makila, the DRC minister of transport, has stated that the Navy will be used to surveil river traffic on the Congo.[39] On 10 May, the Nigerian Ministry of Health reported it would start screening at its borders,[65] and As of 18 May 2018, a total of 20 countries have instituted screening of travelers coming from the DRC.[20] WHO has sent teams to 8/9 of the neighboring countries to assess their capability to deal with EVD spread and facilitate their surveillance.[21] The DRC Ministry of Public Health is working with surveyors and cartographers from UCLA and OpenStreetMap DRC to improve mapping of the affected area.[66] A laboratory has been operational in Bikoro since 16 May, enabling local testing of patient samples for Ebola virus.[19]

Burials are being organized by MSF and the Red Cross of the Democratic Republic of the Congo to minimize the risk of transmission.[20] The United Nations Radio is broadcasting EVD awareness information, and posters and leaflets are being prepared and distributed.[20] UNICEF has warned 143 churches across Mbandaka of the risks of prayer meetings.[21]

Treatment

Ring vaccination with rVSV-ZEBOV

ZEBOV

Health authorities including DRC's Ministry of Public Health are using recombinant vesicular stomatitis virus–Zaire Ebola virus (rVSV-ZEBOV) vaccine – a recently developed experimental Ebola vaccine, produced by Merck – to try to suppress the outbreak. This live-attenuated vaccine expresses the surface glycoprotein of the Kikwit 1995 strain of Zaire ebolavirus in a recombinant vesicular stomatitis virus vector.[67] rVSV-ZEBOV was trialed in Guinea and Sierra Leone during the West African epidemic of 2013–16, with 5837 people receiving the vaccine; the trial authors concluded that rVSV-ZEBOV provided "substantial protection" against EVD,[68] but subsequent commentators have questioned the degree of protection obtained.[69] As the vaccine has yet to be approved by any regulatory authority, it is being used in DRC under a compassionate use trial protocol.[18] A review, by Medaglini, et al, indicates that "long-term protection is undefined" via the vaccine mechanism.[70]

A ring vaccination strategy is ongoing, which involves vaccinating only those most likely to be infected: direct contacts of infected individuals, and contacts of those contacts.[6][71][72][73][74] Other groups targeted include health workers, laboratory personnel, surveillance workers and people involved with burials.[61][75] People who have been vaccinated will be followed up for 84 days to assess whether they are protected from infection and to monitor any adverse events.[18] A total of 4,320 doses of the rVSV-ZEBOV vaccine were delivered to DRC's capital Kinshasa by WHO on 16 May, and a further 3,240 doses arrived three days later;[19] another 8,000 doses will also be made available.[76] The vaccine must be transported and stored at between −60 and −80 °C.[61] A cold chain was established in Kinshasa by 18 May and has been extended to Mbandaka. WHO plans to concentrate on vaccinating three sets of contacts of confirmed EVD cases, two in Bikoro and one in Mbandaka.[20]

Vaccination started on 21 May among health workers in Mbandaka,[63] with 7,560 vaccine doses ready for immediate use, according to WHO.[19][61] The DRC health minister Oly Ilunga Kalenga stated that vaccination of health workers and Ebola case contacts in the Wangata and Bolenge areas of Mbandaka would take five days, after which vaccination would start in Bikoro and Iboko.[63] As of 24 May 2018, 154 people in Mbandaka have been vaccinated, and preparations have started for vaccinating in Bikoro and Iboko.[21]

Up to 1,000 people are expected to have been vaccinated by 26 May, according to WHO.[19] It is the first time that vaccination has been attempted in the early stages of an Ebola outbreak.[18]

Experimental therapeutic agents

Chemical formula for Favipiravir

Health officials are exploring the idea of trialing experimental treatments, including the antiviral agents favipiravir and GS-5734, and the antibody ZMapp. All three agents were given to patients during the West African epidemic, but none has yet been proved to be effective.[77] The DRC Ministry of Public Health has also requested that the US trial mAb114 treatment in the current outbreak. The mAb114 monoclonal antibody was developed by Jean-Jacques Muyembe at the National Institute for Biomedical Research, and is derived from an EVD survivor of the 1995 Kikwit outbreak who still had circulating anti-Ebola antibodies eleven years later; it has been tested in macaques but not in humans.[49][78][79]

The ZMapp cocktail was assessed by the World Health Organization for emergency use under the MEURI ethical protocol. The panel agreed that "the benefits of ZMapp outweigh its risks" while noting that it presented logistical challenges, particularly that of requiring a cold chain for distribution and storage.[80] Four alternative therapies (Remdesivir, REGN3470-3471-3479, Favipiravir, and mAb114) were also considered for use under some circumstances, but they are at earlier stages of development.[80][81]

Prognosis

While the rVSV-ZEBOV vaccine proved effective for the strain of the Ebola virus in this outbreak, having via ring vaccination protected some 3,481 individuals,[7][82] Post-Ebola virus syndrome affects those who have survived from the infection of EVD, the resulting symptoms can include muscle pain, eye problems, neurological problems, and a variety of other symptoms.[83][84]

