2018–19 Kivu Ebola epidemic

2018–19 Kivu Ebola epidemic
Kongo und Uganda 2.svg
Democratic Republic of the Congo & Uganda
Date1 August 2018–present
Casualties
Country Cases (conf/prob/susp) Deaths Last update
Democratic Republic of the Congo DRC 3,019/111/402 2,096[1]
Uganda Uganda 4/0/0 4[2][3][4][5][6]
Total 3,532
(see note 1)
2,100
[note 1]
As of 16 September 2019

The 2018–19 Kivu Ebola epidemic[note 2] began on 1 August 2018, when it was confirmed that four cases had tested positive for Ebola virus disease (EVD) in the eastern region of Kivu in the Democratic Republic of the Congo (DRC).[9][10][11] The Kivu outbreak includes Ituri Province, after the first case was confirmed on 13 August,[8] and in June 2019, the virus reached Uganda, having infected a 5-year-old Congolese boy who entered Uganda with his family.[12] but was contained. In November 2018, the outbreak became the biggest Ebola outbreak in the DRC's history,[13][14][15] and by November, it had become the second-largest Ebola outbreak in recorded history,[16][17][18] behind only the 2013–2016 West Africa epidemic. On 3 May 2019, nine months into the outbreak, the DRC outbreak death toll surpassed 1,000.[19][20]

Since January 2015, the affected province and general area have been experiencing a military conflict, which is hindering treatment and prevention efforts. The World Health Organization (WHO) has described the combination of military conflict and civilian distress as a potential "perfect storm" that could lead to a rapid worsening of the outbreak.[21][22] In May 2019, the WHO reported that since January there had been 42 attacks on health facilities and 85 health workers had been wounded or killed. In some areas, aid organizations have had to stop their work due to violence.[23] Health workers also have to deal with misinformation spread by opposing politicians.[24]

Due to the deteriorating situation in North Kivu and surrounding areas, the WHO raised the risk assessment at the national and regional level from "high" to "very high" in September 2018.[25] In October, the United Nations Security Council stressed that all armed hostility should come to a stop in the DRC, to better fight the ongoing EVD outbreak.[26][27][28] A confirmed case in Goma triggered the decision by the WHO to convene an emergency committee for the fourth time,[29][30] and on 17 July 2019, they announced a Public Health Emergency of International Concern, the highest level of alarm the WHO can sound.[31] On 15 September some slowdown of EVD cases was noted by the WHO in DRC,[32] however contact tracing continues to be below 100%, currently at 89%.[32]

Epidemiology

Figure 1. 2018–19 Kivu Ebola epidemic (total cases-death as of 19 August[33])

Democratic Republic of the Congo

Figure 2. Map of the Democratic Republic of the Congo; North Kivu (orange, middle) South Kivu (dark red, bottom) and Ituri (green, top)

On 1 August 2018, the North Kivu health division notified Congo's health ministry of 26 cases of hemorrhagic fever, including 20 deaths. Four of six samples were sent for analysis to the National Institute of Biological Research in Kinshasa. Four of the six came back positive for Ebola and an outbreak was declared on that date.[34][35] The index case is believed to have been the death and unsafe burial of a 65-year-old woman on 25 July in the town of Mangina; soon afterwards seven members of her immediate family died.[36] This outbreak started just days after the end of the outbreak in Équateur province.[37][38]

By 3 August, the virus had developed in multiple locations; cases were reported in five health zones – Beni, Butembo, Oicha, Musienene and Mabalako – in North Kivu province and additionally, Mandima and Mambasa in Ituri Province.[39] However, one month later there had been confirmed cases only in the Mabalako, Mandima, Beni and Oicha health zones. The five suspected cases in the Mambasa Health Zone proved not to be EVD; it was not possible to confirm the one probable case in the Musienene Health Zone and the two probable cases in the Butembo health zone. No new cases had been recorded in any of those health zones. The first confirmed case in Butembo was announced on 4 September, the same day that it was announced that one of the cases registered at Beni had actually come from the Kalunguta Health Zone.[40]

