Jean-Jacques MUYEMBE-Tamfum, MD, PhD

Prof Microbiology (Univ.Kinshasa)

Director General (INRB)

Democratic Republic of Congo (DRC): 30 years of Ebola outbreaks experience. Ebola: The Human Factor in a Dehumanising Disease

INSTITUTE OF TROPICAL MEDICINE

ANTWERPEN, BELGIUM, 25 NOV 2014.

Order Mononegavirales

Family Filoviridae

Genus Marburgvirus

Species Marburg marburgvirus

Virus 1: Marburg virus

Virus 2: Ravn virus (RAVV)

Genus Ebolavirus

Species Tai Forest ebolavirus

Virus: Taı¨ Forest virus (TAFV)

Species Reston ebolavirus

Virus: Reston virus (RESTV)

Species Sudan ebolavirus

Virus: Sudan virus (SUDV)

Species Zaire ebolavirus

Virus: Ebola virus (EBOV)

Species Bundibugyo ebolavirus

Virus: Bundibugyo virus (BDBV)

Genus Cuevavirus

Species Lloviu cuevavirus

Virus: Lloviu virus (LLOV)

Feldmann H. N Engl J Med 2014. DOI: 10.1056/NEJMp1405314

Species and virulence.

Zaire Ebolavirus: lethality 60-90%.

Sudan Ebolavirus: lethality 40-60%.

Bundibugyo Ebolavirus: lethality 25-50%.

Taï Forest Ebolavirus: lethality 0%.

Modes of contamination Injection: incubation period 6.3days , lethality 100%.

(Yambuku).

Contact: incubation 9.5days, lethality 80%.

Geographic distribution of Ebola virus species.

EBOLAVIRUS

ZAIRE EBOLAVIRUS

RDCONGO GABON

RCONGO GUINEE

SIERRA LEONE

LIBERIA

USA ESPAGNE

NIGERIA SENEGAL

SUDAN EBOLAVIRUS

SUDAN UGANDA

BUNDIBUGYO EBOLAVIRUS

UGANDA DRCONGO

Ebola Reston • USA/Italy: Macaca fascicularis, 1989.

• Philippines: pics.

Taï Forest Ebolavirus • C.Ivoire in 1994: epizootic/chimpanzees

and one human case.

Ecology

EVD is a zoonosis.

Animal reservoir ?

Nonhuman primates (monkeyss, chimpanzees) and others…

Rodents ( bushmeat)

Bats (Viral RNA and Ab, but no Ebola virus isolation)

Hypsignatus monstrosus.

Epomops franquety

Myonycteris torquata

This graphic shows the life cycle of the ebolavirus. Bats are strongly implicated as both reservoirs and

hosts for the ebolavirus. Of the five identified ebolavirus subtypes, four are capable of human-to-human

transmission. Initial infections in humans result from contact with an infected bat or other wild animal.

Strict isolation of infected patients is essential to reduce onward ebolavirus transmission.

EVD Symptoms/signs

Incubation period:2-21 days.

Hemorrhagic manifestations~40%

Neuropsychiatric Manifestations

Photos taken in Uige 2005 on Marburg patient

Agitations in an

Ebola patient,

Kikwit,1995

Ghost face

Documented Ebola virus outbreaks in Congo and Nile bassins.

2001-2002

2003

2005

1994

1996

1997

2001-2003

2000

2007

2008

2011

2012

1976

1979

2007

Yambuku, 1976

Tandala, 1977

Kikwit, 1995

Mweka, 2007

Kaluamba, 2008

Isiro, 2012

Boende, 2014

Mysterious disease of Yambuku,1976

Ecology: region of tropical forests.

Alert: 21 September 1976. Typhoid fever?

Yelow fever?

Severity of situation: « from 5 to 22 September 30 cases , 22 deaths, 4 fled and no cure».

National response : 23 Sept mission to investigate the nature of the deadly disease.

Mysterious disease of Yambuku: serological investigations, 24 Sept.

Collect blood from 5 patients(blood culture) :negative. Widal Test:

1.Mb., wife of the index case: TO=1/10; TH=1/20. blood sample of 17 September. TH= 1/160; TH= 1/80 blood sample of 24 September.

2.Ng., sister of an Ebola patient. TO:1/320; TH:1/160.

3.Ma., pregnant woman (chloramphenicol). TO=1/80; TH: 1/160.