Previous and subsequent outbreaks

The Democratic Republic of the Congo (formerly Zaire) has had eight previous EVD outbreaks, the earliest in 1976.[85][86] All have been located in the west or north of the country.[76] Three previous outbreaks (in 1976, 1977 and 2014) occurring in former province of Équateur, of which the current Équateur province forms part.[2] The most recent prior outbreak occurred in the northern Congo in 2017,[87] with eight confirmed or probable cases including four deaths.[88] The DRC regulatory authorities approved use of the experimental rVSV-ZEBOV vaccine, but logistical issues delayed implementation until the outbreak was already under control.[18][77][89]

DRC lags behind the rest of Africa in health expenditures, at Intl$ 32 per head in 2014.[90][91] Shortly before the first cases of the 2018 Ebola outbreak, the country experienced a widespread cholera epidemic (June 2017 – spring 2018), which was the most serious in the country since 1994.[92][93][94]

The table below indicates the 10 outbreaks that have occurred since 1976:

1976-2018[note 1]
Timeline of Ebola outbreaks in the Democratic Republic of the Congo (formerly Zaire)
V・T
Date		CountryMajor locationOutbreak informationSource
StrainCasesDeathsCFR
Aug 1976 ZaireYambukuEBOV31828088%[95]
Jun 1977 ZaireTandalaEBOV11100%[86][96]
May–Jul 1995 ZaireKikwitEBOV31525481%[97]
Aug–Nov 2007 Democratic Republic of the CongoKasai-OccidentalEBOV26418771%[98]
Dec 2008–Feb 2009 Democratic Republic of the CongoKasai-OccidentalEBOV321445%[99]
Jun–Nov 2012 Democratic Republic of the CongoOrientaleBDBV773647%[86]
Aug–Nov 2014 Democratic Republic of the CongoTshuapaEBOV664974%[100]
May–Jul 2017 Democratic Republic of the CongoLikatiEBOV8450%[101]
Apr–Jul 2018 Democratic Republic of the CongoBikoroEBOV543361%[102]
Aug 2018–present Democratic Republic of the CongoKivuEBOVongoingongoingongoing–

See also

Notes

  1. ↑ Per "DR Congo: Ebola Outbreak - May 2018". ReliefWeb. Retrieved 20 July 2018. the current outbreak started in April though it was not official until May 8 by WHO

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  85. ↑ Rosello, Alicia; Mossoko, Mathias; Flasche, Stefan; Van Hoek, Albert Jan; Mbala, Placide; Camacho, Anton; Funk, Sebastian; Kucharski, Adam; Ilunga, Benoit Kebela; Edmunds, W John; Piot, Peter; Baguelin, Marc; Muyembe Tamfum, Jean-Jacques (2015). "Ebola virus disease in the Democratic Republic of the Congo, 1976-2014". eLife. 4: e09015. doi:10.7554/eLife.09015. ISSN 2050-084X. PMC 4629279. PMID 26525597.
  86. 1 2 3 "Years of Ebola Virus Disease Outbreaks". www.cdc.gov. 18 May 2018. Retrieved 22 May 2018.
  87. ↑ Beavers, Olivia (14 May 2017). "Second Ebola case in Congo confirmed". The Hill. Retrieved 9 May 2018.
  88. ↑ "Situation Report" (PDF). WHO.org. World Health Organization. Retrieved 9 May 2018.
  89. ↑ "Ebola virus disease: Democratic Republic of the Congo: External Situation Report 22" (PDF). WHO. 8 June 2017. Retrieved 21 May 2018.
  90. ↑ "Democratic Republic of the Congo". World Health Organization. Retrieved 24 May 2018.
  91. ↑ "Democratic Republic of the Congo: WHO statistical profile" (PDF). World Health Organization. January 2015. Retrieved 24 May 2018.
  92. ↑ "DRC: MSF Treats 17,000 People in One of the Largest National Cholera Outbreaks Ever". Médecins Sans Frontières. 27 September 2017. Archived from the original on 25 May 2018. Retrieved 24 May 2018.
  93. ↑ "DRC: Fighting the Country's Worst Cholera Epidemic in Decades". Médecins Sans Frontières. 25 January 2018. Archived from the original on 25 May 2018. Retrieved 24 May 2018.
  94. ↑ "Cholera – Kinshasa, Democratic Republic of the Congo". World Health Organization. 25 January 2018. Retrieved 24 May 2018.
  95. ↑ "Ebola haemorrhagic fever in Zaire, 1976". Bulletin of the World Health Organization. 56 (2): 271–293. 1978. ISSN 0042-9686. PMC 2395567.
  96. ↑ Heymann, D. L.; et al. (1980). "Ebola Hemorrhagic Fever: Tandala, Zaire, 1977–1978". Journal of Infectious Diseases. 142: 372–76. doi:10.1093/infdis/142.3.372.
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  98. ↑ "Outbreak news. Ebola virus haemorrhagic fever, Democratic Republic of the Congo--update". Releve Epidemiologique Hebdomadaire. 82 (40): 345–346. 5 October 2007. ISSN 0049-8114. PMID 17918654.
  99. ↑ "WHO | End of Ebola outbreak in the Democratic Republic of the Congo". www.who.int. Retrieved 22 May 2018.
  100. ↑ "Congo declares its Ebola outbreak over". Reuters. November 15, 2014. Retrieved 22 May 2018.
  101. ↑ "Democratic Republic of the Congo Ebola virus" (PDF). World Health Organization. Retrieved 22 May 2018.
  102. ↑ "Ebola virus disease – Democratic Republic of the Congo: Disease outbreak news, 25 July 2018". ReliefWeb. Retrieved 26 July 2018.

