Four decades of Ebola outbtreaks experience in Democratic Republic of Congo (DRC): African perspective.

JJ Muyembe-Tamfum. MD, PhD.

Professor of Microbiology, Kinshasa

University Medical School.

• RDCONGO

• 1999

• 2007

• 2008

• 2012

• 2014

• RCONGO

• 2001

• 2002

• 2003

• 2005

• GABON

• 1996

• 1997

• 2001

• 2002

• ANGOLA

• 2004

• SUDAN

• 2004

• UGANDA

• 2000

• 2007

• 2008

• 2011

• 2012

2014 • GUINEA

• LIBERIA

• SIERRA LEONE

• NIGERIA

• SENEGAL

• MALI

• USA

• Spain

EBOLA 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

Watsa/Durba, 1998-2000

Mweka, 2007

Mweka, 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 ».

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

Mysterious disease of Yambuku: bacteriological investigations, 24 Sept.

Collect blood from 6 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/CDC,

Novel virus was isolated: Ebola virus

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

19 years after Yambuku Ebola outbreak: Kikwit outbreak,1995

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.

Kikwit outbreak:National response: bacteriological investigation on 28 April 1995 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 links 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.

Characteristics of Ebola outbreaks in 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 preparation ? + 4 months

2008 Mweka 32(42) Bats preparation? 0 21 days

2012 ISIRO 77 (49) ? ++++

4months

2014 Boende 66 (49) Dead monkey ++ 15 days

Characteristics of Ebola outbreaks in DRC,1976-2014.

Year Location Alert Ebola type Ecology

1976 Yambuku Typhoid Fever, Yellow Fever

Ebola Zaire Rural,Region of tropical forests

1995 Kikwit Typhoid Fever Shegellosis

Ebola Zaire Urban, Région of savannah

2007 2008

Mweka Typhoid fever and shigelosis

Ebola Zaire Rural, Region of savannah with forested galeries

2012 Isiro Malaria and bacteremia

Ebola Bundibugyo

Urban, region of tropical forests

2014 Boende Gastro enteritis Ebola Zaire Rural, Region of tropical forests.

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

Locations Num cases (%) Number cases transfered to Kinshasa

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

Mweka, 2008 32(42%) 0 0

ISIRO, 2012 77(49%) 0 0

BOENDE, 2014 66( 49%) 0 0

The 7th Ebola outbreak in DRCongo, 2014

Epidemic curve of EVD in Boende

0

2

4

6

8

10

12

14

16

18

S29 S30 S31 S32 S33 S34 S35 S36 S37 S38 S39 S40 S41 S42 S43 S44 S45 S46

Nb

re d

es c

as

semaine épidemiologique

Evolution hebdomadaire des cas confirmés et probables selon la semaine de

debut de symptome , MVE BOENDE, S30-46,2014

confirmé Probable

The index case: pregnant women

who fell ill on 27 July and died on

11 August

Source of infection: monkey

found dead in the forest by her

husband

From July to November 2014:66

cases

• Probable cases: 28

• Confirmed cases:38.

• Death:49

Epidemic curve of Ebola outbreak in West Africa, 2014: New feature.

No link between the two

outbreaks in West Africa

and Boende.according

to the results of

sequencing of the two

viruses.

EBOV Boende showed

99,2% identity with the

isolate of Kikwit and

96,8% identity to EBOV

variant of West Africa

Control measures: community approach.

National coordinating committee: MOH

Provincial coordinating committee: pMOH

International technical and scientific coordinating committee at the affected district

Epidemiological surveillance

Case management and infection control

Social mobilisation

Hygiene, water and sanitation.

Logistics

Psycho-social support.

Mobile Laboratory and ecological study

Control measures: community approach

Community approach aims to early community engagement and early ownership for implenting Ebola prevention and control measures.

The pluridisciplinary technical teams have to work closely with: APA: administratives/political/Privates local leaders.

Other opinion leaders (priests, pastors, traditionnal healers).

RECO: community relay (community delegate for health)

IT: nurse responsible of the Health zone.

Control measures: community approach

Roles of APA,RECO and IT: Sensitization of community members

Identification of Ebola survivors for prevention and management of community resistance by disseminating their messages in the communities

Dialogue and negociation with communities and affected families.

Promotion of Ebola survivors reintegration in the communities.

Guided visit of the Ebola treatment centers (ETC), because regarded as a « place for dying ».

Implenmentation of negociated solutions with communities members.

CHALLENGE: LOGISTICS

Outbreaks in remote regions;

Difficulties to reach the outbreak epicenters.

.

Difficulties to conduct field activities: long distances for contact follow-up…Bad roads.

Inaccessibility of villages with suspect cases..

CHALLENGE: TO OVERCOME THE SOCIO-CULTURAL ASPECTS OF EBOLA OUTBREAK.

Resistance of population to accept control measures.

Engagements of community leaders

Traditional funeral practices…..

Social mobilization :radio, mass gathering

CHALLENGE TO DELIVER A SAFE BURIAL DURING KIKWIT EBOLA OUTBREAK,1995.

SAFE AND HUMANIZED BRURIAL DURING ISIRO EBOLA OUTBREAK

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

CHALLENGES FOR EBOLA PATIENTS ISOLATION WARDS.

Most Ebola patients were

reluctant to stay at the isolation

wards.

•Far away from the city: Makokou/Gabon in

2000.