On 1 August, just after the Ebola epidemic had been declared, Doctors Without Borders/Médecins Sans Frontières (MSF) arrived in Mangina, the epicenter of the outbreak to mount a response against the outbreak.[41] On 2 August, Oxfam indicated it would be taking part in the response to this latest outbreak in the DRC.[42] On 4 August, the World Health Organization (WHO) indicated that the current situation in the DRC, due to several factors, warranted a "high risk assessment" at the national and regional level for public health.[43]

In November, it was reported that the EVD outbreak ran across two provinces (and 14 health zones). The Table 1. Timeline of reported cases reflects cases that were not able to have a laboratory test sample prior to burial as probable cases.[44] By 23 December, the EVD outbreak had spread to more health zones, and at that time 18 such areas had been affected.[45] The current population in DRC is more than 84,000,000 people.[46]

Transition to the 2nd biggest EVD outbreak

The Uganda Ministry of Health has issued an alert for extra surveillance as the neighboring outbreak in the DRC is just 100 kilometres (62 mi) away from its border.[47] On 7 August, the DRC Ministry of Public Health indicated that the total count had climbed to almost 90 cases;[48] two days later, on 9 August, it was nearly 100 cases.[49] On 16 August, the United Kingdom indicated it would help with EVD diagnosis and monitoring in the Democratic Republic of the Congo.[50] On 17 August, the WHO reported that "contacts" numbered about 1500 individuals, however there could be more in certain conflict zones in the DRC that can not be reached.[51] Some 954 contacts were successfully followed up on 18 August, however, Mandima Health Zone indicated resistance; as a consequence, contacts were not followed up there per the World Health Organization.[52]

On 4 September, Butembo, a city with almost one million people and an international airport, logged its first fatality in the Ebola outbreak. The city of Butembo, in the Democratic Republic of the Congo, has trade links to Uganda, which it borders.[53][40]

On 24 September, it was reported that all contact tracing and vaccinations would stop for the foreseeable future in Beni, due to an attack the day before by rebel groups that left several individuals dead.[54] On 25 September, Peter Salama of the World Health Organization indicated that insecurity is obstructing efforts to stop the virus and believes a combination of factors could establish conditions for an epidemic.[55] On 18 October, the Centers for Disease Control and Prevention raised its travelers' alert to the Democratic Republic of the Congo from a level 1 to level 2 for all U.S. travelers.[56] On 26 October, the World Health Organization indicated that half of confirmed cases were not showing any fever symptom, thus making diagnosis more difficult.[57]

On 6 November, the Centers for Disease Control and Prevention (CDC) indicated that the current outbreak in the east region of the DRC may not be containable due to several factors. This would be the first time since 1976 that an outbreak has not been able to be curbed.[58] Due to various situations surrounding the current EVD outbreak, WHO indicated on 13 November, that the viral outbreak would last at least six months.[59]

On 23 November, it was reported that due to a steady increase in cases, it is expected that the EVD outbreak in DRC will overtake the Uganda 2000 outbreak of 425 total cases, to become the second biggest EVD outbreak behind only the West Africa Ebola virus epidemic.[60][17] According to the available statistics, women are being infected at a higher rate, 60%, than their male counterparts due to the EVD outbreak, a report issued 4 December indicated.[61]

On 29 December, the DRC Ministry of Public Health declared "0 new confirmed cases detected because of the paralysis of the activities of the response in Beni, Butembo, Komanda and Mabalako" and no vaccination has occurred for three consecutive days.[62] On 22 January the total case count began to approach 1,000 cases, (951 suspected, probable, confirmed) in the DRC Ministry of Public Health situation report.[63] The graphs below demonstrate the EVD intensity in different locations in the DRC, as well as in the West African epidemic of 2014–15 as a comparison:

