Kivu Ebola epidemic

This article is about the ongoing Ebola virus outbreak in the Democratic Republic of the Congo and Uganda. For the prior Ebola outbreak in DRC, see 2018 Équateur province Ebola outbreak.

2018–19 Kivu Ebola epidemic

Democratic Republic of the Congo & Uganda
Date	1 August 2018–present
Casualties
Country Cases (conf/prob/susp) Deaths Last update DRC 3,168/118/531 2,191 Uganda 4/0/0 4 Total 3,821 (see note 1) 2,195 As of 6 November 2019

The 2018–19 Kivu Ebola epidemic began on 1 August 2018, when it was confirmed that four cases had tested positive for Ebola virus disease (EVD) in the eastern region of Kivu in the Democratic Republic of the Congo (DRC). The Kivu outbreak includes Ituri Province, after the first case was confirmed on 13 August, and in June 2019, the virus reached Uganda, having infected a 5-year-old Congolese boy who entered Uganda with his family, but was contained. In November 2018, the outbreak became the biggest Ebola outbreak in the DRC's history, and by November, it had become the second-largest Ebola outbreak in recorded history, behind only the 2013–2016 West Africa epidemic. On 3 May 2019, nine months into the outbreak, the DRC outbreak death toll surpassed 1,000.

Since January 2015, the affected province and general area have been experiencing a military conflict, which is hindering treatment and prevention efforts. The World Health Organization (WHO) has described the combination of military conflict and civilian distress as a potential "perfect storm" that could lead to a rapid worsening of the outbreak. In May 2019, the WHO reported that since January there had been 42 attacks on health facilities and 85 health workers had been wounded or killed. In some areas, aid organizations have had to stop their work due to violence. Health workers also have to deal with misinformation spread by opposing politicians.

Due to the deteriorating situation in North Kivu and surrounding areas, the WHO raised the risk assessment at the national and regional level from "high" to "very high" in September 2018. In October, the United Nations Security Council stressed that all armed hostility should come to a stop in the DRC, to better fight the ongoing EVD outbreak. A confirmed case in Goma triggered the decision by the WHO to convene an emergency committee for the fourth time, and on 17 July 2019, they announced a Public Health Emergency of International Concern (PHEIC), the highest level of alarm the WHO can sound.

On 15 September, some slowdown of EVD cases was noted by the WHO in DRC, however contact tracing continued to be below 100%, then at 89%. As of mid-October 2019 the transmission of the virus has significantly reduced; it is now confined to the Mandima region near where the outbreak began, and is only affecting 27 health zones in the DRC (down from a peak of 207).

While those infected by EVD are afforded immunity, it has been suggested to have a finite duration. On 31 October, it was reported that an EVD survivor who had been assisting at a treatment center in Beni had been reinfected with EVD and died; such an incident is unprecedented.

Epidemiology

Figure 1. 2018–19 Kivu Ebola epidemic (total cases-death as of 3 November)

Democratic Republic of the Congo

Figure 2. Map of the Democratic Republic of the Congo; North Kivu (orange, middle) South Kivu (dark red, bottom) and Ituri (green, top)

On 1 August 2018, the North Kivu health division notified Congo's health ministry of 26 cases of hemorrhagic fever, including 20 deaths. Four of six samples were sent for analysis to the National Institute of Biological Research in Kinshasa. Four of the six came back positive for Ebola and an outbreak was declared on that date. The index case is believed to have been the death and unsafe burial of a 65-year-old woman on 25 July in the town of Mangina; soon afterwards seven members of her immediate family died. This outbreak started just days after the end of the outbreak in Équateur province.

By 3 August, the virus had developed in multiple locations; cases were reported in five health zones – Beni, Butembo, Oicha, Musienene and Mabalako – in North Kivu province and additionally, Mandima and Mambasa in Ituri Province. However, one month later there had been confirmed cases only in the Mabalako, Mandima, Beni and Oicha health zones. The five suspected cases in the Mambasa Health Zone proved not to be EVD; it was not possible to confirm the one probable case in the Musienene Health Zone and the two probable cases in the Butembo Health Zone. No new cases had been recorded in any of those health zones. The first confirmed case in Butembo was announced on 4 September, the same day that it was announced that one of the cases registered at Beni had actually come from the Kalunguta Health Zone.

On 1 August, just after the Ebola epidemic had been declared, Doctors Without Borders/Médecins Sans Frontières (MSF) arrived in Mangina, the epicenter of the outbreak to mount a response against the outbreak. On 2 August, Oxfam indicated it would be taking part in the response to this latest outbreak in the DRC. On 4 August, the WHO indicated that the current situation in the DRC, due to several factors, warranted a "high risk assessment" at the national and regional level for public health.

In November, it was reported that the EVD outbreak ran across two provinces (and 14 health zones). The Table 1. Timeline of reported cases reflects cases that were not able to have a laboratory test sample prior to burial as probable cases. By 23 December, the EVD outbreak had spread to more health zones, and at that time 18 such areas had been affected. The current population in DRC is more than 84,000,000 people.

Transition to the 2nd biggest EVD outbreak

On 7 August 2018, the DRC Ministry of Public Health indicated that the total count had climbed to almost 90 cases, and The Uganda Ministry of Health issued an alert for extra surveillance as the outbreak was just 100 kilometres (62 mi) away from its border. Two days later the total count was nearly 100 cases. On 16 August, the United Kingdom indicated it would help with EVD diagnosis and monitoring in the DRC. On 17 August, the WHO reported that "contacts" numbered about 1,500 individuals, however there could be more in certain conflict zones in the DRC that can not be reached. Some 954 contacts were successfully followed up on 18 August, however, Mandima Health Zone indicated resistance; as a consequence, contacts were not followed up there per the WHO.

