four decades of ebola outbtreaks experience in democratic .../media/files/activity...
TRANSCRIPT
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