Recently, the World Health Organization (WHO) declared the Ebola outbreak in the Democratic Republic of Congo (DRC) a Public Health Emergency of International Concern (PHEIC). This article describes the reasons for the same, and provides basic information about the disease.

Background Information:

A Public Health Emergency of International Concern (PHEIC) is “an extraordinary event that poses a public health risk to other countries through international spread and that potentially requires a coordinated international response.”

The government of DRC declared an outbreak of Ebola Virus Disease (EVD) on 1 August 2018 in North Kivu province of DRC. Over a year later, the outbreak is still continuing.

Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a rare but severe, often fatal illness in humans.

The virus family Filoviridae includes three genera:

1. Cuevavirus,
2. Marburgvirus, and
3. Ebolavirus.

Within the genus Ebolavirus, six species have been identified:

1. Zaire,
2. Bundibugyo,
3. Sudan,
4. Taï Forest,
5. Reston and
6. Bombali.

The virus causing the current outbreak in DRC and the 2014–2016 West African outbreak belongs to the Zaire ebolavirus species.

Transmission:

It is thought that fruit bats of the Pteropodidae family are natural Ebola virus hosts. Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals such as fruit bats, chimpanzees, gorillas, monkeys, forest antelope or porcupines found ill or dead or in the rainforest.

Ebola then spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with:

• Blood or body fluids of a person who is sick with or has died from Ebola
• Objects that have been contaminated with body fluids (like blood, feces, vomit) from a person sick with Ebola or the body of a person who died from Ebola

Health-care workers have frequently been infected while treating patients with suspected or confirmed EVD. This occurs through close contact with patients when infection control precautions are not strictly practiced.

Burial ceremonies that involve direct contact with the body of the deceased can also contribute in the transmission of Ebola.

People remain infectious as long as their blood contains the virus.

Clinical Features:

A person infected with Ebola cannot spread the disease until they develop symptoms.

Symptoms of EVD can be sudden and include:

• Fever
• Fatigue
• Muscle pain
• Headache
• Sore throat

This is followed by:

• Vomiting
• Diarrhoea
• Rash
• Symptoms of impaired kidney and liver function
• In some cases, both internal and external bleeding (for example, oozing from the gums, or blood in the stools).
• Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes.

The average EVD case fatality rate is around 50%. Case fatality rates have varied from 25% to 90% in past outbreaks.

Diagnosis:

It can be difficult to clinically distinguish EVD from other infectious diseases such as malaria, typhoid fever and meningitis.

Current WHO recommended tests include:

• Automated or semi-automated nucleic acid tests (NAT) for routine diagnostic management.
• Rapid antigen detection tests for use in remote settings where NATs are not readily available. These tests are recommended for screening purposes as part of surveillance activities, however reactive tests should be confirmed with NATs.

The preferred specimens for diagnosis include:

• Whole blood collected in ethylenediaminetetraacetic acid (EDTA) from live patients exhibiting symptoms.
• Oral fluid specimen stored in universal transport medium collected from deceased patients or when blood collection is not possible.

Samples collected from patients are an extreme biohazard risk; laboratory testing on non-inactivated samples should be conducted under maximum biological containment conditions. All biological specimens should be packaged using the triple packaging system when transported nationally and internationally.

Treatment:

Supportive care – rehydration with oral or intravenous fluids – and treatment of specific symptoms improves survival. There is as yet no proven treatment available for EVD.

Vaccines:

Vaccines to protect against Ebola are under development (rVSV-ZEBOV vaccine) and have been used to help control the spread of Ebola outbreaks in Guinea and in the Democratic Republic of the Congo (DRC).

Prevention and Control:

Community engagement is key to successfully controlling outbreaks.

Good outbreak control relies on applying a package of interventions, namely

• case management,
• infection prevention and control practices,
• surveillance and contact tracing,
• a good laboratory service,
• safe and dignified burials and
• social mobilisation.

*WHO recommends that male survivors of EVD practice safer sex and hygiene for 12 months from onset of symptoms or until their semen tests negative twice for Ebola virus. Contact with body fluids should be avoided and washing with soap and water is recommended.

*WHO does not recommend isolation of male or female convalescent patients whose blood has been tested negative for Ebola virus.

Key Messages:

The ongoing outbreak of EVD in DRC was declared a Public Health Emergency of International Concern (PHEIC) on 17 July 2019 under International Health Regulations (IHR) (2005), based on the following:

The epicentre of the current outbreak has moved from Mabalako to Beni; and there was one imported case in Goma- a provincial capital with a population of 1 million; an airport with international flights; and bordering Rwanda. 15,000 people cross the border from Goma to Rwanda every day, as Goma is an important centre of economic activities with Rwanda. Closing this border would strongly affect the population of Goma and have adverse implications for the response.

Factors affecting the outbreak include

• population movement in highly densely populated areas;
• weak infection and prevention control practices in many health facilities;
• complex political environment;
• continued reluctance in the community; and
• the ongoing unstable security situation, which led to the recent murders
  of two community health workers.
• delays in case detection and isolation,
• challenges in contact tracing,
• a highly mobile population, and
• multiple routes of transmission.

Nosocomial transmission, burial practices, and the use of traditional healers continue to amplify transmission in affected communities.

There are worrying signs of possible extension of the epidemic. Despite significant improvement in many places, there is concern about potential spread from Goma, even though there have been no new cases in that city. There is also concern about the reinfection and ongoing transmission in Beni, which has been previously associated with seeding of virus into multiple other locations.

Further, the murder of two Health Care Workers demonstrates continued risk for responders owing to the security situation.

In addition, despite previous recommendations for increased resources, the global community has not contributed sustainable and adequate technical assistance, human or financial resources for outbreak response.

The declaration of the PHEIC is not a reflection on the performance of the response team but rather a measure that recognizes the possible increased national and regional risks and the need for intensified and coordinated action to manage them.

The situation will be reassessed within three months.

Useful Links:

Link to WHO’s Ebola Virus Disease site:

https://www.who.int/health-topics/ebola/#tab=overview

Link to WHO news release declaring Ebola outbreak in DRC as PHEIC:

https://www.who.int/news-room/detail/17-07-2019-ebola-outbreak-in-the-democratic-republic-of-the-congo-declared-a-public-health-emergency-of-international-concern

Link to Statement of the Emergency Committee on Ebola (July 2019):

Click to access statement-emergency-committee-ebola-drc-july-2019.pdf

Link to WHO fact sheet on Ebola Virus Disease:

https://www.who.int/news-room/fact-sheets/detail/ebola-virus-disease

Link to WHO guidance on Clinical care for survivors of Ebola Virus Disease:

https://www.who.int/csr/resources/publications/ebola/guidance-survivors/en/

Link to WHO’s Frequently Asked Questions page on Ebola Virus Disease:

https://www.who.int/emergencies/diseases/ebola/frequently-asked-questions