On 4 September, Butembo, a city with almost one million people and an international airport, logged its first fatality in the Ebola outbreak. The city of Butembo, in the DRC, has trade links to Uganda, which it borders.

On 24 September, it was reported that all contact tracing and vaccinations would stop for the foreseeable future in Beni, due to an attack the day before by rebel groups that left several individuals dead. On 25 September, Peter Salama of the WHO indicated that insecurity is obstructing efforts to stop the virus and believed a combination of factors could establish conditions for an epidemic. On 18 October, the U.S. Centers for Disease Control and Prevention (CDC) raised its travelers' alert to the DRC from a level 1 to level 2 for all U.S. travelers. On 26 October, the WHO indicated that half of confirmed cases were not showing any fever symptom, thus making diagnosis more difficult.

According to a September 2018 Lancet survey, 25% of respondents in Beni and Butembo believed the Ebola outbreak to be a hoax. These beliefs correlated with decreased likelihood of seeking healthcare or agreeing to vaccination.

On 6 November, the CDC indicated that the current outbreak in the east region of the DRC may not be containable due to several factors. This would be the first time since 1976 that an outbreak has not been able to be curbed. Due to various situations surrounding the current EVD outbreak, WHO indicated on 13 November, that the viral outbreak would last at least six months.

On 23 November, it was reported that due to a steady increase in cases, it is expected that the EVD outbreak in DRC will overtake the Uganda 2000 outbreak of 425 total cases, to become the second biggest EVD outbreak behind only the West Africa Ebola virus epidemic. According to the available statistics, women are being infected at a higher rate, 60%, than their male counterparts due to the EVD outbreak, a report issued 4 December indicated.

On 29 December, the DRC Ministry of Public Health declared "0 new confirmed cases detected because of the paralysis of the activities of the response in Beni, Butembo, Komanda and Mabalako" and no vaccination had occurred for three consecutive days. On 22 January, the total case count began to approach 1,000 cases, (951 suspected) in the DRC Ministry of Public Health situation report. The graphs below demonstrate the EVD intensity in different locations in the DRC, as well as in the West African epidemic of 2014–15 as a comparison:

• 
  Figure 3. New cases per week in Mabalako between 2018-07-16 and 2018-12-31
• 
  Figure 4. New cases per week in town Beni between 2018-07-23 and 2019-01-28
• 
  Figure 5. New cases per week in Butembo (brown) and Katwa (yellow) between 2018-07-23 and 2019-02-04
• 
  Figure 6. West Africa Ebola epidemic cases per week, for comparison with current outbreak

On 16 March, the director of the CDC indicated that the outbreak in the DRC could last another year, additionally indicating that vaccine supplies could run out. According to the WHO, resistance to vaccination in the Kaniyi Health Zone was ongoing as of March 2019. There was still a belief by some in surrounding areas that the epidemic was a hoax.

Spread to Goma

On 14 July 2019, the first case of EVD was confirmed in the capital of North Kivu, Goma, a city with an international airport and a highly mobile population of 2 million people, which is right at the DRC's eastern border with Rwanda. This case was a man who passed through three health checkpoints, with different names on traveller lists. The WHO stated that he died in a treatment centre, whereas according to Reuters he died en route to a treatment centre. This case triggered the decision by the WHO to again reconvene an emergency committee, at which the situation was officially announced as a PHEIC on 17 July 2019.

On 30 July, a second case of EVD was confirmed in the city of Goma, apparently not linked to the first case, and declared dead the following day. Across the border from Goma in the country of Rwanda, Ebola simulation drills are being conducted at health facilities. A third case of EVD was confirmed in Goma on 1 August. On 22 August 2019, Nyiragongo Health Zone, the affected area on the outskirts of Goma, reached 21 days without further cases being confirmed.

Spread to South Kivu Province

On 16 August 2019, it was reported that the Ebola virus disease had spread to a third province - South Kivu - via two new cases who had travelled from Beni, North Kivu. By August 22, the number of cases in Mwenga had risen to four, including one person at a health facility visited by the first case.

Uganda

Further information: Refugees of Uganda

Figure 7. Map of Uganda; District Kasese in Western Region

On 13 August 2018, the DRC reported a total of 115 cases of the virus within its borders so far. A UN agency indicated that steps were being taken to ensure that those leaving the DRC into Uganda were not infected with Ebola, this being done via active screening. The government of Uganda opened two Ebola treatment centers at the border with the DRC, though there had not yet been any confirmed cases in the country of Uganda. By 13 June 2019, nine treatment units were in place near the affected border.

According to the International Red Cross, a "most likely scenario" entails an asymptomatic case will at some point enter the country of Uganda undetected among the numerous refugees coming from the DRC. On 20 September, Uganda indicated it was ready for immediate vaccination, should the Ebola virus be detected in any individual.

On 21 September, officials of the DRC indicated a confirmed case of EVD at Lake Albert, an entry point into Uganda, though no cases were then confirmed within Ugandan territory.

On 2 November, it was reported that the Ugandan government would start vaccination of health workers along the border with the DRC as a proactive measure against the virus. Vaccinations started on 7 November, and by 13 June 2019, 4,699 health workers at 165 sites had been vaccinated. Proactive vaccination has also been carried out in South Sudan, with 1,471 health workers vaccinated by 7 May 2019.

On 2 January 2019, it was reported that refugee movement from the DRC to Uganda had increased after the presidential elections. On 12 February, it was reported that 13 individuals had been isolated due to their contact with a suspected Ebola case in Uganda; the lab results came back negative several hours later.