On 16 March, the director of the Centers for Disease Control and Prevention indicated that the outbreak in the Democratic Republic of the Congo could last another year, additionally indicating that vaccine supplies could run out.[64]

According to a September 2018 Lancet survey, 25% of respondents in Beni and Butembo believed the Ebola outbreak to be a hoax. These beliefs correlated with decreased likelihood of seeking healthcare or agreeing to vaccination.[65][66] Furthermore, according to the World Health Organization, resistance to vaccination in the Kaniyi health area was ongoing as of March 2019.[67]

On 16 August it was reported that the Ebola virus disease had spread to South Kivu (the third such province where this has occurred in DRC), via two new cases who had travelled from Beni, North Kivu.[68][69] By August 22 the number of cases in Mwenga had risen to four, including one person at a health facility visited by the first case.[70]

Spread to Goma

On 14 July 2019, the first case of EVD was confirmed in the capital of North Kivu, Goma, a city with an international airport and a highly mobile population of 2 million people, which is right at the DRC's eastern border with Rwanda.[71][72][73][74] This case was a man who passed through three health checkpoints, with different names on traveller lists.[30] The WHO stated that he died in a treatment centre,[75] whereas according to Reuters he died en route to a treatment centre.[76] This case triggered the decision by the WHO to again reconvene an emergency committee,[29][30] at which the situation was officially announced as a PHEIC on 17 July 2019.[31]

On 30 July, a second case of EVD was confirmed in the city of Goma, apparently not linked to the first case,[77] and declared dead the following day.[78] Across the border from Goma in the country of Rwanda, Ebola simulation drills are being conducted at health facilities.[79] A third case of EVD was confirmed in Goma on 1 August.[80] On 22 August 2019, Nyiragongo Health Zone, the affected area on the outskirts of Goma, reached 21 days without further cases being confirmed.[81]

Uganda

Figure 7. Map of Uganda; District Kasese in Western Region

On 13 August 2018, the DRC reported a total of 115 cases of the virus within its borders so far.[8][82] A UN agency indicated that steps were being taken to ensure that those leaving the DRC into Uganda were not infected with Ebola, this being done via active screening.[8][82] The government of Uganda opened two Ebola treatment centers at the border with the Democratic Republic of the Congo, though there had not yet been any confirmed cases in the country of Uganda.[83][84] By 13 June 2019, nine treatment units were in place near the affected border.[85]

According to the International Red Cross, a 'most likely scenario' entails an asymptomatic case will at some point enter the country of Uganda undetected among the numerous refugees coming from the DRC.[86] On 20 September, Uganda indicated it was ready for immediate vaccination, should the Ebola virus be detected in any individual.[87][88]

On 21 September, officials of the Democratic Republic of the Congo indicated a confirmed case of EVD at Lake Albert, an entry point into Uganda, though no cases were then confirmed within Ugandan territory.[89][90]

On 2 November, it was reported that the Ugandan government would start vaccination of health workers along the border with the Democratic Republic of the Congo as a proactive measure against the virus.[91] Vaccinations started on 7 November, and by 13 June 2019, 4699 health workers at 165 sites had been vaccinated.[85] Proactive vaccination has also been carried out in South Sudan, with 1471 health workers vaccinated by 7 May 2019.[92]

On 2 January 2019, it was reported that refugee movement from the DRC to Uganda had increased after the presidential elections.[93] On 12 February, it was reported that 13 individuals had been isolated due to their contact with a suspected Ebola case in Uganda;[94] the lab results came back negative several hours later.[95]

On 11 June 2019, the WHO reported that the virus had spread to Uganda. A 5-year-old Congolese boy entered Uganda on the previous Sunday with his family to seek medical care. On 12 June, the WHO reported that the 5-year-old patient had died, while 2 more cases of Ebola infection within the same family were also confirmed.[12][96] On 14 June it was reported that there were 112 contacts since EVD was first detected in Uganda.[97] Ring vaccination of Ugandan contacts was scheduled to start on 15 June.[28] As of 18 June 2019, 275 contacts have been vaccinated per Uganda Ministry of Health.[98]

