The affected province and general area are currently undergoing a military conflict, which is hindering treatment and prevention efforts. The World Health Organization's (WHO) Deputy Director-General for Emergency Preparedness and Response 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 fake news and other misinformation spread by opposing politicians.
By 13 February 2019, the total cases (confirmed, probable and suspected) equalled 1,000 individuals in the DRC; it is a cases count ( ≥ 1,000) for a single country not seen since the 2013 West Africa Epidemic, in Liberia, Guinea and Sierra Leone. On 3 May 2019, nine months into the outbreak, the DRC outbreak surpassed 1,000 deaths due to the EVD epidemic that has yet to be brought under control. For comparison, during the West African Ebola virus outbreak which lasted two years, Guinea (one of the three hardest hit countries) had a total of approximately 2,500 deaths due to EVD.
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. Following the confirmation of cases in Uganda, a third review was conducted by the WHO on 14 June 2019. It concluded that while the outbreak was a health emergency in the DRC and the region, it does not meet all the three criteria for it to be considered a Public Health Emergency of International Concern (PHEIC).
Figure 1. 2018-19 Kivu Ebola epidemic (total cases-death as of 9 June.) (note-above graph omits 9-21, 11/11, 12/10 & 1/11 due to n/a)
Democratic Republic of the Congo
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.
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 World Health Organization (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 2nd biggest EVD outbreak
The Uganda Ministry of Health has issued an alert for extra surveillance as the neighboring outbreak in the DRC is just 100 kilometres (62 mi) away from its border. On 7 August, the DRC Ministry of Public Health indicated that the total count had climbed to almost 90 cases; two days later, on 9 August, it was nearly 100 cases. On 16 August, the United Kingdom indicated it would help with EVD diagnosis and monitoring in the Democratic Republic of the Congo.
On 17 August, the WHO reported that "contacts" numbered about 1500 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 World Health Organization.
On 4 September, Butembo, a city with almost one million people, logged its first fatality in the Ebola outbreak. The city of Butembo, in the Democratic Republic of the Congo, 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 World Health Organization indicated that insecurity is obstructing efforts to stop the virus and
believes a combination of factors could establish conditions for an epidemic. On 18 October, the Centers for Disease Control and Prevention raised its travelers' alert to the Democratic Republic of the Congo from a level 1 to level 2 for all U.S. travelers. On 26 October, the World Health Organization indicated that half of confirmed cases were not showing any fever symptom, thus making diagnosis more difficult.
On 6 November, the Centers for Disease Control and Prevention 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 6 months.
On 23 November, it was reported that due to a steady increase in cases, it is expected that the current 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 current 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 has occurred for three consecutive days. On 22 January the total case count began to approach 1,000 cases, (951 suspected, probable, confirmed) in the DRC Ministry of Public Health situation report. The graphs below demonstrate the EVD intensity in different locations in the DRC:
Figure 2. New cases per week in Mabalako between 2018-07-16 and 2018-12-31
Figure 3. New cases per week in town Beni between 2018-07-23 and 2019-01-28
Figure 4. New cases per week in Butembo (brown) und Katwa (yellow) between 2018-07-23 and 2019-02-04
Figure 5. Evolution of the West Africa Ebola virus epidemic in semiLog plot
On 16 March, the director of the Centers for Disease Control and Prevention indicated that the current outbreak in the Democratic Republic of the Congo could last another year, additionally indicating that vaccine supplies could run out.
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. Furthermore, according to the World Health Organization, resistance to vaccination in the Kaniyi health area is ongoing.
On 11 August, a UN agency indicated that steps were being taken to ensure that those leaving the DRC into Uganda are not infected with Ebola; this is being done via active screening. On 13 August, the DRC reported a total of 115 cases of the virus within its borders so far. Three individuals in Uganda that were suspected of contracting the virus were tested, with negative results.
On 22 August, it was reported that the government of Uganda had opened two Ebola treatment centers at the border with the Democratic Republic of the Congo, though there had not yet been any confirmed cases in the country of Uganda.