On 11 June 2019, the WHO reported that the virus had spread to Uganda. A 5-year-old Congolese boy entered Uganda on the previous Sunday with his family to seek medical care. On 12 June, the WHO reported that the 5-year-old patient had died, while 2 more cases of Ebola infection within the same family were also confirmed. On 14 June it was reported that there were 112 contacts since EVD was first detected in Uganda. Ring vaccination of Ugandan contacts was scheduled to start on 15 June. As of 18 June 2019, 275 contacts have been vaccinated per the Uganda Ministry of Health.

Other countries that border the DRC are South Sudan, Rwanda and Burundi, as well as Angola, Zambia, Tanzania, Central African Republic and Republic of Congo, which are considered to have a lower risk of transmission.

On 14 July, an individual entered the country of Uganda from DRC while symptomatic for EVD; there is an ongoing search for contacts in Mpondwe. On 24 July, Uganda marked the needed 42 day period without any EVD cases to be declared Ebola-free. On 29 August, a 9-year-old Congolese girl became the fourth individual in Uganda to test positive for EVD when she crossed from the DRC into the district of Kasese.

Tanzania

In regards to possible EVD cases in Tanzania, the WHO stated on 21 September that "to date, the clinical details and the results of the investigation, including laboratory tests performed for differential diagnosis of these patients, have not been shared with WHO. The insufficient information received by WHO does not allow for a formulation of a hypotheses regarding the possible cause of the illness". On 27 September, the CDC and U.S. State Department alerted potential travellers to the possibility of unreported EVD cases within Tanzania. On 28 September, the United Kingdom began indicating to potential travelers to Tanzania, the undiagnosed death of an individual (and referencing the WHO, 21 September statement).

The Tanzanian Health Minister Ummy Mwalimu stated on 3 October that there was no Ebola outbreak in Tanzania. The WHO were provided with a preparedness update on 18 October which outlined a range of actions, and included commentary that since the outbreak commenced, there had been "29 alerts of Ebola suspect cases reported, 17 samples tested and were negative for Ebola (including 2 in September 2019)".

Countries with medically evacuated individuals

On 29 December, an American physician who was exposed to the Ebola virus (and who was non-symptomatic) was evacuated, and taken to the University of Nebraska Medical Center. On 12 January, the individual was released after 21 days without symptoms.

