25 Jun 2019

Ebola virus disease (EVD) in Democratic Republic of Congo and Uganda

Case numbers decrease in some key areas of DRC; other areas have seen significant increases while no further cases are reported from Uganda Ebola virus disease (EVD) in Democratic Republic of Congo and Uganda

An epidemic of EVD, which began on 1 August 2018, is continuing in North Kivu and Ituri provinces (north east of the country) [1]. This region is affected by a long-standing humanitarian crisis; the security situation remains unpredictable and poses an ongoing challenge to outbreak response and containment activities [2].

As of 20 June 2019, a cumulative total of 2190 EVD cases were confirmed with 1376 deaths. In the 21 days between 29 May and 18 June, 245 confirmed cases were reported [1]. Although the number of new EVD infections in Katwa and Butembo, both previous hotspots, decreased over in recent weeks, overall, case numbers have increased, most notably in the health district of Mabalako [1,2]. Cases in healthcare workers and infections acquired in hospital settings also increased and areas that were previously affected remain at risk of reintroduction [1].

The number of new confirmed cases may fluctuate daily; over recent weeks case investigations and reporting have been affected by pockets of mistrust in affected communities, political tensions and increasing insecurity in some areas [1].

On 11 June 2019, the Ministry of Health Uganda, confirmed a case of EVD in a child from the Mabalako Health Zone in DRC; the child and his family attended the funeral of the grandfather (confirmed EVD on 2 June 2019). On 10 June 2019 the family crossed into Uganda from DRC via the Bwera border; the first child and two more of the family group were admitted to hospital with suspected EVD [3]. All three were later confirmed and they all died; [4]. A public health response, including contact tracing and vaccination is underway, mainly in Kisinga and Bwera subcounties, Kasese District, Uganda. No further cases have been reported in Uganda since 13 June 2019 [1].

Following this report of cross border spread of EVD from DRC into Uganda, the WHO Director General, under International Health Regulations, convened a meeting of the Emergency Committee (EC) to discuss the ongoing EVD situation. The EC concluded that the outbreak is a health emergency in DRC and the region but the presentation of cases in Uganda was an anticipated event, and as such does not meet all the three criteria for a PHEIC under the IHR and, whilst acknowledging the risk of international spread, considered that the ongoing response would not be enhanced by formal Temporary Recommendations under the IHR (2005) [5]. The full statement of the EC is available.

The European Centre for Disease prevention and Control (ECDC) consider that the probability that EU/EEA citizens living or travelling in EVD-affected areas of DRC will be exposed to the virus is low, provided they adhere to precautionary measures [6]. This outbreak continues to present a negligible to very low risk to the UK public [7].

WHO advises against any restriction of travel and trade to DRC based on the currently available information [1]. The Foreign and Commonwealth Office (FCO) has restrictions on travel to some areas of DRC: travellers are recommended to review the current information prior to departure. 

A weekly situation report is published by the (WHO).

EVD is a severe, often fatal illness in humans and is introduced into human populations by close contact with the blood and other bodily fluids and organs of infected wild animals such as antelopes, bats, chimpanzees, gorillas and monkeys. The virus then spreads from person to person by direct contact with blood, faeces, vomit, organs or other bodily fluids of infected persons; Infection can be transmitted via contact with objects, like contaminated needles or soiled clothing. Outbreaks have been spread by traditional burial practices, when mourners have direct contact with the deceased (such as touching or washing the body, which still contains high levels of Ebola virus) [8,9]. Hospital workers have been infected through close contact with infected patients and insufficient use of correct infection control precautions and barrier nursing procedures. Sexual transmission has been documented, as the virus can be present in semen for months after recovery [8.

