Ebola virus disease over in the DRC....

Another year, another outbreak of Ebola virus disease (EVD) overcome in the Democratic Republic of the Congo with the help of a mix of expert local skill and knowledge, isolation and rapid global response.

The World Health Organization have summed up the end of an outbreak in which 4 died, 5 cases were lab confirmed and there were a total of 8 likely EVD cases.

References...

1. http://www.afro.who.int/en/media-centre/pressreleases/item/9744-who-declares-an-end-to-the-ebola-outbreak-in-the-democratic-republic-of-the-congo.html

Ebola in the DRC: list of border-checking countries at seven...

Starting from WHO Regional Office for Africa Ebola Virus Disease (EVD) Situation Report No. 2,[1] there have been an increasing number of countries that are screening ill-looking people for EVD at their ports of entry. Currently [7] there are 7 and they are:

• Kenya
• Nigeria
• Rwanda
• South Africa
• United Republic of Tanzania
• Zambia
• Zimbabwe 

Quite a few more than I listed yesterday. 

Latest EVD figures form the DRC.
Click on image to enlarge.

No borders are closed to travellers from, or who have travelled through, the Democratic Republic of the Congo, which is good news.

Screenshot from SitRep No.5.[1]
Click on image to enlarge.

Presumably this screening relies on the appearance of signs of illness, questionnaires and perhaps thermal camera images to identify feverish people.

As I alluded to yesterday, these efforts are not very effective at actually picking up EVD cases from among a milieu of other febrile illness that stumble through a port of entry.

Studies - some of which are summed up in this Canadian review [2] - are usually not supportive of any practical benefit from using fever as a screening tool to pick out a single disease in passing travellers.[3,4,5] 

However, these screening efforts do play a role in making citizens and politicians feel better and more useful. The precautions may also be helpful in keeping travel flowing.[6] Whether the continued flow of travel during an epidemic that may leak from a hotzone is a good thing or not will no doubt (once again) be dissected after a more more transmissible pathogen sweeps across the world I expect.

References....

1. http://apps.who.int/iris/bitstream/10665/255463/1/EbolaDRC-1652017-eng.pdf?ua=1
2. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0071254/
3. http://afludiary.blogspot.com.au/2011/05/study-thermal-scanners-pandemic.html
4. http://afludiary.blogspot.com.au/2014/11/eid-journal-evaluating-border-entry.html
5. http://afludiary.blogspot.com.au/2014/10/why-airport-screening-cant-stop-mers.html
6. https://www.ncbi.nlm.nih.gov/pubmed/27390092
7. http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=10836&Itemid=2593

Ebola virus disease in the DRC: first graphs...

The World Health Organization have apparently found an outlet for their Ebola virus disease (EVD) reports for 2017's Democratic Republic of the Congo outbreak.

It's not the Disease Outbreak News site. It's not the WHO media page. It's not any of the past EVD outbreak pages on the central WHO site.

Turns out the Situation Reports (SitReps) are to be found on a new page on the WHO African site.[1] Okay. Why not? Found it eventually. I've plotted the first 4 (they started from 15th of May) below. Not much to say about trends at this early stage obviously!

Click on image to enlarge.

Don't go expecting to find how we got to the totals shown on the 15th - those may well be lost details. Or they may come out later. We'll have to wait and see. Outbreaks viewed from the public point of view are very much about patience and trying not to leap to any dramatic conclusions - like those decisions taken by at least one country in Africa to start screening passengers for signs of EVD.[2] It's your budget guys - spend up if it makes you feel safe. At this stage, and perhaps ever, its a pretty wasteful exercise though; apart from your citizens seeing you doing something.

Back to numbers. I'm pretty impressed with the WHOAfro SitRep - the 4th Report carries a detailed table of cases, deaths and locations and also a timeline graphic (below) which is fantastic. 

Click on image to enlarge.This image is part of SitRep No.4.[3]

And to wrap up, just for a glimpse of what has come before and where we are now (and because I promised @kristindownie I would!), I've also added an updated "EVD through time" bar graph. Where we are with the current outbreak total is highlighted using a red arrow and the towering totals of West Africa are indicated by yellow arrows.

Click on image to enlarge.

References...

1. http://www.afro.who.int/en/ebola/ebola-situation-reports.html
2. http://www.premiumtimesng.com/news/231328-ebola-nigeria-intensifies-screening-at-airports.html
3. http://apps.who.int/iris/bitstream/10665/255526/1/EbolaDRC-1852017-eng.pdf?ua=1

Ebola returns to the Democratic Republic of the Congo (DRC): Zaire...

