Update on Ebola outbreak in the Democratic Republic of Congo
The World Health Organization (WHO) has determined that the current Ebola outbreak in the Democratic Republic of the Congo (DRC), which started in August 2018, is a Public Health Emergency of International Concern. This is the second largest outbreak of Ebola since the 2014-2016 outbreak in West Africa.
As of 3 December 2019, 3313 cases (3195 confirmed and 118 probable), including 2207 deaths (a case fatality rate of 67%), have been reported in the North Kivu and Ituri provinces of the DRC. A disproportionate number of women and children have been infected during this outbreak. Of the total number of cases, 56% were female and 28% were children <18 years of age. A total of 163 health care workers (5%) have been infected.
The WHO notes that the prolonged humanitarian crisis and deterioration of security in this area sometimes limits the implementation of response activities. There has been increased violence reported, including large-scale, organised attacks on Ebola treatment centres. Violence, widespread civil unrest, and targeted attacks have severely disrupted the response in multiple locations in the last few weeks, threatening to reverse recent progress.
Ring vaccination in health care workers and contacts of Ebola patients using the rVSV-ZEBOV vaccine is ongoing. WHO have prequalified the vaccine, a step that helps to speed up its licensing, access, and roll out in countries most at risk of Ebola outbreaks. The European Medicines Agency has also granted the vaccine a conditional marketing authorisation in the European Union for active immunisation of adults at risk of infection with Ebola. A second vaccine (Ad26.ZEBOV/MVA-BN-Filo, a 2-dose heterologous vaccine regimen) is also now being used.
The experimental Ebola treatments mAb114, remdesivir, ZMapp, REGN-EB3, and favipiravir have been approved for use in the outbreak under the framework of compassionate use. Initial data from a randomised controlled trial showed that REGN-EB3 and mAb114 were associated with a higher likelihood of survival compared to ZMapp and remdesivir. Patients will now receive one of the two better performing drugs in treatment centres going forward.
The WHO rate the risk of national and regional spread as very high, but the global risk level is low. WHO advises against any restriction of travel and trade to the DRC based on the currently available information.
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Initial stages of infection are non-specific, which makes the differential diagnosis broad; therefore, clinical suspicion of the infection with prompt isolation is very important in the context of a history of exposure.
Management is centred around supportive care and infection control. The lack of any specific antiviral treatment or approved vaccine makes treatment difficult; however, several potential therapeutic agents are undergoing accelerated development, and clinical studies are either planned or ongoing.
Case fatality rates range from 25% to 90%, but the average rate was approximately 50% in most treatment centres in the 2014 outbreak in West Africa. Survivors often have prolonged ill health with significant disability.
The risk of sexual transmission from male survivors may persist for at least 12 months.
As there is the possibility of infected people travelling, all countries should have tested and practised protocols ready for screening and managing patients.
A severe, often fatal, zoonotic infection caused by infection by a virus of the Filoviridae family (genus Ebolavirus). There are currently 5 known species: Zaire ebolavirus, Sudan ebolavirus, Tai Forest ebolavirus, Bundibugyo ebolavirus, and Reston ebolavirus. The Zaire ebolavirus is responsible for the outbreak that started in West Africa in 2014, the largest outbreak since the virus was first discovered in 1976.
The virus is thought to be initially acquired from infected animals such as bats and non-human primates, but has potential for human-to-human transmission. Transmission occurs by close contact with body fluids of infected patients. The incubation period after infection is 2 to 21 days (typically 3-12 days). Incubation periods may be shorter in children. Patients are not considered infectious until they develop symptoms. Human infection carries a high case fatality rate depending on the Ebola virus species and quality of supportive care available.
Ebola virus infection is part of the group of conditions known as viral haemorrhagic fevers, and was formerly known as Ebola haemorrhagic fever.
History and exam
Senior Lecturer (Honorary Consultant)
Liverpool School of Tropical Medicine and Royal Liverpool University Hospital
NJB is an author of several references cited in this monograph. NJB is partially supported by the National Institute of Health Research Health Protection Unit in Emerging and Zoonotic Infections at the University of Liverpool and Public Health England. He is affiliated with the Liverpool School of Tropical Medicine. Views expressed in this monograph are those of the contributor and do not necessarily represent the official position of the National Health Service, the National Institute for Health Research, the Department of Health, or Public Health England.
Specialist Trainee in Infectious Diseases
Royal Liverpool University Hospital
MF declares that he has no competing interests.
Wellcome Trust/MoD Research Fellow
Liverpool School of Tropical Medicine
TEF is an author of a number of references cited in this monograph. TEF is a consultant/expert panel member to the World Health Organization, and is funded by the UK Surgeon General and the Wellcome Trust. TEF has received research grants from the Medical Research Council and the UK Public Health Rapid Support Team (UK-PHRST).
University College London
Honorary Clinical Lecturer
London School of Hygiene and Tropical Medicine
CFH declares that she has no competing interests.
Dr Nicholas J. Beeching, Dr Manuel Fenech, Dr Tom E. Fletcher, and Dr Catherine F. Houlihan would like to thank Dr Colin Brown (Infectious Disease Lead, Kings Sierra Leone Partnership) for his helpful comments and insights. CB declares that he has no competing interests.
Wade Hampton Frost Professor of Epidemiology
Professor of Medicine, Microbiology, and Pathology
Division of Infectious Diseases and International Health
University of Virginia
WAP declares that he has no competing interests.
Professor of Medicine and Epidemiology
UT Health Medical School
Medical Director of Epidemiology
Memorial Hermann Texas Medical Center
LO-Z declares that he has no competing interests.
Consultant in Microbiology and Infectious Diseases
Royal Free London NHS Foundation Trust
SM declares that he has no competing interests.
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