4.Ab., child 5years old, his mother was sick. TO= 1/40; TH= 1/40.

5.Mba., woman (chloramphenicol). TO= 1/40; TH= 1/40.

6.Suk., nurse (chloramphenicol). TO= 1/320; TH= 1/640.

Mysterious disease of Yambuku: pathology investigations.

Post-mortem liver samples collected on 24 Sept 1976.

1. Anangi A35/76: histological aspect compatible with Yellow fever.

2. Amene A37/76: histological aspect compatible with active liver congestion.

3. Mabulu A36/76: Important phenomenon of liver congestion.

BLOOD SAMPLES COLLECTED

ITM/ANTWERP,6 MAY

Novel virus was isolated: Ebola virus

Yambuku outbreak: Transfer of a sick catholic Belgian sister to Kinshasa

Summary of Ebola outbreak in Yambuku, 1976

318 cases, 280 deaths

11 of 17 health care workers infected.

Index case on 5 Sept, last case died on 5 november 1976.

International team on 18 October(WHO/CDC/IMT/IPP/NICD).

Main modes of transmission: reused syringes and participation in traditional funerals.

Dissemination: 55 villages affected and virus introduced to Kinshasa (2 cases).

19 years after Yambuku Ebola outbreak: Kikwit outbreak,1995

525Km, East of Kinshasa.

400.000 inhabitants

Kikwit 2 hospiital: 60 beds.

Kikwit general hospital: 300 beds.

Health Centers: 42.

Alert,27 April,1995.

Bloody diarrhea.

Fever.

Several deaths in communities and among health care workers.

Severity of the situation: even European nuns died of the mysterious disease.

National response: bacteriological

investigation on 28 April 1995.

Departure to Kikwit and set up of small mobile bacteriology lab.

Stool samples from acute cases: S.dysenteriae.

Blood samples: Salmonella Typhi.

Kikwit outbreak: laboratory findings on 1st May, 1995.

NATURE NUMBER NEGATIVE POSITIVE

STOOL CULTURE/

SHIGELLA 97

93 4

BLOOD CULTURE/

S.TYPHI 9 9 0

Kikwit outbreak: age and sex distribution

of diarrhoea cases as of 1st May,1995.

AGE MAN FEMALE TOTAL

<1 1 2 3

1-10 4 2 6

11-20 21 8 29

21-30 16 12 28

>30 20 20 40

TOTAL 62 44 106

Kikwit outbreak: epidemiological

investigations.

FEVER

BLOODY DIARRHOEA

WHO?

WHEN? WHERE?

ADULT.

•Lab technicians ( 2).

•Nurses.

•Medical doctors.

•Others

•KKT2 hospital

•KKT General hospital

•Mosango hospital

•Bonga-Yassa hospital

•10 April, 1995.

•Post-surgery.

•intensive care

Kikwit outbreak:epidemiological lings between cases.

Beya

Médecin

Malade 2/5/95

Palata

Médecin

Malade 1/5/95

Ofur

Médecin

Malade 5/5/95

Mubiala M

Anesthésiste

Malade 15/4/95

Décédé 26/4/95

Dina R

Malade 1/5/95

Daniella

Malade 30/4/95

Clara

Malade 30/4/95

Rde Floralba

Infirmière S.O.

Malade 14/4/95

Décédée 25/4/95

Kingansi

Infirmier S.O.

Malade 14/4/95

Décédée 26/4/95

Musiela F O

Anesthésiste

Malade 1/5/95

Kimfumu M 36 ans

Laborantin KK2

Transféré HGK 9/4/95

Opéré 10 et 11/4/95

EBOLA KIKWIT:sœurs victimes

14 BLOOD SAMPLES COLLECTED ON 4 MAY,1995.

KINSHASA, 5 MAY

ITM/ANTWERP,6 MAY CDC/ATLANTA,9 MAY

KIKWIT, 10 MAY,1995.

Ebola positive

•Ebola Ag.

•Ebola IgM.

•Ebola PCR

Kikwit outbreak: virological

investigations.

summary:Ebola outbreak in Kikwit,1995.

Index case: January, and confirmation of the outbreak: 10 May 1995.

315 cases (75 health care workers).

244 deaths (60 health care workers).

Convalescents: 70.

Families affected: 180; Orphans: 727.

Extension: 25 villages and 1 case in Kinshasa.