UPDATE No.1 14MAY2017 AEST

UPDATE No.2 15MAY2017 AEST

UPDATE No.3 17MAY2017 AEST

UPDATE No.4 18MAY2017 AEST

 UPDATE No.5 18MAY2017 AEST

UPDATE No.6 10MAY2018 AEST

The World Heath Organization alerted the world on May 12th [1] to an outbreak of Ebola virus disease (EVD) in Likati, a remote region in the Bas-Uele province of the Democratic Republic of the Congo (DRC).[4] The news had been communicated to them on the 11th May by the DRC Ministry of Heath.[6]

This is the 8th recorded outbreak in the DRC and it is hoped that their expertise, together with a range of rapidly mobilised outside expertise, will contain this one quickly and with a minimal loss of life.[5]

It reportedly took 10 days for the first samples to reach the lab in Kinshasa for testing.[8] Google estimates about 47 hours  to travel the ~3,000km from Kinshasa to Aketi (about 50km beyond Likati via Google's inland suggested route - doesn't account for off the 'main' road and forest parts) - it doesn't give estimates for Likati direct. The WHO explained...

See thread here if you use Twitter.

The journey to Likati is not an easy one.[16] Planes and helicopters are being used and there are questions around how secure the area is.[18] While remoteness is anecdotally beneficial for containing the spread of an outbreak, there are 2 clusters of illness and death outside of Bas-Uele, marked on the Ebola SitRep maps, which may test this theory.[17]

There are reportedly 300,000 (GAVI/Merck emergency stockpile [13])-700,000 doses of the  rVSV-ZEBOV vaccine which has been reported to be highly effective at preventing EVD.[3,9,10]

Early numbers were a bit confusing [2] - as often happens in the fog of announcement of an outbreak - but since 22nd April there seem to have been:

• 20 suspected and confirmed cases in total [17]
• 3 fatal cases (proportion of fatal cases: 15%)
• 1 of 5 samples was initially laboratory confirmed (PCR) at Institut National de Recherche Biomédicale (INRB) in Kinshasa - it tested positive for Zaire ebolavirus
• a 2nd case has since been Zaire ebolavirus lab confirmed [12]; 3 have tested negative [17]
• at least 6 cases hospitalised [7]
• ≧416 contacts being traced [17]
• 1st case - 45 year old (or 39yo) male (45M) transported by taxi; died on arrival [11]
• driver fell ill and died
• carer of 45M fell ill and died (=25 contacts) 

• Nambwa health district has notified the greatest number of the earliest cases: 13 in all, with 2 deaths (case fatality: 15%).[15]

References...

1. https://twitter.com/WHO/status/863022054223773697 
2. https://www.theatlantic.com/science/archive/2017/05/a-new-ebola-outbreak-in-the-democratic-republic-of-congo/526506/ 
3. http://www.npr.org/sections/thetwo-way/2017/05/12/528124232/ebola-death-confirmed-in-democratic-republic-of-congo 
4. https://www.wired.com/2017/05/ebola-returns-central-africas-virus-hunters-ready/ 
5. https://foreignpolicy.com/2017/05/12/ebola-returns-in-congo-a-test-of-next-time/ 
6. www.minisanterdc.cd 
7. http://www.who.int/csr/don/13-may-2017-ebola-drc/en/ 
8. http://www.mysanantonio.com/news/local/article/New-Ebola-case-reported-in-Democratic-Republic-of-11143890.php?cmpid=twitter-tablet 
9. http://www.sciencemag.org/news/2017/05/will-vaccine-help-curb-new-ebola-outbreak-drc 
10. http://www.nature.com/news/ebola-vaccine-could-get-first-real-world-test-in-emerging-outbreak-1.21989 
11. http://www.afro.who.int/en/media-centre/pressreleases/item/9609-dr-moeti-in-kinshasa-to-discuss-reponse-to-ebola-outbreak.html 
12. http://www.reuters.com/article/us-health-ebola-congo-idUSKCN18A0ZP
13. https://www.newscientist.com/article/2131131-ebola-once-again-on-the-prowl-as-emergency-teams-stand-ready/
14.  http://reliefweb.int/report/democratic-republic-congo/ebola-virus-disease-democratic-republic-congo-external-situation-0
15. http://www.afro.who.int/en/media-centre/pressreleases/item/9631-drc-response-to-the-ebola-virus-disease-outbreak-in-bas-uele.html
16. http://www.radiookapi.net/2017/05/15/actualite/sante/ebola-en-rdc-defis-et-chances-dun-lointain-enclavement 
17. http://apps.who.int/iris/bitstream/10665/255486/1/EbolaDRC-1752017-eng.pdf?ua=1 
18. http://www.healio.com/infectious-disease/emerging-diseases/news/online/%7Bf835f3ce-da12-4ae7-9c8c-0e0f3d6ef8f3%7D/extent-of-ebola-outbreak-in-drc-may-not-be-known-for-weeks

Maps used to help place Likati and Bas-Uele...

