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2018 Kivu Ebola outbreak

The 2018 Kivu Ebola outbreak[note 1] began on 1 August 2018, when it was confirmed that four cases had tested positive for Ebola virus in the eastern region of Kivu in the Democratic Republic of the Congo (DRC).[3][4][5] The Kivu outbreak included Ituri Province, after the first case was confirmed on 13 August.[2] This outbreak started just days after the 2018 Équateur province Democratic Republic of the Congo Ebola virus outbreak.[6][7]

2018 Kivu Ebola outbreak
Initial case: 1 August 2018
North Kivu and Ituri province, DRC
Location of North Kivu and Ituri province in the Democratic Republic of the Congo
Map showing the location the Democratic Republic of the Congo in Africa
Location of the Democratic Republic of the Congo in Africa
Confirmed cases457[1]
Probable cases48[1]
Suspected cases100[1]
Total cases605[1]
Deaths298[1]

The affected province and general area are currently undergoing a military conflict, which is hindering treatment and prevention efforts. The World Health Organization's 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.[8][9] Due to the deteriorating situation in North Kivu and surrounding areas the World Health Organization, on 27 September, has raised the risk assessment at the national and regional level from "high" to "very high".[10]

On 3 October, the United Nations Security Council stressed that all armed hostility should come to a stop in the DRC, to better fight the ongoing Ebola virus outbreak.[11] For the week ending 14 October, DRC indicated 33 cases of EVD were identified, of which 24 died, in one week.[12] On 9 November, at 319 probable and confirmed cases (not counting suspected cases) the 2018 North Kivu and Ituri province Ebola virus outbreak became the biggest in the DRC's history.[13][14]

On 29 November, the 2018 Kivu Ebola outbreak surpassed the total case count of each EVD outbreak that had occurred before, except the West Africa epidemic, to become the second biggest EVD outbreak ever.[15][16][17]

Contents

EpidemiologyEdit

First cases and transmissionEdit

The Democratic Republic of Congo declared an Ebola outbreak on 1 August, when four cases had tested positive for the Ebola virus in the province of North Kivu. That same day, 26 individuals with haemorrhagic signs, along with 20 deaths, were reported in the area of North Kivu.[18][19] On 2 August, Oxfam indicated it would be taking part in the response to this latest outbreak in the DRC.[20]

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.[21] 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.[22]

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.[23] Health authorities in the DRC confirmed they would use the ZEBOV vaccine once again.[23]

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.[24]

 
2018 Kivu Democratic Republic of the Congo Ebola virus outbreak (total cases-death as of 07 Dec.[25]
(note-above graph omits 09-21, 11/11 & 12/10 due to n/a)


Currently the EVD outbreak runs across two provinces (and 14 health zones). The table below reflects cases that were not able to have a laboratory test sample prior to burial as probable cases.[26]

Timeline of reported cases and deaths[27]
Date Cases #  Deaths CFR Contacts Sources
Confirmed Probable Suspected Total
 2018-08-01 4 22 0 26 20 - - [28]
2018-08-03 13 30 33 76 33 76.7% 879 [29][30]
2018-08-05 16 27 31 74 34 79%    966 [31][32]
2018-08-10 25 27 48 100 39 75%    953 [33]
2018-08-12 30 27 58 115 41 - 997 [34]
2018-08-17 64 27 12 103 50 55.6% 1,609 [35]
2018-08-20 75 27 9 111 59 - 2,408 [36]
2018-08-24 83 28 6 117 72 65%    3,421 [37]
2018-08-26 83 28 10 121 75 67.6% 2,445 [38]
2018-08-31 90 30 8 128 78 65%    2,462 [39]
2018-09-02 91 31 9 131 82 - 2,512 [40]
2018-09-07 100 31 14 145 89 68%    2,426 [41]
2018-09-09 101 31 9 141 91 - 2,265 [42][43]
2018-09-14 106 31 17 154 92 67.2% 1,751 [44]
2018-09-16 111 31 7 149 97 - 2,173 [45][46]
2018-09-21 116 31 n/a 147 99 67.3% 1,641 [47]
2018-09-23 119 31 9 159 100 67%    1,836 [48]
2018-09-28 126 31 23 180 102 65%    1,410 [49]
2018-10-02 130 32 17 179 106 65.4% 1,463 [50]
2018-10-05 142 35 11 188 113 63.8% 2,045 [51]
2018-10-07 146 35 21 202 115 63.5% 2,115 [52]
2018-10-12 176 35 32 243 135 64%    2,663 [53]
2018-10-15 181 35 32 248 139 64%    4,707 [54]
2018-10-19 202 35 33 270 153 65%    5,518 [55]
2018-10-21 203 35 14 252 155 65%    5,341 [56]
2018-10-26 232 35 43 310 170 64%    6,026 [57]
2018-10-28 239 35 32 306 174 63.5% 5,991 [58]
2018-11-02 263 35 70 368 186 62.4% 5,036 [59]
2018-11-04 265 35 61 361 186 62%    4,971 [60]
2018-11-09 294 35 60 389 205 62%    4,779 [61]
2018-11-11 295 38 n/a 333 209 - 4,803 [62]
2018-11-16 319 47 49 415 214 59%    4,430 [64]
2018-11-21 326 47 90 463 217 - 4,668 [65]
2018-11-23 365 47 45 457 236 57%    4,354 [66]
2018-11-26 374 47 74 495 241 57%    4,767 [67]
2018-11-30 392 48 63 503 255 58%    4,820 [68]
2018-12-03 405 48 79 532 268 59%    5,335 [69]
2018-12-07 446 48 95 589 283 57%    6,417 [25]
2018-12-10 452 48 n/a 500 289 58%    6,509 [70]