Table 1. Timeline of reported cases
Date	Cases #				Deaths	CFR	Contacts	Sources
	Confirmed	Probable	Suspected	Totals
2018-08-01†DRC	4	22	0	26	20	-	-
2018-08-03	13	30	33	76	33	76.7%‡	879
2018-08-05	16	27	31	74	34	79%‡	966
2018-08-10	25	27	48	100	39	75%‡	953
2018-08-12	30	27	58	115	41	-	997
2018-08-17	64	27	12	103	50	55.6%‡	1,609
2018-08-20	75	27	9	111	59	-	2,408
2018-08-24	83	28	6	117	72	65%‡	3,421
2018-08-26	83	28	10	121	75	67.6%‡	2,445
2018-08-31	90	30	8	128	78	65%‡	2,462
2018-09-02	91	31	9	131	82	-	2,512
2018-09-07	100	31	14	145	89	68%‡	2,426
2018-09-09	101	31	9	141	91	-	2,265
2018-09-14	106	31	17	154	92	67.2%‡	1,751
2018-09-16	111	31	7	149	97	-	2,173
2018-09-21	116	31	n/a	147	99	67.3%‡	1,641
2018-09-23	119	31	9	159	100	67%‡	1,836
2018-09-28	126	31	23	180	102	65%‡	1,410
2018-10-02	130	32	17	179	106	65.4%‡	1,463
2018-10-05	142	35	11	188	113	63.8%‡	2,045
2018-10-07	146	35	21	202	115	63.5%‡	2,115
2018-10-12	176	35	32	243	135	64%‡	2,663
2018-10-15	181	35	32	248	139	64%‡	4,707
2018-10-19	202	35	33	270	153	65%‡	5,518
2018-10-21	203	35	14	252	155	65%‡	5,341
2018-10-26	232	35	43	310	170	64%‡	6,026
2018-10-28	239	35	32	306	174	63.5%‡	5,991
2018-11-02	263	35	70	368	186	62.4%‡	5,036
2018-11-04	265	35	61	361	186	62%‡	4,971
2018-11-09	294	35	60	389	205	62%‡	4,779
2018-11-11	295	38	n/a	333	209	-	4,803
2018-11-16	319	47	49	415	214	59%‡	4,430
2018-11-21	326	47	90	463	217	-	4,668
2018-11-23	365	47	45	457	236	57%‡	4,354
2018-11-26	374	47	74	495	241	57%‡	4,767
2018-11-30	392	48	63	503	255	58%‡	4,820
2018-12-03	405	48	79	532	268	59%‡	5,335
2018-12-07	446	48	95	589	283	57%‡	6,417
2018-12-10	452	48	n/a	500	289	58%‡	6,509
2018-12-14	483	48	111	642	313	59%‡	6,695
2018-12-21	526	48	118	692	347	60%‡	8,422
2018-12-28	548	48	52	648	361	61%‡	7,007
2019-01-04	575	48	118	741	374	60%‡	5,047
2019-01-11	595	49	n/a	644	390	61%‡	4,937
2019-01-18	636	49	209	894	416	61%‡	4,971
2019-01-25	679	54	204	937	459	63%‡	6,241
2019-02-01	720	54	168	942	481	62%‡	>7,000
2019-02-10	750	61	148	959	510	63%‡	7,846
2019-02-18	773	65	135	973	534	64%‡	6,772
2019-02-24	804	65	219	1,088	546	63%‡	5,739
2019-03-03	830	65	182	1,077	561	63%‡	5,613
2019-03-10	856	65	191	1,112	582	63%‡	4,830
2019-03-17	886	65	231	1,182	598	63%‡	4,158
2019-03-25	944	65	226	1,235	629	62%‡	4,132
2019-03-31	1,016	66	279	1,361	676	62%‡	6,989
2019-04-07	1,080	66	282	1,428	721	63%‡	7,099
2019-04-14	1,185	66	269	1,520	803	64%‡	10,461
2019-04-21	1,270	66	92	1,428	870	65%‡	5,183
2019-04-28	1,373	66	176	1,615	930	65%‡	11,841
2019-05-05	1,488	66	205	1,759	1,028	66%‡	12,969
2019-05-12	1,592	88	534	2,214	1,117	67%‡	13,174
2019-05-19	1,728	88	278	2,094	1,209	67%‡	12,608
2019-05-26	1,818	94	277	2,189	1,277	67%‡	20,415
2019-06-02	1,900	94	316	2,310	1,339	67%‡	19,465
2019-06-09	1,962	94	271	2,327	1,384	67%‡	15,045
2019-06-16 DRC & Uganda	2,051 / 3	94 / 0	319 / 1	2,468	1,440	67%‡   /100%‡	15,992 / 90	(see note 1)
2019-06-23	2,145 / 3	94 / 0	276 / 0	2,515	1,506	67%‡   /100%‡	15,903 / 110
2019-06-30	2,231 / 3	94 / 0	309 / 0	2,634	1,563	67%‡   /100%‡	18,088 / 108
2019-07-07	2,314 / 3	94 / 0	323 / 0	2,731	1,625	68%‡   /100%‡	19,227 / 0
2019-07-14	2,407 / 3	94 / 0	335 / 0	2,836	1,665	67%‡   /100%‡	19,118 / 0
2019-07-21	2,484 / 3	94 / 0	361 / 0	2,939	1,737	67%‡   /100%‡	20,505 / 19
2019-07-28 DRC	2,565	94	358	3,017	1,782	67%‡	20,072
2019-08-04	2,659	94	397	3,150	1,843	67%‡	19,156
2019-08-11	2,722	94	326	3,142	1,888	67%‡	15,988
2019-08-19	2,783	94	387	3,264	1,934	67%‡	15,817
2019-08-25	2,863	105	396	3,364	1,986	67%‡	17,293
2019-09-01	2,926	105	365	3,396	2,031	67%‡	16,370
2019-09-08	2,968	111	403	3,486	2,064	67%‡	14,737
2019-09-15	3,005	111	497	3,613	2,090	67%‡	13,294
2019-09-22	3,053	111	415	3,583	2,115	67%‡	11,335
2019-09-29	3,074	114	426	3,618	2,133	67%‡	7,775
2019-10-06	3,090	114	414	3,622	2,146	67%‡	7,807
2019-10-13	3,104	114	429	3,647	2,150	67%‡	5,622
2019-10-20	3,123	116	420	3,659	2,169	67%‡	5,570
2019-10-28	3,146	117	357	3,624	2,180	67%‡	4,437
2019-11-03	3,157	117	513	3,787	2,185	67%‡	6,078
# These figures may increase when new cases are discovered, and fall consequently, when tests show cases were not Ebola-related. † DRC Ministry of Public Health ‡ indicates suspected cases were not counted towards CFR

Containment and military conflict

Further information: Kivu conflict

Figure 8. Goma, which is the capital of North Kivu province

The area in question, North Kivu, is in the middle of the Kivu Conflict, a military conflict with thousands of displaced refugees. The affected area has about one million uprooted people and shares borders with Rwanda and Uganda, with cross border movement because of trade activities. The humanitarian crisis and deterioration of the security situation is expected to affect any response to the outbreak.

There are about 70 armed military groups, among them the Alliance of Patriots for a Free and Sovereign Congo and the Mai-Mayi Nduma défense du Congo-Rénové, in North Kivu. The armed fighting has displaced thousands of individuals. According to WHO, health care workers are to be accompanied by military personnel for protection and ring vaccination may not be possible. On 11 August 2018, it was reported that seven individuals were killed in Mayi-Moya due to a military group, about 24 miles from the city of Beni where there were several EVD cases.

On 24 August, it was reported that an Ebola-stricken physician had been in contact with some 97 individuals in an inaccessible military area, hence those 97 contacts could not be diagnosed. In September, it was reported that 2 peacekeepers were attacked and wounded by rebel groups in Beni, and 14 individuals were killed in a military attack. In September 2018, the WHO's Deputy Director-General for Emergency Preparedness and Response described the combination of military conflict and civilian distress as a potential "perfect storm" that could lead to a rapid worsening of the outbreak.

On 20 October, an armed rebel group in the DRC killed some 13 civilians and took 12 children as hostages. This attack occurred in Beni, the epicenter of the outbreak. On 11 November, six people were killed in an attack by an armed rebel group in Beni; as a consequence vaccinations were suspended there. In November 2018, a paper by the U.S. Center for Strategic and International Studies on the violence and the EVD outbreak indicated the situation might worsen depending on the result and response of presidential elections in the country in 2018. Yet another attack reported on 17 November, in Beni by an armed rebel group forced the cessation of EVD containment efforts and WHO staff to evacuate to another DRC city for the time being. Beni continues to be the site of attacks by militant groups as 18 civilians were killed on 6 December. On 22 December it was reported that elections for the President of the DRC would go forward despite the EVD outbreak, including in the Ebola-stricken area of Beni. Four days later, on 26 December, the DRC government reversed itself to indicate those Ebola-stricken areas, such as Beni, would not vote for several months; as a consequence election protesters ransacked an Ebola assessment center in Beni just 24 hours later. Post election tensions continued when it was reported that the DRC government had cut-off internet connections for the population, as the vote results were yet to be released.

