EBOLA UPDATE (06): DEMOCRATIC REPUBLIC OF CONGO, SUSPECTED, RFI, VULNERABILITY, RESPONSE, CONTROL
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International Society for Infectious Diseases
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In this update:
[1] Suspected, RFI
[2] Vulnerability of Congo DR
[3] Response, funding
[4] Control

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[1] Suspected, RFI
11 May 2018. More than 120 unexplained deaths in northeast DRC.
https://www.challenges.fr/monde/cor-plus-de-120-deces-inexpliques-dans-le-nord-est-de-la-rd-congo_586640; in French.
[Congolese authorities have reported more than 120 unexplained deaths in March and April [2018] among refugees in the northeastern Democratic Republic of Congo (DRC), near Uganda, according to a UN report released [Fri 11 May 2018] in Geneva. 93 children under the age of 15 are among the deceased who had symptoms of fever and anemia. The deceased were refugees who came since mid-February [2018] into Djugu territory and were accommodated in Kandoyi, 350 km [about 217 mi] north of Bunia, in Ituri province, the report said.] [Reuters]

[There is no clear evidence that these deaths are related to the current outbreak in the DRC. More information is requested, as a number of infectious agents cause similar symptoms.- Mod.LK]

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[2] Vulnerability of Congo DR
11 May 2018: Why does Ebola keep showing up in the Democratic Republic of the Congo?
https://www.scientificamerican.com/article/why-does-ebola-keep-showing-up-in-the-democratic-republic-of-the-congo/
[Ebola experts have various suspicions about why the DRC remains so vulnerable. Most theories involve the country's large forested areas, and the possibility that infected fruit bats -- widely believed to be the primary reservoir animal for the disease -- are common in the affected areas... In certain areas of the DRC -- including where Ebola has been reported recently -- the disease can now be considered endemic in reservoir animals, Daniel Bausch (a veteran Ebola responder and director of the UK Public Health Rapid Support Team) says.
The extent to which individual countries can detect, confirm, and report the disease may also affect scientists' understanding of why it occurs where it does. Whether or not the DRC is truly seeing the disease much more than some of its neighbors is debatable, Pierre Rollin [Ebola expert with CDC] says. "I think there could be surveillance bias -- it's difficult to say," he says, noting the neighboring Republic of the Congo had multiple Ebola outbreaks in the early 2000s, although none have been reported since 2003. "The reservoir [animal] is in DRC, Gabon, and the Republic of [the] Congo," he says. So what's different? The DRC has more robust Ebola surveillance and lab testing capacity in place, he says, and that may be a factor.] [Byline: Dina Fine Maron]

[Since 2007, the DRC has had more Ebola virus outbreaks than other countries in Africa. Since 1976, 30 Ebola virus outbreaks have been recorded, with this being the 9th known Ebola outbreak to strike DRC, including one with 5 confirmed cases in 2017.
In this report, forestation is considered one important factor contributing to this frequency of outbreaks in the DRC, but deforestation also has been incriminated as a cause for Ebola virus outbreaks. See ProMED archives 20180511.5792856 and 20150924.3667797 for discussion of impact of deforestation. It may be that fragmentation of forests is most important in bringing humans and reservoir hosts in contact with each other. - Mod.LK]

