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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
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