# 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

Increasing cases and second biggest EVD outbreak everEdit

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.[71] On 7 August, the DRC Ministry of Public Health indicated that the total count had climbed to almost 90 cases;[72] two days later, on 9 August, it was nearly 100 cases.[73] On 16 August, the United Kingdom indicated it would help with EVD diagnosis and monitoring in the Democratic Republic of the Congo.[74] 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.[75] 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.[35] On 3 September, WHO stated that 16 health workers had contracted the lethal virus.[40] Health workers must don PPE for protection during treatment of those affected by the virus, as well as various other tasks.[76]

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.[77][22]

 
Evolution of the West Africa Ebola virus epidemic in semiLog plot (currently the only EVD outbreak the 2018 Kivu Ebola outbreak has yet to surpass[17])

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.[78] 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.[79] 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.[80] On 26 October, the World Health Organization indicated that half of confirmed cases were not showing any fever symptom, thus making diagnosis more difficult.[57]

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.[81] Due to various situations surrounding the current EVD outbreak, WHO indicated on 13 November, that the viral outbreak would last at least 6 months.[82]

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.[83][16] 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.[84]

Military conflictEdit

 
North Kivu

The area in question, North Kivu, is also currently in the middle of the Kivu Conflict, a military conflict with thousands of displaced refugees.[85][86] 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.[87][88] The DRC is expected to hold presidential elections at the end of this year.[89]

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.[90] According to WHO, health care workers will be accompanied by military personnel for protection; additionally, ring vaccination may not be possible.[91] 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.[92][93] The WHO is asking for safe passage to those areas that are within conflict zones, so that possible EVD cases may be found.[94]

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 cannot be diagnosed.[95][96]

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.[97] 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.[98] 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.[8][9] 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.[99]

On 20 October, an armed rebel group in DRC killed some 13 civilians and took 12 children as hostages. This attack occurred in Beni which is the current epicenter of the Ebola virus outbreak.[100][101] On 11 November, six people were killed in an attack by an armed rebel group in Beni; as a consequence vaccinations have been suspended there.[102][103] A recent position paper by a 'think tank' on the violence and health problem (EVD outbreak) indicates the situation in DRC may get worse depending on the result and response of presidential elections in the country this year.[104] Yet another attack reported on 17 November, in Beni by an armed rebel group has 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.[105] Beni continues to be the site of attacks by militant groups as 18 civilians were killed on 6 December, according to a report[106]

Bordering countriesEdit

 
Uganda

On 11 August, a UN agency indicated that steps were being taken to assure that those leaving the DRC into Uganda are not infected with Ebola; this is being done via active screening.[2][107] On 13 August, the DRC reported a total of 115 cases of the virus within its borders so far.[2][107] Three individuals in Uganda that were suspected of contracting the virus were tested, with negative results.[108]

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 are as yet no confirmed cases in the country of Uganda.[109][110]

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.[111] On 20 September Uganda indicated it was ready for immediate vaccination, should the Ebola virus be detected in any individual.[112][113]

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.[114][115]

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.[116] Other countries that border the Democratic Republic of the Congo are South Sudan and Rwanda.[117]

VirologyEdit

 
Fruit bats

Zaire ebolavirus strain is the most lethal of the six known strains (including the newly discovered Bombali strain);[118] it is fatal in up to 90% of cases.[119] Both Ebola and Marburg virus are part of the Filoviridae family.[120]