• https://www.google.com.au/maps/place/Likali,+Democratic+Republic+of+the+Congo/@2.8367393,24.0767423,12.58z/data=!4m5!3m4!1s0x174c091f836ed3a7:0x953f2989ce06ee1c!8m2!3d3.3632652!4d23.8882172 
• http://www.maphill.com/democratic-republic-congo/haut-zaire/bas-uele/aketi/likati/maps/physical-map/ 
• https://fr.wikipedia.org/wiki/Bas-Uele 
• http://www.geographic.org/geographic_names/name.php?uni=-2845643&fid=1034&c=congo_democratic_republic_of_the 
• http://www.radiookapi.net/2017/05/12/actualite/sante/rdc-lepidemie-debola-declaree-likati 
• http://nona.net/features/map/placedetail.1780382/Likati/# 
• http://archive.wikiwix.com/cache/?url=http://www.rgc.cd/doctech/UNDP-GIS-25_RDC_administratif.pdf&title=D%C3%A9coupage%20administratif%20de%20la%20R%C3%A9publique%20d%C3%A9mocratique%20du%20Congo 
• https://www.google.com.au/maps/dir/Kinshasa,+Democratic+Republic+of+the+Congo/Aketi,+Democratic+Republic+of+the+Congo/@-1.7639114,16.4322338,6z/data=!4m24!4m23!1m15!1m1!1s0x1a6a3130fe066a8b:0x168b7e4e1f52378d!2m2!1d15.2662931!2d-4.4419311!3m4!1m2!1d16.2417626!2d-4.4576406!3s0x1a6ac3e4a2e33e05:0x9c6b3712d00e8f72!3m4!1m2!1d22.0079434!2d-6.0510275!3s0x1a272e5aeb6c7c2d:0x7dd2311ec9e5eb94!1m5!1m1!1s0x174dc9c406f0b635:0x23818b9272381546!2m2!1d23.7811324!2d2.7388719!3e0 
• http://dlca.logcluster.org/display/public/DLCA/2.3+Democratic+Republic+of+Congo+Road+Network;jsessionid=A0C4684E811ABB1397C9B6C608B9B86F

Updates...

1. Fixed spelling mistakes in Likati, added detail about sampling delays
2. Added references 10-12; noted 2 cases now confirmed, 19 suspect cases in total 
3. Update on where the 300,000 vaccines come from [13]
4. Update on contacts and ReliefWeb and WHO references
5. New SitRep from WHOAfro - altered case & testing numbers
6. Replaced maps to add in the correct population!

Perhaps Bili|1956 was an Ebola virus disease outbreak...

I didn't blog this one earlier in April when it was mentioned in the literature, but have been reminded of it by Secret Squirrel D in relation to my last post.[1]

The main gist of the Letter to Lancet Infectious Diseases by Colebunders and Van den Ende [2] is that there was a clinically compatible outbreak of disease in Bili, Democratic Republic of Congo in 1956 - 20 years earlier than the first documented and laboratory-confirmed EVD outbreak there - when the DRC was called Zaire.

The 5-week disease outbreak manifested as a fever and rash followed after 10 or so days by bleeding from the mouth and nose and some times bloody diarrhoea. Vomiting blood was a precursor to death. Those without any bleeding survived and recovered after 3-weeks.

About 80 of at least 215 people died (37%), with cases clustering among family groups. A very good survival rate for some filovirus infections. Quarantine efforts and safe burials  seemed to halt the outbreak although some bodies were "recovered" by family for re-burial under more traditional circumstances. Its not clear if this process caused any new infections as it did in west Africa in 2014.

The authors of this letter conclude that the disease course, consumption of monkey meat (but not bats, despite the proximity of colonies) suggests the outbreak could have been due to a filovirus of some sort.[1]

Unfortunately we don't know which filovirus, if a filovirus at all, was responsible since there was no laboratory testing to confirm the specific agent. 

So this one remains a "could be" for now. If only there were stored samples.

References...