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[3] Response, funding
11 May 2018: WHO and partners working with national health authorities to contain new Ebola outbreak in the Democratic Republic of the Congo
http://www.who.int/news-room/detail/11-05-2018-who-and-partners-working-with-national-health-authorities-to-contain-new-ebola-outbreak-in-the-democratic-republic-of-the-congo
[As of 11 May, 34 Ebola cases have been reported in the area in the past 5 weeks, including 2 confirmed, 18 probable [deceased; case fatality rate 52.9 percent], and 14 suspected cases. 5 samples were collected from 5 patients and 2 have been confirmed by the laboratory. Bikoro health zone is 250 km [about 155 mi] from Mbandaka, capital of Equateur province in an area of the country that is that is very hard to reach. 2 mobile labs are planned to be deployed on 12 May 2018.
"WHO and its partners including MSF [Medecins Sans Frontieres], World Food Programme (WFP), UNICEF [UN Children's Fund], International Federation of Red Cross and Red Crescent Societies (IFRC) and the Congolese Red Cross, UNOCHA [UN Office for the Coordination of Humanitarian Affairs] and MONUSCO [UN Stabilization Mission in the Democratic Republic of the Congo], US Centers for Disease Control and Prevention (US-CDC), the International Organization for Migration (IOM), are all stepping up their support," said Dr Matshidiso Moeti, WHO Regional Director for Africa.
Current bed capacity includes 15 beds in Bikoro. MSF is currently establishing isolation on site and has also deployed 4 mobile isolation units (5 beds each).
WHO is coordinating a major flight plan with UNHAS/WFP [UN Humanitarian Air Service managed by the World Food Programme] to deploy experts, equipment and materials to the field and is working closely with other health partners to prevent further geographical spread, improve surveillance data, and reduce deaths by improving treatment of Ebola patients in Bikoro and the epicentre of Ikoko-Impenge. The cost of the air bridge for 3 months is estimated at USD 2.4 million.
A logistician is expected to arrive in Bikoro this afternoon/evening [11 May 2018] to arrange accommodation/staff logistics. Additional information on access, transportation, and logistics requirements will be communicated tomorrow.
WHO is in the process of sending [Sat 12 May 2018] medical supplies to Bikoro to support the Ebola response, including: personal protective equipment kits (PPE), Interagency Emergency Health Kit (IEHK), boxes for transportation, body bags.
WHO is helping with surveillance of cases by setting up community-based data collection to complement information provided by health facilities.]

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[4] Control
11 May 2018: WHO eyes tough Ebola response, reports 2 new cases
http://www.cidrap.umn.edu/news-perspective/2018/05/who-eyes-tough-ebola-response-reports-2-new-cases
[At a media briefing in Geneva, Peter Salama (WHO Deputy Director-General for Emergency Preparedness and Response), said the outbreak area near Bikoro -- located about 174 miles [280 km] from the provincial capital city of Mbandaka -- has few paved roads and little electricity, and currently the only way to get supplies in is by motorbike.
He said the WHO is in talks with the World Food Programme (WFP) about setting up a helicopter air bridge, but he added that helicopters have limited payloads. To allow small planes to land in the area, officials are exploring the possibility of clearing an airstrip in Bikoro. The WHO estimates that the 3-month air bridge cost to be USD 2.4 million. Despite the remote location, one worrying sign is that the outbreak involves 3 separate locations that cover about 37 miles [about 60 km].
Though the DRC has its own unique cultural practices, he said funeral rituals in the country that include washing and having contact with the dead body and the use of traditional healers, both of which played a superspreading role in in West Africa's 2014-16 outbreak, are similar to those in West Africa. Pierre Formenty, a WHO Ebola expert, told reporters that investigators already know funeral transmission has been an issue in the current outbreak.
Health officials think the DRC Ebola outbreak may have begun sometime in April [2018] because of epidemiologic links with the most recently sick patients, but Salama downplayed suspicions that an illness cluster in January and February in an overlapping area near Bikoro might be related to the outbreak. He said the earlier event consisted of 15 cases and 8 deaths, and 2 samples from patients tested negative for Ebola. The last death in the cluster was reported in February [2018], and so far investigators haven't turned up an epidemiologic links between the previous and current outbreaks. Salama said confusion surrounding possible links between the 2 outbreaks may be stem from nonspecific symptoms of the disease.
The WHO is still waiting on approval from the DRC to use the experimental Ebola vaccine, but plans for deployment are already under way as officials wait for a formal decision from the country's health ministry. Salama said that, fortunately, GAVI, the Vaccine Alliance has already agreed to pay for the vaccine, and the WHO has part of the stockpile in Geneva ready to deploy.
Salama said, however, that there are many complications in using an experimental vaccine, and it's not a simple logistical effort. He said the vaccine must be maintained at -60 to -80 deg C [-76 to -112 F], but cold chain requirements have been mobilized and should be in place as early as the weekend [12-13 May 2018]. The WHO has reached out to experienced Ebola vaccinators from Guinea.
The DRC Ebola outbreak in 2017 ended before a vaccine could be deployed. This current outbreak is the perfect opportunity to test its efficacy in protecting the vulnerable population.]