Further reading

  • Maganga, Gaël D.; et al. (27 November 2014). "Ebola virus disease in the Democratic Republic of Congo". The New England Journal of Medicine. 371 (22): 2083–2091. doi:10.1056/NEJMoa1411099. ISSN 1533-4406. PMID 25317743.
  • Laupland, KB; Valiquette, L (May 2014). "Ebola virus disease". The Canadian Journal of Infectious Diseases & Medical Microbiology = Journal Canadien des Maladies Infectieuses et de la Microbiologie Medicale. 25 (3): 128–9. ISSN 1712-9532. PMC 4173971. PMID 25285105.
  • Kadanali, Ayten; Karagoz, Gul (24 April 2015). "An overview of Ebola virus disease". Northern Clinics of Istanbul. 2 (1): 81–86. doi:10.14744/nci.2015.97269. ISSN 2536-4553. PMC 5175058. PMID 28058346.
  • Nanclares, Carolina; Kapetshi, Jimmy; et al. (2016). "Ebola Virus Disease, Democratic Republic of the Congo, 2014". Emerging Infectious Diseases. 22 (9): 1579–1586. doi:10.3201/eid2209.160354. ISSN 1080-6040. PMC 4994351. PMID 27533284.
  • "Experimental Ebola vaccines elicit year-long immune response/NIH reports final data from large clinical trial in West Africa". National Institutes of Health (NIH). NIH.gov. 11 October 2017. Retrieved 20 May 2018.
  • Kuhn, Jens H.; et al. (24 November 2014). "Nomenclature- and Database-Compatible Names for the Two Ebola Virus Variants that Emerged in Guinea and the Democratic Republic of the Congo in 2014". Viruses. 6 (11): 4760–4799. doi:10.3390/v6114760. ISSN 1999-4915. PMC 4246247. PMID 25421896.
  • Chippaux, Jean-Philippe (2014). "Outbreaks of Ebola virus disease in Africa: the beginnings of a saga". Journal of Venomous Animals and Toxins Including Tropical Diseases. 20 (1): 44. doi:10.1186/1678-9199-20-44. ISSN 1678-9199. PMC 4197285. PMID 25320574.
  • Mulangu, Sabue; et al. (30 January 2018). "Serologic Evidence of Ebolavirus Infection in a Population With No History of Outbreaks in the Democratic Republic of the Congo". The Journal of Infectious Diseases. 217 (4): 529–537. doi:10.1093/infdis/jix619. ISSN 1537-6613. PMC 5853806. PMID 29329455.
  • "Ebola Treatment Research | NIH: National Institute of Allergy and Infectious Diseases". www.niaid.nih.gov. National Institutes of Health. Retrieved 28 May 2018.
  • "WHO | WHO Regional Strategic EVD Readiness Preparedness Plan Regional Preparedness Plan for EVD in 9 Countries 31 May: follow up discussions". WHO. Retrieved 8 June 2018.
  • Barry, Ahmadou; et al. (June 2018). "Outbreak of Ebola virus disease in the Democratic Republic of the Congo, April–May, 2018: an epidemiological study". The Lancet. 392 (10143): 213–221. doi:10.1016/S0140-6736(18)31387-4. PMID 30047375.
  • Mbala Kingebeni, Placide; Villabona-Arenas, Christian-Julian; Vidal, Nicole; Likofata, Jacques; Nsio-Mbeta, Justus; Makiala-Mandanda, Sheila; Mukadi, Daniel; Mukadi, Patrick; Kumakamba, Charles; Djokolo, Bathe; Ayouba, Ahidjo; Delaporte, Eric; Peeters, Martine; Muyembe Tamfum, Jean-Jacques; Ahuka Mundeke, Steve (2018). "Rapid confirmation of the Zaire Ebola Virus in the outbreak of the Equateur province in the Democratic Republic of Congo: implications for public health interventions". Clinical Infectious Diseases. doi:10.1093/cid/ciy527. PMID 29961823.
  • "Consultation on Monitored Emergency Use of Unregistered and Investigational Interventions for Ebola Virus Disease (EVD)". ReliefWeb. World Health Organization. Retrieved 9 July 2018.
  • World Health Organization Democratic Republic of the Congo crisis information
  • World Health Organization Ebola situation reports
  • "Ebola (Ebola Virus Disease) | CDC". www.cdc.gov. Centers for Disease Control and Prevention. 23 May 2018. Retrieved 28 May 2018.

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