1. Yes, there were signs that Ebola was in west Africa, perhaps as far back as 1973...
   http://virologydownunder.blogspot.com.au/2015/04/yes-there-were-signs-that-ebola-was-in.html
2. Filovirus epidemic in 1956 in Bili, DRC
   http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(15)70092-7/fulltext

The battle of Ebola gains a second front...the Democratic Republic of Congo (DRC; formerly Zaire) [UPDATE #3]

So there are three reasons for this post. 

• It may be a little while before we get solid confirmed information from the DRC and I think maps are useful for those of us who are ignorant of where countries live! [See below for update from WHO]
• I'm looking for a quick post so I can move the previous post's grisly pictures down the page!
• Mike Reid (see comments below; many thanks) brought to my attention that the range of the hammer-headed bat (Hypsignathus monstrosus; [5]) overlays the current ebolavirus outbreak areas strikingly well. I lifted that range graphic and (imperfectly, in pink) overlaid it onto my map - et voila!

Data for the hammer head bat's (Hypsignathus monstrosus) range come from The International Union for Conservation of Nature (IUCN) Red List of Threatened Species. I adapted the graphic for VDU from Wikipedia [3]

An 24-Aug report quoted the Minister for Health, Felix Kabange Numbi.[2] This latest outbreak occurs in a country that was the site of the first (known) outbreak of a virus of species Zaire ebolavirus (called Ebola virus [1] or EBOV), and which has had six other battles with Ebola virus disease (EVD).

One of the two viruses was reported to have been genotyped as a member of the species Sudan ebolavirus (SUDV) and the second was a "mixed" infection of SUDV and an EBOV.[2] A mixed natural infection of a human would be very...unheard of. Can't really say much more though, until we get this all clarified. 

A 26-Aug WHO-AFRO update noted that the index case, a woman from Ikanamongo village, died 11-Aug sometime after butchering a bush animal.[6] 24 suspected cases of haemorrhagic fever occurred between 28-Jul and 18-Aug. 

The latest updates define that the outbreak is solely due to viruses from the species Zaire ebolavirus.[7,8,9] The EBOV viral variants share 99% nucleotide identity with the Kikwit lineage of viruses from this same species (not "strain"). Put simply, this is the evidence needed to be able to state that the two concurrent EVD outbreaks (indicated in the map above as distinct events), are indeed due to genetically distinct viral variants of Zaire ebolavirus and are not related outbreaks. 

For more on naming ebolaviruses - check out my earlier post "Behind the naming of ebolaviruses".[10]

This latest outbreak was previously and relatively quickly (too quickly? Perhaps a message in there for all of us) described by the World Health Organization as being due to gastroenteritis with haemorrhaging...

.@Fla_Medic It is febrile gastroenteritis with haemorrhaging. If i can find the notice, I will posting. DRC is definitely not #Ebola. Best
— Gregory Härtl (@HaertlG) August 21, 2014

SitRep on #DRC and febrile gastroenteritis with haemorrhaging is only available in French. I can send by email if u ask me. It is not #Ebola
— Gregory Härtl (@HaertlG) August 21, 2014

...but subsequently, we learn today that...

.@Potrblog @WHO I was given premature information from the field. National lab has now tested + for #Ebola. Will be confirmed in a 2nd lab.
— Gregory Härtl (@HaertlG) August 24, 2014

The outbreaks share at least one common potential animal vector range. This is one of three bat species often pointed to as a possible natural host for ebolaviruses.

Since this is not the first time concurrent outbreaks of ebolaviruses have occurred, I was wondering about seasonal factors and whether they attract or affect bats. This new information adds another piece of the puzzle.

References

1. http://virologydownunder.blogspot.com.au/2014/08/behind-naming-of-ebola-virusesnot-yet.html
2. http://www.aljazeera.com/news/africa/2014/08/congo-ebola-outbreak-2014824183430461469.html
3. http://en.wikipedia.org/wiki/File:Hammer-headed_Bat_area.png
4. http://www.iucnredlist.org
5. http://en.wikipedia.org/wiki/Hammer-headed_bat
6. http://www.afro.who.int/en/clusters-a-programmes/dpc/epidemic-a-pandemic-alert-and-response/outbreak-news/4263-ebola-virus-disease-drc.html
7. http://reliefweb.int/report/democratic-republic-congo/update-ebola-virus-disease-drc-no-5-30-august-2014
8. http://www.who.int/mediacentre/news/ebola/2-september-2014/en/
9. http://reliefweb.int/report/democratic-republic-congo/virological-analysis-no-link-between-ebola-outbreaks-west-africa
10. http://virologydownunder.blogspot.com.au/2014/08/behind-naming-of-ebola-virusesnot-yet.html