Other countries that border the Democratic Republic of the Congo are South Sudan, Rwanda and Burundi,[99][100] as well as Angola, Zambia, Tanzania, Central African Republic and Republic of Congo, which are considered to have a lower risk of transmission.[85]

On 14 July an individual entered the country of Uganda from DRC while symptomatic for EVD; there is an ongoing search for contacts in Mpondwe.[101] On 24 July, Uganda marked the needed 42 day period without any EVD cases to be declared Ebola-free.[102] On 29 August, a 9-year-old Congolese girl became the fourth individual in Uganda to test positive for EVD when she crossed from the DRC into the district of Kasese.[103]

Countries with medically evacuated individuals

On 29 December, an American physician who was exposed to the Ebola virus (and who was non-symptomatic) was evacuated, and taken to the University of Nebraska Medical Center.[104][105] On 12 January, the individual was released after 21 days without symptoms.[106]

Table 1. Timeline of reported cases[107]
Date Cases #  Deaths CFR Contacts Sources
Confirmed Probable Suspected Totals
         2018-08-01DRC 4 22 0 26 20 - - [108]
2018-08-03 13 30 33 76 33 76.7% 879 [109][110]
2018-08-05 16 27 31 74 34 79%    966 [111][112]
2018-08-10 25 27 48 100 39 75%    953 [113]
2018-08-12 30 27 58 115 41 - 997 [114]
2018-08-17 64 27 12 103 50 55.6% 1,609 [52]
2018-08-20 75 27 9 111 59 - 2,408 [115]
2018-08-24 83 28 6 117 72 65%    3,421 [116]
2018-08-26 83 28 10 121 75 67.6% 2,445 [117]
2018-08-31 90 30 8 128 78 65%    2,462 [118]
2018-09-02 91 31 9 131 82 - 2,512 [119]
2018-09-07 100 31 14 145 89 68%    2,426 [120]
2018-09-09 101 31 9 141 91 - 2,265 [121][122]
2018-09-14 106 31 17 154 92 67.2% 1,751 [123]
2018-09-16 111 31 7 149 97 - 2,173 [124][125]
2018-09-21 116 31 n/a 147 99 67.3% 1,641 [126]
2018-09-23 119 31 9 159 100 67%    1,836 [127]
2018-09-28 126 31 23 180 102 65%    1,410 [128]
2018-10-02 130 32 17 179 106 65.4% 1,463 [129]
2018-10-05 142 35 11 188 113 63.8% 2,045 [130]
2018-10-07 146 35 21 202 115 63.5% 2,115 [131]
2018-10-12 176 35 32 243 135 64%    2,663 [132]
2018-10-15 181 35 32 248 139 64%    4,707 [133]
2018-10-19 202 35 33 270 153 65%    5,518 [134]
2018-10-21 203 35 14 252 155 65%    5,341 [135]
2018-10-26 232 35 43 310 170 64%    6,026 [57]
2018-10-28 239 35 32 306 174 63.5% 5,991 [136]
2018-11-02 263 35 70 368 186 62.4% 5,036 [137]
2018-11-04 265 35 61 361 186 62%    4,971 [138]
2018-11-09 294 35 60 389 205 62%    4,779 [139]
2018-11-11 295 38 n/a 333 209 - 4,803 [140]
2018-11-16 319 47 49 415 214 59%    4,430 [141]
2018-11-21 326 47 90 463 217 - 4,668 [142]
2018-11-23 365 47 45 457 236 57%    4,354 [143]
2018-11-26 374 47 74 495 241 57%    4,767 [144]
2018-11-30 392 48 63 503 255 58%    4,820 [145]
2018-12-03 405 48 79 532 268 59%    5,335 [146]
2018-12-07 446 48 95 589 283 57%    6,417 [147]
