Ebola Outbreak

Authors: Ifrah Ahmad, Claire Alexander, Katelyn Miyasaki

Timeline

The current Ebola outbreak simmered for weeks before being identified, making its timeline difficult to determine. According to the International Red Cross/Red Crescent, three Red Cross volunteers have died of Ebola after being exposed to infected bodies in late March [1]. The first identified death in this outbreak was a healthcare worker who died in Bunia, Democratic Republic of Congo (DRC), in late April and was buried in Mongbwalu. A close contact died within days. On April 30, samples from Bunia tested negative for Zaire Ebola virus [2].

By the time the WHO learned of the outbreak on May 5, over 50 people had already died, including healthcare workers. On May 11, a Congolese man presented with Ebola symptoms 700 miles away in Kampala, Uganda. He died three days later. On May 13, the World Health Organization (WHO) deployed a rapid response team to Mongbwalu and Rwampara [2].

On May 15, 8 of 13 samples tested in Kampala tested positive for Bundibugyo virus, leading the Congo Health Ministry to announce an Ebola outbreak. At this point, there were 246 suspected cases and 65 deaths in the Democratic Republic of Congo and two cases in Uganda resulting from travel from the DRC [2]. On May 17, the WHO determined that the outbreak constituted a Public Health Emergency of International Concern, the highest alert level excepting a pandemic [3].

On May 18, the United States Centers for Disease Control and Prevention, under the temporary direction of NIH Director Dr. Jay Bhattacharya, announced a Title 42 Order, restricting travel to the United States from the Democratic Republic of Congo, Uganda, and South Sudan [4].

By May 20, there were 600 suspected cases and 139 suspected deaths, with 51 confirmed cases in the Democratic Republic of Congo [5]. On May 22, the WHO updated the DRC’s risk to “very high” [1].

Due to tensions over balancing respect and safety in burials, some communities have reacted violently against treatment centers. On May 21, a treatment center was burned down in Rwampara. On May 23, a treatment tent was burned down in Mongbwalu, causing healthcare workers to lose track of 18 suspected Bundibugyo patients [6]. A third attack on healthcare centers occurred on May 24 [7].

As of May 25, there are 900 suspected cases, including 7 suspected cases in Uganda, some of which were contracted within Uganda. Confirmed cases in Ituri province, Democratic Republic of Congo, have passed 100, and the DRC has reported 220 suspected Ebola deaths [6].

As of May 27, Uganda has closed its border to the DRC amidst Ebola concerns, only allowing entry to “authorized Ebola response teams, humanitarian operations, food and cargo transportation, and essential security personnel” who will also be be required to undergo to “strict health screening” and “continuous monitoring,” and a mandatory isolation of 21 days [8].

Spread

Like other Orthoebolaviruses, Bundibugyo virus is spread through contact with bodily fluids [5]. Because it is not a respiratory virus in primates, it does not typically spread through aerosols, although Orthoebolaviruses can infect primates when aerosolized [9,10].

Orthoebolaviruses are typically infectious only after symptoms have begun, which usually occurs eight to ten days after exposure, although some people develop symptoms in as few as two days or as many as three weeks [11]. Deceased individuals remain highly infectious because viral load increases until death, with the highest viral load at that time. Field studies from previous outbreaks have shown Ebola RNA can be detected in corpses for days to weeks, and enough evidence exists that public health authorities assume recently deceased Ebola victims remain infectious [12,13]. Orthoebolaviruses have an R around two, meaning each patient infects two others in a naive population [13].

Ebola symptoms begin with fever, nausea, body aches, and tiredness [11], making misdiagnosis as malaria or typhoid fever caused by Salmonella bacteria quite likely [13]. The disease progresses to diarrhea and vomiting, bleeding, organ failure, and death [5,11]. Bundibugyo virus likely has a mortality rate between 30 and 50% [13].

This outbreak is especially worrisome because Bundibugyo lacks any therapeutics or vaccines, the outbreak has affected the major cities of Kampala and Goma, healthcare workers have died after treating unidentified cases, and armed conflict in the DRC hampers public health responses [13]. South Sudan, a neighbor of Uganda and the DRC, is similarly impacted by conflict and migration.

WHO Concerns

This also follows after funding cuts to the WHO, with the US withdrawing from the organisation, dismantling USAID, and major lay-offs of many experts from the CDC [14]. The WHO Chief has also noted that efforts are currently outpaced by the spread of Ebola [15].

Response

Efforts to send aid have been made by Direct Relief, Unicef, Doctors without Borders, and the European Union, among other organizations [16–19]. Cuts to WHO funding, particularly due to the withdrawal of the US from the WHO, and the dissolution of USAID have led to further concerns around containment of the virus; although US officials claim that funding changes did not affect the response, former USAID officials and anonymous sources stated that funding, personnel, and trust in the region have been starkly depleted, contributing to the slowness of the response [20].

Contact tracing has previously been a central component to the containment of Ebola, paired with travel restriction to prevent the spread of the virus as cases for this strain have been growing rapidly [21]. Since traditional contact tracing can be time-intensive and incomplete, especially when individuals in urban areas have many untraceable contacts, a program of early detection led by community health workers can be especially effective in exponentially reducing the spread of Ebola [21]. This policy requires enough effective personal protective equipment to prevent spread of Ebola to and through these community health workers.