•Old morgue (Libreville, Gabon 2000)

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

during Kikwit/DRC outbreak, 1995.

CHALLENGE TO DELIVER ADEQUATE EDUCATIONAL MESSAGES.

MHF IN ANGOLA « There is no cure for this disease »

MHF IN ANGOLA « Come to hospital and receive treatment »

CHALLENGES TO OVERCOME SOCIAL STIGMA

Smiling Ebola survivors receiving compensation kits (Isiro outbreak 2012)

Visiting Ebola orphans (Kikwit outbreak 1995)

Burning Ebola patients belongings, Kikwit, 1995

Ebola transmission cycle in village-based outbreaks in DRCongo.

Number of cases reported

Number of affected villages (%)

Yambuku,1976. Kikwit, 1995

1

2-5

6-9

10-14

15-19

20-29

30 +

17(30,9)

18*(32,7)

12(21,8)

4(7,3)

1(1,8)

1(1,8)

2(3,7)

*Kinshasa case(1) non

included

15*(60)

10(40)

0

0

0

0

0

*Kinshasa case (1)non

included

Total 55 25

Ebola transmission cycle in village-based outbreaks (Ekata, Gabon), 2002.

A.F.

début:24 déc.01

Vivant

L.F.

Début: 24 déc.01

Vivante

M;D; 19 ans

Petit-frère de M;J.

Début: 28 nov 01à Ekata

Décès: 02 déc.01à Ekata

N;O.F. 27 ans

Grand-frère de A.F.

Début: 28 nov01à Ekata

Vivant

Antilope

Cephalopus dorsalis

trouvée morte dans la forêt.

25 nov.01 à Ekata

Ebola outbreak amplification by Makokou Hospital, Gabon, 2002.

N. Judith 23 ansInfirmière HR Makokou

Début 13 déc.01

Décès 20 déc.01

N.Willy 16 ansHR Makokou

Début 20 déc.01

Convalescent

N.Thérèse 77 ansCena Rest

Début 18 fév.02

Décès 21 fév.02

M. 18 moisMakokou Cena Rest

Début 09 fév.02

Décès 10 fév.02

I. Agnès 77 ans

Makokou

Début 18 fév.02

Décès 23 fév.02

I.M. Amstelle 4 ansMakokou

Début 08 fév.02

Décès 12 fév.02

N. Christine 41 ansCena Rest

Début 12 fév.02

Décès 17 fév.02.

K.Madeleine 47 ansLoa Loa

Début 24 janv.02

Décès 03 fév 02

F.Flaubert 32 ansLoa loa

Début 04 janv.02

Décès 18 janv.02

M. Christian 27 ansMakokou

Début 12 janv.02

Décès 19 janv.02

M.Lenny 18 ansHR makokou

Début O2 janv.02

Décès 07 janv.02 à Makokou

M.Jonas 28 ansHR makokou

Début 25 déc.01

Décès 31 déc.01 à Makokou

N.Francis 56 ansHR Makokou

Début 27 déc.01

Convalescent

E.Prosper 56 ansHR Makokou

Début 10 déc.01

Décès 15 déc.01 à Makokou

B.Béatrice 36 ans

Infirmière contaminée à Mékambo.

Début 25 nov 01

Décès 03 déc.01 à Makokou

Gabon-Makokou.Distribution des cas par semaines de début des

symptomes-2001-2002.

0

1

2

3

4

2001

-43

2001

-44

2001

-45

2001

-46

2001

-47

2001

-48

2001

-49

2001

-50

2001

-51

2001

-52

2002

-01

2002

-02

2002

-03

2002

-04

2002

-05

2002

-06

2002

-07

2002

-08

2002

-09

2002

-10

2002

-11

Semaines

No

mb

re d

e c

as Décédé

Vivant

.

HUMAN

HUMAN

HUMAN

RESERVOIR?

VECTOR?

African perspective: Africa without Ebola?

Three slogans for Africa without Ebola.

No animal to human transmission, No Ebola outbreak.

No nosocomial Ebola infection, no Ebola outbreak.

No community Ebola amplification, no Ebola outbreak

Action at the primary contamination source (upstream):

Hunting activities can’t be banned.

But we can promote behaviours changes of hunters/farmers

Action at the hospital settings (downstream):

Promotion of hygiene and sanitation practices.

Infection control programme.

Action at the community level:

Engagement in integrated diseases surveillance

Behaviours changes in traditional funerals .

Ebola outbreaks as a domain of solidarity in

Africa.

DRC has developped a national expertise in managing Ebola outbreaks (skils in epidemiology, mobile lab, case management, coordination):

Sierra Leone and Liberia; lab

experts.

Guinea/Mali:

90 multidisciplinary trained staff.

3 teams of 2 lab experts (rotation).

Côte d’Ivoire: from 2-14 March

2015, Congolese experts went to Abidjan to train

their colleagues in Ebola outbreaks control.

36

CONCLUSION.

Ebola outbreaks in DRC more and more frequent and circulation of both Ebola Zaire and Ebola Bundibugyo.

Remoteness of the epidemic focus

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

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

In DRC Ebola outbreaks are localised without expansion and under control by using simple public health control measures based on community approach.

EBOLA GREETINGS SAVED LIVES

KIKWIT OUTBREAK,1995 ISIRO OUTBREAK, 2012.

THANK YOU FOR YOUR ATTENTION