2018-12-10 452 48 n/a 500 289 58%    6,509 [148]
2018-12-14 483 48 111 642 313 59%    6,695 [149]
2018-12-21 526 48 118 692 347 60%    8,422 [150]
2018-12-28 548 48 52 648 361 61%    7,007 [151]
2019-01-04 575 48 118 741 374 60%    5,047 [152]
2019-01-11 595 49 n/a 644 390 61%    4,937 [153]
2019-01-18 636 49 209 894 416 61%    4,971 [154][155]
2019-01-25 679 54 204 937 459 63%    6,241 [156][157]
2019-02-01 720 54 168 942 481 62%    >7,000   [158][159]
2019-02-10 750 61 148 959 510 63%    7,846 [160][161]
2019-02-18 773 65 135 973 534 64%    6,772 [162][163]
2019-02-24 804 65 219 1,088 546 63%    5,739 [164][165]
2019-03-03 830 65 182 1,077 561 63%    5,613 [166][167]
2019-03-10 856 65 191 1,112 582 63%    4,830 [168][169]
2019-03-17 886 65 231 1,182 598 63%    4,158 [170][171]
2019-03-25 944 65 226 1,235 629 62%    4,132 [172][173]
2019-03-31 1,016 66 279 1,361 676 62%    6,989 [67][174]
2019-04-07 1,080 66 282 1,428 721 63%    7,099 [175]
2019-04-14 1,185 66 269 1,520 803 64%    10,461 [176]
2019-04-21 1,270 66 92 1,428 870 65%    5,183 [177]
2019-04-28 1,373 66 176 1,615 930 65%    11,841 [178]
2019-05-05 1,488 66 205 1,759 1,028 66%    12,969 [179]
2019-05-12 1,592 88 534 2,214 1,117 67%    13,174 [180]
2019-05-19 1,728 88 278 2,094 1,209 67%    12,608 [181]
2019-05-26 1,818 94 277 2,189 1,277 67%    20,415 [182]
2019-06-02 1,900 94 316 2,310 1,339 67%    19,465 [183]
2019-06-09 1,962 94 271 2,327 1,384 67%    15,045 [184]
                           2019-06-16 DRC & Uganda 2,051 / 3 94 / 0 319 / 1 2,468 1,440 67%   /100%    15,992 / 90                  [185](see note 1)
2019-06-23 2,145 / 3 94 / 0 276 / 0 2,515 1,506 67%   /100%      15,903 / 110 [186][5]
2019-06-30 2,231 / 3 94 / 0 309 / 0 2,634 1,563 67%   /100%      18,088 / 108 [187][188]
2019-07-07 2,314 / 3 94 / 0 323 / 0 2,731 1,625 68%   /100%    19,227 / 0   [189][190]
2019-07-14 2,407 / 3 94 / 0 335 / 0 2,836 1,665 67%   /100%    19,118 / 0   [191][190]
2019-07-21 2,484 / 3 94 / 0 361 / 0 2,939 1,737 67%   /100%    20,505 / 19 [192][193]
         2019-07-28 DRC 2,565 94 358 3,017 1,782 67%    20,072 [194]
2019-08-04 2,659 94 397 3,150 1,843 67%    19,156 [195]
2019-08-11 2,722 94 326 3,142 1,888 67%    15,988 [196]
2019-08-19 2,783 94 387 3,264 1,934 67%    15,817 [33]
2019-08-25 2,863 105 396 3,364 1,986 67%    17,293 [197]
                          2019-09-01 DRC & Uganda 2,926 / 4 105 / 0 365 / 0 3,396 2,031 67%   /100%    16,370 / 0 [198]
2019-09-08 2,968 / 4 111 / 0 403 / 0 3,486 2,064 67%   /100%    14,737 / 0 [199]
2019-09-15 3,005 / 4 111 / 0 497 / 0 3,613 2,090 67%   /100%    13,294 / 0 [32]

# These figures may increase when new cases are discovered, and fall consequently, when tests show cases were not Ebola-related.
DRC Ministry of Public Health
indicates suspected cases were not counted towards CFR

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