On 29 December, Oxfam said it would suspend its work due to the ongoing violence in the DRC; on the same day, the International Rescue Committee suspended their Ebola support efforts as well.

On 18 January, the African Union indicated that presidential election results announcements should be suspended in the DRC, and have furthermore decided not to travel to the DRC.

On 12 June 2019, in Uganda, a 5-year-old boy became the first cross-border victim of Ebola, with two more people testing positive for Ebola. This shows the spread of Ebola to neighboring countries because of rebel attacks and community resistance hampering virus containment work in eastern Congo.

Virology

Further information: Ebola virus

See also: Ebola virus disease § Pathophysiology

Figure 9. Fruit bats (group of Rousettus aegyptiacus)

The DRC Ministry of Public Health confirmed that the new Ebola outbreak is caused by the Zaire ebolavirus species. This is the same strain that was involved in the early 2018 outbreak in western DRC.

Zaire ebolavirus strain is the most lethal of the six known strains (including the newly discovered Bombali strain); it is fatal in up to 90% of cases. Both Ebola and Marburg virus are part of the Filoviridae family.

The filovirus genome contains seven genes, including VP40. The natural reservoir of the virus is thought to be the African fruit bat, which is used in many parts of Africa as bushmeat.

Viral mechanism

A significant part of the actual EVD infection is based on immune suppression. When an individual is infected the pathophysiological process indicates that as systemic inflammation sets in there are coagulation problems, as well as vascular and the aforementioned immune system issues.

Containment

Contact tracing

Contact tracing is a way of identifying those who have been in direct contact with an infected individual and are thus at higher risk of becoming infected or infecting others. Such individuals are monitored for up to 21 days in the case of EVD.

Burials

The IFRC has called funerals "super-spreading events" as burial traditions include kissing and generally touching bodies. Safe burial teams formed by healthworkers are subject to suspicion.

Travel restrictions and border closings

On 26 July, it was reported that the country of Saudi Arabia would not allow visas from the DRC after the WHO declared it an international emergency due to EVD. On 1 August, the country of Rwanda closed its border with the DRC, due to multiple cases in the city of Goma which borders the country in the upper Northwestern region.

Treatment

Further information: Ebola virus disease treatment research

In August 2018, the WHO evaluated the benefits and risks of drug treatment for EVD: Remdesivir, ZMapp, REGN3470-3471-3479, mAb114 and favipiravir. The drug mAb114 (which is a monoclonal antibody) is being used for the first time to treat infected individuals during this EVD outbreak.

In November 2018, the DRC gave approval to start clinical trials for EVD treatment. Medical authorities will not choose which of four experimental treatments will be given to an individual; instead it will be randomized.

On 12 August 2019, it was announced that two clinical trial medications were found to improve the rate of survival in those infected by EVD. They are REGN-EB3, a cocktail of three monoclonal Ebola antibodies, and mAb114. These two will be further used in therapy; when used shortly after infection they were found to have a 90% survival rate. ZMapp and Remdesifir have been discontinued.

Vaccination

Figure 10. Number of vaccinated people in the epidemic area DRC

On 8 August 2018, the process of vaccination began with rVSV-ZEBOV Ebola vaccine. While several studies have shown the vaccine to be safe and protective against the virus, additional research is needed before it can be licensed. Consequently, the WHO reports that it is being used under a ring vaccination strategy with what is known as "compassionate use" to protect persons at highest risk of the Ebola outbreak, i.e. contacts of those infected, contacts of those contacts, and front-line medical personnel. As of 15 September, according to the WHO, almost a quarter of a million individuals have been vaccinated in this current outbreak. Additionally on the same date the FDA set a target action date for March 14, 2020, for Merck's vaccine; should it be approved it'd be the first licensed Ebola vaccine.

On 20 September it was reported that a second vaccine by Johnson & Johnson would be introduced in the current EVD epidemic in the DRC.

Pregnant and lactating women

Based on a lack of evidence about the safety of the vaccine during pregnancy, the DRC ministry of health and the WHO decided to not vaccinate women who are pregnant or lactating. This decision has been criticized as "utterly indefensible" from an ethical perspective by some authorities. They note that as caregivers of the sick, pregnant and lactating women are more likely to contract Ebola. They also note that since it is known that almost 100% of pregnant women who contract Ebola will die, a safety concern should not be a deciding factor. As of June 2019, pregnant and lactating women were also being vaccinated.

Vaccine stockpile

The DRC Ministry of Public Health reported on 16 August 2018 that 316 individuals had been vaccinated. On 24 August, the DRC indicated it had vaccinated 2,957 individuals, including 1,422 in Mabalako against the Ebola virus. By late October, more than 20,000 individuals had been vaccinated. In December, Dr. Peter Salama, who is Deputy Director-General of Emergency Preparedness and Response for WHO, reported that the current 300,000 vaccine stockpile may not be enough to contain this EVD outbreak; additionally it takes several months to make more of the Zaire EVD vaccine (rVSV-ZEBOV). On 11 December, it was reported that the stock of vaccine in Beni was 4,290 doses.