End of the outbreak: 24 August,1995.

EVD documented outbreaks in

DRC,1976-2014.

Year Location Cases (% death)

Risk factors (index cases)

Nosocomial infection

Delay in response

1976 Yambuku 318(88) Bushmeat contact ++++ 4 months

1977 Tandala 1(100) ? 0

1995 Kikwit 315(88) Farming activities ++++ 5 months

2007 Mweka 264(71) Bats consumption ? + 4 months

2008 Kaluamba 32(42) Bats consumption ? + 21 days

2013 ISIRO 77 (49,5%)

? ++++

4months

2014 Boende 69 (60%)

Bushmeat contact

+++ 15 days

Kikwit outbreak response by national, regional and district task forces

In 1976

International

team of medical

doctors,

epidemiologists

and virologists.

.

HUMAN

HUMAN

HUMAN

RESERVOIR?

VECTOR?

Ebola virus disease (evd) is a zoonosis

Ebola is a socio-cultural disease

Its emergence: index case

hunting activities (traps, guns).

Bushmeat consumption (nonhuman primates, frugivorous bats).

Virus spread and amplification

Hospitals

Communities: burial practices.

Burial practices as a major factor Ebola virus amplification

Social importance of the dead.

Cleaning of corpses by friends, relatives.

Cutting fingernails and hair to be sent to villages.

Expressions of love and friendship: touching and kissing.

Challenge: to overcome the socio-cultural aspects of Ebola outbreak.

Resistance of population to accept control measures.(What you do without me, is against me).

Engagements of community leaders

Traditional funeral practices…..

Social mobilization :radio, mass gathering

Challenge to overcome hostilities from the communities.

• It will start with children

stones etc.

• Then adults

• Disease from

experts;

• Disease of secret

societies of

educated people.

• Disease of

vampires

• Dramatic situation:

death of members of

Ebola team experts

like in Congo and

Guinea.

Challenge to deliver a safe burial during Kikwit Ebola outbreak,1995.

Safe and humanized burial during Isiro Ebola outbreak

Family’s members wearing gloves,are participating in the burial

Ebola team wearing

PPE is preparing the

corps

Challenges for Ebola patients isolation wards.

Most Ebola patients were

reluctant to stay at the isolation

wards.

•Far away from the city and surrounded by

black plastic materials: Makokou/Gabon in

2000.

•Old mortuary morgue (Libreville, Gabon

2000)

•No running water, no electricity, no W.C.

during Kikwit/DRC outbreak, 1995.

Challenge to deliver appropriate messages.

MHF IN ANGOLA

« There is no cure for this disease »

MHF IN ANGOLA

« Come to hospital and receive treatment »

• High mortality

rate >80% in

isolation center

• Lack of

appropriate

message.

challenge to mitigate stigmatisation of Ebola patients and their families

Smiling Ebola survivors receiving compensation kits (Isiro outbreak 2012)

Visiting Ebola orphans in a village,Kikwit 1995

Burning Ebola patients belongings, Kikwit, 1995

Weekly incidence in Boende district in Equateur province from July 26, 2014 to September 25, 2014

Ebola Virus Disease in West Africa, 2014.

Flambée localisée d’Ebola transformée en épidémies transfrontalières hors contrôle Crise sanitaire en crises économiques, humanitaires.

EVD in DRC were confined at the outbreaks epicenters(1976-2014).

Locations Num cases (%)

Num cases transfered

Secondary Infections

YAMBUKU,1976 318(88%) 1 2

Tandala (1977) 1(100%) 0 0

KIKWIT,1995 315(88%) 1 0

MWEKA, 2007 264(71%) 0 0

Kaluamba, 2008 32(42%) 0 0

ISIRO, 2012 77(49%) 0 0

BOENDE, 2014 67( 49%) 0 0

In summary.

Ebola outbreaks more and more frequent in DRC.

Virus? Yes ++. (2 species)

Socio-cultural dimensions? Yes +++(burial practices).

Remoteness of the epidemic focus

The poor acknowledge of the disease by doctors and nurses who confuse and treat Ebola disease like malaria or typhoid fever.

National expertise in managing Ebola outbreaks (skils in epidemiology, lab, case management, coordination)

EBOLA GREETINGS SAVED LIVES

KIKWIT OUTBREAK,1995 ISIRO OUTBREAK, 2012.

THANK YOU FOR YOUR ATTENTION