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 Democratic Republic of the Congo indicated a confirmed case of EVD at Lake Albert, an entry point into Uganda, though no case has been 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 Democratic Republic of the Congo as a proactive measure against the virus. Other countries that border the Democratic Republic of the Congo are South Sudan, Rwanda and Burundi. 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. There are currently 27 contacts being followed. On 14 June it was reported that there were 112 contacts since EVD was first detected in Uganda.
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.
#numbers are subject to revision both up, when new cases are discovered, and down consequently, when tests show cases were not Ebola-related. † DRC Ministry of Public Health ‡ indicates suspected cases were not counted towards CFR
Figure 7. Goma, which is the capital of North Kivu province
The area in question, North Kivu, is also currently 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 apparently displaced thousands of individuals. According to WHO, health care workers will be accompanied by military personnel for protection; additionally, ring vaccination may not be possible. On 11 August, it was reported that seven individuals were killed in Mayi-Moya due to a military group, about 24 miles from Beni where there are several EVD cases. The WHO is asking for safe passage to those areas that are within conflict zones, so that possible EVD cases may be found.
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.On 4 September, it was reported that on the outskirts of the city of Beni (one of the areas affected by the EVD outbreak) 2 peacekeepers were attacked and wounded by rebel groups in the area which is part of a larger military conflict. On 23 September, it was reported that 14 individuals were killed in a military attack in the city of Beni, which is an area affected by the current EVD outbreak. In September 2018, the World Health Organization'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 5 October, the Nobel Peace Prize was awarded to Denis Mukwege, who tends to the female victims of the ongoing internal armed conflict in the Democratic Republic of the Congo.
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 current 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. A recent position paper by a 'think tank' on the violence and health problem (EVD outbreak) indicates the situation in the DRC may get worse 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 city in Democratic Republic of the Congo for the time being. Beni continues to be the site of attacks by militant groups as 18 civilians were killed on 6 December, according to a report On 22 December it was reported that elections for president of the Democratic Republic of the Congo 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 Democratic Republic of the Congo, and have furthermore decided not to travel to the DRC.
As of 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.
Figure 8. Fruit bats (Group of Rousettus aegyptiacus)
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.
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.
On 27 August, the World Health Organization evaluated the benefits and risks of drug treatment for EVD: Remdesivir, ZMapp, REGN3470-3471-3479, mAb114 and favipiravir.mAb114 (which is a monoclonal antibody) is being used for the first time to treat infected individuals during this EVD outbreak. An alternative treatment of ZMapp has not been used because it requires storage at −20 °C (−4 °F).
On 25 November, the Democratic Republic of the Congo gave approval to start clinical trials for Ebola (EVD) treatment. Medical authorities will not choose which of the four experimental treatments will be given to an individual; instead it will be randomized.
Figure 9. Number of vaccinated people in the epidemic area DRC
On 8 August 2018, the process of vaccination began with rVSV-ZEBOVEbola 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.
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 contact 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.
The Democratic Republic of the Congo Ministry of Public Health reported on 16 August 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.
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.
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."
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.
As of 10 December 2018[update], 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 Democratic Republic of the Congo infected with EVD, of which 33 have died.
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.
Post-Ebola syndrome signs and symptoms in an individual may include, but are not limited to the following:
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 Democratic Republic of Congo, only a few days after the prior outbreak in the same country had been declared over on 24 July.
World Health Organization 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 Democratic Republic of the Congo since 1976:
This map shows previous EVD outbreaks in the area of central Africa, which includes the Democratic Republic of the Congo. This current 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 World Health Organization 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 United States Centers for Disease Control and Prevention (CDC) Special Pathogens Branch.
Figure 11. Ebola (and Marburg virus) outbreaks on the African continent
Figure 12. 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)
Until the current outbreak in North Kivu in 2018, no outbreak had surpassed 320 total cases. As of 24 February 2019, the current 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 current 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".
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.
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.
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