As of August 2019, Merck & Co, the producers of the vaccine in use, reported a stockpile sufficient for 500,000 individuals, with more in production.

Effectiveness

In April 2019, the WHO published the preliminary results of its research, in association with the DRC's Institut National pour la Recherche Biomedicale, into the effectiveness of the ring vaccination program, including data from 93,965 at-risk people who had been vaccinated. WHO stated that the rVSV-ZEBOV-GP vaccine had been 97.5% effective at stopping Ebola transmission, relative to no vaccination. The vaccine had also reduced mortality among those who were infected after vaccination. The ring vaccination strategy was effective at reducing EVD in contacts of contacts (tertiary cases), with only two such cases being reported.

Treatment centres

In August 2018, it was reported that the Mangina Ebola Treatment Center was operational. A fourth Ebola Treatment Center (after those in Mangina, Beni and Butembo) was inaugurated in September in Makeke in the Mandima Health Zone of Ituri Province. Makeke is less than five kilometers from Mangina along a well-traveled local road; the site had been proposed in August when it appeared that a second Ebola Treatment Center would be needed in the area, and space was insufficient in Mangina itself to accommodate one. By mid-September, however, there had been only two additional cases in the Mandima Health Zone, and only sporadic cases were being reported in the Mabalako Health Zone.

In February 2019, it was reported that attacks at treatment centers had been carried out in Butembo and Katwa. The motives behind the attacks were unclear. Due to the violence, international aid organizations had to stop their work in the two communities. In April, an epidemiologist from WHO was killed and two health workers injured in a militia attack on Butembo University Hospital in Katwa. In May, WHO's health emergencies chief said insecurity had become a "major impediment" to controlling the outbreak. He reports that since January there have been 42 attacks on health facilities and 85 health workers have been wounded or killed. "Every time we have managed to regain control over the virus and contain its spread, we have suffered major, major security events. We are anticipating a scenario of continued intense transmission."

Healthcare workers

Health workers must don personal protection equipment during treatment of those affected by the virus, as well as various other tasks. On 3 September, WHO stated that 16 health workers had contracted the virus. On 10 December, the WHO reported that the current DRC outbreak had affected 49 healthcare workers as confirmed cases, and 15 had died. As of 30 April 2019, there have been 92 health care workers in the DRC infected with EVD, of which 33 have died.

On 5 October 2018, the Nobel Peace Prize was awarded to Denis Mukwege, who tends to the female victims of the ongoing internal armed conflict in the DRC.

Prognosis

Main article: Post-Ebola virus syndrome

In terms of prognosis, aside from the possible effects of post-Ebola syndrome, there is also the reality of survivors returning to communities where they might be shunned due to the fear many have in the respective areas of the Ebola virus, hence psychosocial assistance is needed. Per the world Health Organization the current outbreak of EVD has left about 1,000 survivors.

Post-Ebola syndrome signs and symptoms in an individual may include, but are not limited to the following:

• Joint pain
• Muscle pain
• Chest pain
• Hearing loss
• Hair loss
• Memory problems
• Anxiety attacks
• Vision loss

History

Figure 11. Colorized scanning electron micrograph of Ebola virus particles (green)

Further information: List of Ebola outbreaks

Further information: List of epidemics

The Ebola virus disease outbreak in Zaire (Yambuku) started in late 1976, and was the second outbreak ever after the earlier one in Sudan the same year. On 1 August 2018, the tenth Ebola outbreak was declared in the DRC, only a few days after the prior outbreak in the same country had been declared over on 24 July.

WHO chief Tedros Adhanom Ghebreyesus indicated on 15 August, that the current outbreak in DRC may be worse than the West Africa outbreak of 2013–2016, due to several factors. The table below indicates the ten outbreaks that have occurred in the DRC since 1976:

Table 2.

Timeline of Ebola outbreaks in the Democratic Republic of the Congo (formerly Zaire) since 1976

V・T Date	Country	Major location	Outbreak information				Source
			Strain	Cases	Deaths	CFR
Aug 1976	Zaire	Yambuku	EBOV	318	280	88%
Jun 1977	Zaire	Tandala	EBOV	1	1	100%
May–Jul 1995	Zaire	Kikwit	EBOV	315	254	81%
Aug–Nov 2007	Democratic Republic of the Congo	Kasai-Occidental	EBOV	264	187	71%
Dec 2008–Feb 2009	Democratic Republic of the Congo	Kasai-Occidental	EBOV	32	14	45%
Jun–Nov 2012	Democratic Republic of the Congo	Orientale	BDBV	77	36	47%
Aug–Nov 2014	Democratic Republic of the Congo	Tshuapa	EBOV	66	49	74%
May–Jul 2017	Democratic Republic of the Congo	Likati	EBOV	8	4	50%
Apr–Jul 2018	Democratic Republic of the Congo	Équateur Province	EBOV	54	33	61%
Aug 2018–June 2020	Democratic Republic of the Congo	Kivu	EBOV	3,470	2,280	66%
June–Nov 2020	Democratic Republic of the Congo	Équateur Province	EBOV	130	55	42%
Feb 2021–May 2021	Democratic Republic of the Congo	North Kivu	EBOV	12	6	50%
April 2022	Democratic Republic of the Congo	Équateur Province	EBOV	5	5	100%
August 2022	Democratic Republic of the Congo	North Kivu	EBOV	1	1	100%

This map shows previous EVD outbreaks in the area of central Africa, which includes the Democratic Republic of the Congo. This outbreak is the biggest of the ten recorded outbreaks that have occurred in the DRC.