Advice for travellers

Visitors to EVD-affected areas face a low risk of becoming infected if usual and enhanced precautions are followed:

  • Avoid contact with symptomatic patients/their bodily fluids; corpses and/or bodily fluids from deceased patients, and all wild animals, alive and dead.
  • Avoid handling or eating bush/wild meat (the meat of wild or feral mammals killed for food).
  • Wash and peel fruit and vegetables before consumption.
  • Wash hands regularly and carefully using soap and water (or alcohol gel when soap is unavailable).
  • Practise safer sex (using barrier contraception).

Exit screening is in operation for travellers leaving from Goma airport, DRC [5].

Get medical advice if you become ill within 21 days after getting home. You should call NHS111 or contact your GP by telephone; although it is very unlikely you have EVD, you should mention any potential exposure to the virus including dates and itinerary of travel.

Humanitarian and other aid workers

  • Risk to UK personnel (non-clinical) working outside the affected areas in DRC is very low.
  • For those working in affected areas, risk will vary, depending on activities undertaken.
  • Exposure risk for those working directly with infected individuals, such as in treatment centres, is low, if strict barrier techniques have been implemented and all staff are provided with and trained in use of appropriate personal protective equipment [7].

More detailed advice can been found in the Public Health England guidance (PHE): Ebola virus disease: information for humanitarian aid workers.

Individuals planning to go to outbreak areas for humanitarian activities should follow advice from their deploying organisation before they travel. PHE is operating a returning workers scheme for humanitarian and healthcare workers who will be residing in England, Wales, Scotland or Northern Ireland after they have completed their deployments. Deploying organisations are asked to register their workers with the scheme in advance of their return to the UK. Further information on the returning workers scheme is available from PHE.

This outbreak is being closely monitored and the risk will be re-evaluated if the epidemiological situation changes. Travellers should monitor NaTHNaC and FCO updates on a regular basis for more information.

There is no licensed vaccine for general use in travellers to prevent EVD. An investigational, currently unlicensed vaccine is available for high risk populations in EVD risk regions in DRC [10].

Advice for health professionals

In the event of a symptomatic person with a relevant travel history presenting for health care, the Imported Fever Service should be contacted via your local infectious disease clinicians or microbiologists in order to discuss testing. The Rare and Imported Pathogens Laboratory will test patient samples if appropriate. Infection control recommendations and other clinical management advice are provided in the national viral haemorrhagic fever guidelines.

Resources

  1. World Health Organization. Disease Outbreak News (DON). Ebola virus disease – Democratic Republic of the Congo. 20 June 2019. [Accessed 24 June 2019]
  2. United Nations Office for the Coordination of Humanitarian Affairs (OCHA): Democratic Republic of the Congo. [Accessed 24 June 2019]
  3. World Health Organization. Ebola virus disease – Republic of Uganda. Disease Outbreak News 13 June 2019 [Accessed 24 June 2019]
  4. Ebola Virus Disease in Uganda; Situation Report 03. 14 June 2019 [Accessed 25 June 2019]
  5. World Health Organization. Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of Congo 14 June 2019 [Accessed 24 June 2019]
  6. European Centre for Disease Prevention and Control (ECDC) Rapid Risk Assessment Ebola virus disease outbreak in North Kivu and Ituri Provinces, Democratic Republic of the Congo – fourth update. 16 April 2019 [Accessed 24 June 2019]
  7. Public Health England. Ebola and Marburg haemorrhagic fevers: outbreaks and case locations. Information about incidents and outbreaks of Ebola and Marburg, both viral haemorrhagic fevers (VHF). Last updated 12 June 2019. [Accessed 24 June 2019]
  8. Public Health England. Guidance. Ebola: overview, history, origins and transmission. Last updated 15 December 2017. [Accessed 24 June 2019]
  9. World Health Organization. Media Centre. New WHO safe and dignified burial protocol – key to reducing Ebola transmission. 7 November 2014. [Accessed 24 June 2019]
  10. World Health Organization. Emergencies, preparedness and response - Research and Development: diagnostics, vaccines and therapies. [Accessed 24 June 2019]

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