[The rVSV-ZEBOV vaccine produced by Merck has looked extremely effective in preclinical testing in non-human primates, and in limited testing in humans. But because it is still an experimental vaccine, to administer it, ethics approval and a research plan are required. The recommended protocol for vaccination has been considered to be ring vaccination, where people who already have the disease are identified, and all the individuals in contact with them are traced, and then the contacts of those contacts identified. The contacts in these clusters around the outbreak victims are vaccinated. This approach was effective in eliminating smallpox. See Henao-Restrepo AM, Longini IM, Egger M, al. Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial. Lancet. 2015; 386(9996): 857-66. https://doi.org/10.1016/S0140-6736(15)61117-5. - Mod.LK]

11 May 2018: The new Ebola outbreak could take 'three, maybe four' months to control
https://www.theatlantic.com/health/archive/2018/05/ebola-outbreak-drc-three-four-months/560237/
[Bikoro's geographic location is also troubling. It sits on Lake Tumba, which connects to the mighty Congo River. The river then connects to Kinshasa, the DRC's megacity capital with a population of about 11 million, and Brazzaville, the capital of the adjacent Republic of the Congo. There is a risk that travelers could carry the virus along the river to either major city. "If it's a traffic line, there is a risk," Jasarevic (a World Health Organization spokesperson) told me. "The average incubation period is 4-6 days. You can get the virus and travel for a couple of days before you get symptomatic and become infectious."
But Muyembe (Director-General of the Democratic Republic of the Congo National Institute for Biomedical Research and Professor of Microbiology at Kinshasa University Medical School) thinks the risk is low, "because the circulation on the river is not so high." And in the worst-case scenario, the town of Mbandaka would likely act as the canary in the coal mine. It's a large port town that lies on the Congo River, in the opposite direction to the 2 capitals, but far closer to Bikoro. If sick people were traveling on the river, they'd show up in Mbandaka first. And Muyembe says that Congolese health workers are already setting up there to monitor travelers and check temperatures.] [Byline: Ed Yong]
[Focusing on the river traffic seems like an effective measure to control the spread of Ebola virus. In addition, health care facilities will be needed in Mbandaka to treat infected individuals. - Mod.LK]

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Communicated by:
ProMED-mail Rapporteur Mary Marshall

[HealthMap/ProMED-mail map
Bikoro, Equateur, Congo DR: http://healthmap.org/promed/p/15686]

See Also
Ebola update (05): Congo DR, outbreak update, vaccine, preparedness, research 20180511.5792856
Ebola update (04): Nigeria, Kenya, Congo DR (ET), WHO 20180510.5791247
Ebola update (03): Congo DR (ET), WHO 20180509.5790577
Ebola update (02): Congo DR (ET) 20180508.5789723
Ebola update: Hungary (BU), laboratory exposure 20180422.5761694
2017
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Ebola update (41): biomarkers, diagnostics, news 20171118.5451371 Ebola outbreak back as early as December and did nothing. As a result there were 120 Ebola deaths in March. The termed the deaths as unidentified illness deaths so they did not have to admit to Ebola.

I think this outbreak is going to be serious and we will see it spread across Africa, Europe and North America. Time to open the off shore hospitals surrounding NYC and elsewhere across the US.

Patty