Learning from other responses, such as during the 2000 outbreak in Uganda, the WHO established its Global Outbreak Alert and Response Network, and other public health measures were instituted in areas at high risk. Field laboratories were established to confirm cases, instead of shipping samples to South Africa. Additionally, outbreaks are also closely monitored by the CDC Special Pathogens Branch.

Figure 12. Ebola (and Marburg virus) outbreaks on the African continent

Outlook

Figure 13. Democratic Republic of the Congo EVD outbreaks 1976-9 November 2018 (total cases for this date does not reflect 52 suspected cases)
(Uganda has second most EVD cases '00–'01/425
West African Ebola virus epidemic '13-'16/ >28,000)

Projected cases

Until the outbreak in North Kivu in 2018, no outbreak had surpassed 320 total cases in the Democratic Republic of the Congo. As of 24 February 2019, the outbreak has surpassed 1,000 total cases (1,048) and has yet to be brought under control.

On 10 May, the U.S. Centers for Disease control and Prevention indicated that the outbreak could well surpass the West Africa epidemic given time.

The 12 May issue of WHO Weekly Bulletin on Outbreaks and Other Emergencies, indicates that "continued increase in the number of new EVD cases in the Democratic Republic of the Congo is worrying...no end in sight to the difficult security situation".

Statistical measures

One way to measure the outbreak is the basic reproduction number, R₀, a statistical measure of the average number of people expected to be infected by one person who has a disease. If the rate is less than 1, the infection dies out; if it is greater than 1, the infection continues to spread—with exponential growth in the number of cases. A March 2019, paper by Tariq et al. indicated (rho = −0.37, p < 0.001) oscillating around 0.9 for mean R.

Response

During the Ebola outbreak in Democratic Republic of the Congo, a number of organizations have come forward to help in different capacities: CARITAS DRC, CARE International, Cooperazione Internationale (COOPE), Catholic Organization for Relief and Development Aid (CORDAID/PAP-DRC), International Rescue Committee (IRC), Médecins Sans Frontières (MSF), Oxfam, International Federation of Red Cross and Red Crescent Societies (IFRC), International Committee of the Red Cross (ICRC), and Samaritan's Purse.

WHO

On 12 April 2019, the WHO Emergency Committee was reconvened by the WHO Director-General after an increase in the rate of new cases, and determined that the outbreak still failed to meet the criteria for a Public Health Emergency of International Concern.

Following the confirmation of Ebola crossing into Uganda, a third review by the WHO on 14 June 2019, concluded that while the outbreak was a health emergency in the DRC and the region, it does not meet all the three criteria for a PHEIC. Following a case in Goma, the reconvening of a fourth review was announced on 15 July 2019. The WHO officially announced it as a PHEIC on 17 July 2019, and as of 18 October 2019, it continues to be a PHEIC.

International governments

Financial support has been contributed by the governments of the US and the UK, among others. The UK DfID minister, Rory Stewart, visited the area in July 2019, and called for other western countries, including Canada, France and Germany, to donate more financial aid. He identified a funding deficit of $100–300 million to continue responding to the outbreak until December, for example to pay for ring vaccination. He urged WHO to classify the situation as a PHEIC, to facilitate the release of international aid.

See also

• 2014 Democratic Republic of the Congo Ebola virus outbreak
• 2017 Democratic Republic of the Congo Ebola virus outbreak
• Filoviridae
• Haemorrhagic fever
• rVSV-ZEBOV vaccine