The filovirus genome contains seven genes, including VP40.[121] The natural reservoir of the virus is thought to be the African fruit bat,[122] which is used in many parts of Africa as bushmeat.[123]

Viral mechanismEdit

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.[124]

TreatmentEdit

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.[125] mAb114 (which is a monoclonal antibody) is being used for the first time to treat infected individuals during this EVD outbreak.[126] An alternative treatment of ZMapp has not been used because it requires storage at −20 °C (−4 °F).[2]

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.[127]

VaccinationEdit

On 8 August, the process of vaccination began with rVSV-ZEBOV Ebola vaccine.[128] Although the Ebola vaccine has had efficacy, a review by Medaglini et al. indicated that "long-term protection is undefined" via the vaccine mechanism.[129] The DRC Ministry of Public Health reported on 16 August that 316 individuals had been vaccinated.[130]

On 24 August, the Democratic Republic of the Congo Ministry of Public Health indicated it had vaccinated 2,957 individuals, including 1,422 in Mabalako against the Ebola virus.[131] On 29 August it was reported that women who are pregnant are not being given the vaccine,[132] even though more than 20,000 individuals have been and many more continue to be vaccinated.[133]

Vaccine stockpileEdit

Dr Peter Salama, who is Deputy Director-General of Emergency Preparedness and Response for WHO, indicated 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).[134][135]

Treatment centresEdit

On 14 August, it was reported that the Mangina Ebola Treatment Center was now operational.[136][137] A fourth Ebola Treatment Center (after those in Mangina, Beni and Butembo) was inaugurated on 18 September in Makeke in the Mandima Health Zone of Ituri Province.[138] 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 ETC would be needed in the area, and space was insufficient in Mangina itself to accommodate one.[139] 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.[140]

PrognosisEdit

In terms of prognosis, aside from the possible effects of post-Ebola syndrome,[141] 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,[142][143] hence psychosocial assistance is needed.[144]

Post-Ebola syndrome signs and symptoms in an individual may include, but are not limited to the following:[145][146]

HistoryEdit

 
Ebola virus

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.[147][148] 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.[6][7]

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,[149] due to several factors.[150]

The table below indicates the ten outbreaks that have occurred in the Democratic Republic of the Congo since 1976:

Timeline of Ebola outbreaks in the Democratic Republic of the Congo (formerly Zaire)
VT
Date
Country Major location Outbreak information Source
Strain Cases Deaths CFR
Aug 1976   Zaire Yambuku EBOV 318 280 88% [151]
Jun 1977   Zaire Tandala EBOV 1 1 100% [152][153]
May–Jul 1995   Zaire Kikwit EBOV 315 254 81% [154]
Aug–Nov 2007   Democratic Republic of the Congo Kasai-Occidental EBOV 264 187 71% [155]
Dec 2008–Feb 2009   Democratic Republic of the Congo Kasai-Occidental EBOV 32 14 45% [156]
Jun–Nov 2012   Democratic Republic of the Congo Orientale BDBV 77 36 47% [152]
Aug–Nov 2014   Democratic Republic of the Congo Tshuapa EBOV 66 49 74% [157]
May–Jul 2017   Democratic Republic of the Congo Likati EBOV 8 4 50% [158]
Apr–Jul 2018   Democratic Republic of the Congo Bikoro EBOV 54 33 61% [159]
Aug 2018–present   Democratic Republic of the Congo Kivu EBOV ongoing ongoing ongoing

This map and graph also show previous EVD outbreaks in the area of central Africa, which includes the Democratic Republic of the Congo (the graph is updated as total cases and deaths number may increase as the outbreak expands):

Ebola (and Marburg virus) outbreaks on the African continent[15][160]

Of the ten outbreaks that have occurred in the Democratic Republic of the Congo, on 9 November 319 probable and confirmed cases (not counting suspected cases) made this current outbreak the biggest ever in the DRC.[161]

 
Democratic Republic of the Congo EVD outbreaks 1976-November 9, 2018 (total cases for this date does not reflect 52 suspected cases)[13][27]
(Uganda has second most EVD cases '00-'01/425[162]
West African Ebola virus epidemic '13-'16/ >28,000[163])

See alsoEdit

NotesEdit

  1. ^ Ituri province was added to N. Kivu province, in terms of viral infection, when the first case of EVD was confirmed on 13 August.[2]

ReferencesEdit

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