Further reading

• Dokubo, Emily Kainne; Wendland, Annika; Mate, Suzanne E; et al. (September 2018). "Persistence of Ebola virus after the end of widespread transmission in Liberia: an outbreak report". The Lancet Infectious Diseases. 18 (9): 1015–1024. doi:10.1016/S1473-3099(18)30417-1. PMID 30049622.
• Nanclares, Carolina; Kapetshi, Jimmy; Lionetto, Fanshen; et al. (September 2016). "Ebola Virus Disease, Democratic Republic of the Congo, 2014". Emerging Infectious Diseases. 22 (9): 1579–1586. doi:10.3201/eid2209.160354. PMC 4994351. PMID 27533284.
• Claude, Kasereka Masumbuko; Underschultz, Jack; Hawkes, Michael T (October 2018). "Ebola virus epidemic in war-torn eastern DR Congo". The Lancet. 392 (10156): 1399–1401. doi:10.1016/S0140-6736(18)32419-X. PMID 30297137.
• "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.
• Kuhn, Jens; Andersen, Kristian; Baize, Sylvain; 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. PMC 4246247. PMID 25421896.{{cite journal}}: CS1 maint: unflagged free DOI (link)
• Jones-Konneh, Tracey Elizabeth Claire; Suda, Tomomi; Sasaki, Hiroyuki; et al. (2018). "Agent-Based Modeling and Simulation of Nosocomial Infection among Healthcare Workers during Ebola Virus Disease Outbreak in Sierra Leone". The Tohoku Journal of Experimental Medicine. 245 (4): 231–238. doi:10.1620/tjem.245.231. PMID 30078788.
• "International travel and health". World Health Organization (WHO). Retrieved 16 August 2018.
• "Rising to the Ebola challenge, again". Nature Microbiology. 3 (9): 965. 16 August 2018. doi:10.1038/s41564-018-0243-2. PMID 30115963.
• Lévy, Yves; Lane, Clifford; Piot, Peter; et al. (September 2018). "Prevention of Ebola virus disease through vaccination: where we are in 2018". The Lancet. 392 (10149): 787–790. doi:10.1016/S0140-6736(18)31710-0. PMC 6128979. PMID 30104048.
• Dhama, Kuldeep; Karthik, Kumaragurubaran; Khandia, Rekha; et al. (2018). "Advances in Designing and Developing Vaccines, Drugs, and Therapies to Counter Ebola Virus". Frontiers in Immunology. 9: 1803. doi:10.3389/fimmu.2018.01803. PMC 6095993. PMID 30147687.{{cite journal}}: CS1 maint: unflagged free DOI (link)
• West, Brandyn R.; Moyer, Crystal L.; King, Liam B.; et al. (11 September 2018). "Structural Basis of Pan-Ebolavirus Neutralization by a Human Antibody against a Conserved, yet Cryptic Epitope". mBio. 9 (5). doi:10.1128/mBio.01674-18. PMC 6134094. PMID 30206174.
• Nakkazi, Esther (August 2018). "DR Congo Ebola virus outbreak: responding in a conflict zone". The Lancet. 392 (10148): 623. doi:10.1016/S0140-6736(18)31981-0. PMID 30152332.
• Juan-Giner, Aitana; Tchaton, Marie; Jemmy, Jean-Paul; et al. (25 September 2018). "Safety of the rVSV ZEBOV vaccine against Ebola Zaire among frontline workers in Guinea". Vaccine. 37 (48): 7171–7177. doi:10.1016/j.vaccine.2018.09.009. PMID 30266489.
• De Nys, Helene M.; Kingebeni, Placide Mbala; Keita, Alpha K.; et al. (December 2018). "Survey of Ebola Viruses in Frugivorous and Insectivorous Bats in Guinea, Cameroon, and the Democratic Republic of the Congo, 2015–2017". Emerging Infectious Diseases. 24 (12): 2228–2240. doi:10.3201/eid2412.180740. PMC 6256401. PMID 30307845.
• Brett-Major, David; Lawler, James (19 August 2018). "Catching Chances: The Movement to Be on the Ground and Research Ready before an Outbreak". Viruses. 10 (8): 439. doi:10.3390/v10080439. PMC 6116208. PMID 30126221.{{cite journal}}: CS1 maint: unflagged free DOI (link)
• Cousins, Sophie (December 2018). "Violence and community mistrust hamper Ebola response". The Lancet Infectious Diseases. 18 (12): 1314–1315. doi:10.1016/S1473-3099(18)30658-3. PMID 30385158.
• Owens, Michael D.; Rice, Jason (27 November 2018). "The Angolan Pandemic Rapid Response Team: An Assessment, Improvement, and Development Analysis of the First Self-sufficient African National Response Team Curriculum". Disaster Medicine and Public Health Preparedness. 13 (3): 577–581. doi:10.1017/dmp.2018.122. PMID 30479245.
• Den Boon, Saskia; Marston, Barbara J.; Nyenswah, Tolbert G.; et al. (February 2019). "Ebola Virus Infection Associated with Transmission from Survivors". Emerging Infectious Diseases. 25 (2): 249–255. doi:10.3201/eid2502.181011. PMC 6346469. PMID 30500321.
• Coltart, Cordelia E. M.; Lindsey, Benjamin; Ghinai, Isaac; et al. (26 May 2017). "The Ebola outbreak, 2013–2016: old lessons for new epidemics". Philosophical Transactions of the Royal Society B: Biological Sciences. 372 (1721): 20160297. doi:10.1098/rstb.2016.0297. PMC 5394636. PMID 28396469.
• Okoror, Lawrence; Kamara, Abdul; Kargbo, Brima; et al. (6 November 2018). "Transplacental transmission: A rare case of Ebola virus transmission". Infectious Disease Reports. 10 (3): 7725. doi:10.4081/idr.2018.7725. PMC 6297901. PMID 30631407.
• Allegranzi, Benedetta; Ivanov, Ivan; Harrell, Mason; et al. (22 November 2018). "Infection Rates and Risk Factors for Infection Among Health Workers During Ebola and Marburg Virus Outbreaks: A Systematic Review". The Journal of Infectious Diseases. 218 (suppl_5): S679–S689. doi:10.1093/infdis/jiy435. PMC 6249600. PMID 30202878.
• Ilunga Kalenga, Oly; Moeti, Matshidiso; Sparrow, Annie; et al. (29 May 2019). "The Ongoing Ebola Epidemic in the Democratic Republic of Congo, 2018–2019". New England Journal of Medicine. 0 (4): 373–383. doi:10.1056/NEJMsr1904253. ISSN 0028-4793. PMID 31141654.
• Burki, Talha (November 2019). "DRC getting ready to introduce a second Ebola vaccine". The Lancet. Infectious Diseases. 19 (11): 1174–1175. doi:10.1016/S1473-3099(19)30577-8. ISSN 1474-4457. PMID 31657782. Retrieved 31 October 2019.

External links

• World Health Organization Democratic Republic of the Congo crisis information
• World Health Organization Ebola situation reports
• "Ebola outbreak: timeline". Médecins Sans Frontières/Doctors Without Borders. 13 September 2016.
• "Ebola Virus Disease Outbreak Uganda Situation Reports". World Health Organization (WHO). Retrieved 20 June 2019.

Video

Perform Hand Hygiene CDC05

• "Donning PPE: Perform Hand Hygiene Personal Protective Equipment (PPE) | Ebola (Ebola Virus Disease) | CDC". Centers for Disease Control and Prevention (CDC). Retrieved 15 September 2018.
• "Contact tracing/U.S. Department of Health and Human Services Centers for Disease Control and Prevention". Centers for Disease Control and Prevention (CDC). Retrieved 15 September 2018.