Jacqueline Weyer, National Institute for Communicable Diseases

New reports of Ebola in Guinea are causing anxiety given the history of the West Africa outbreak of 2014-2016. This was the largest Ebola outbreak reported to date – 28,000 cases were recorded, including 11,000 deaths. It originated in Guinea and then spread to Sierra Leone and Liberia. The confirmed cases this time have been reported from the southeast of Guinea about 800km by road from the capital, Conakry, but only about 100km from various border points with Liberia and Côte d’Ivoire. The concern is that the virus could spread to other locations in Guinea as well as neighbouring countries if it is not rapidly contained. Jacqueline Weyer answers questions about the latest outbreak.

What’s been done to keep new outbreaks from developing since 2016?

The development, evaluation and registration of Ebola vaccines and antivirals have been major activities in the years following the 2014-2016 outbreak. Since then, two vaccines have been pre-approved by the World Health Organisation (WHO) and registered with different regulatory bodies.

Read more:
Ebola strikes West Africa again: key questions and lessons from the past

During the 2018-2020 Ebola outbreak in the Democratic Republic of Congo (DRC), a number of countries in the region established national registration of these products as well. Nearly 50,000 people were vaccinated as part of the containment efforts in the DRC. Ring vaccination – vaccination of individuals in a ring around cases – with the Ebola vaccine is a vital tool in the prevention of the spread of the infection as it produces a barrier of immunity that disrupts the chain of transmission of the virus.

Why has the disease returned?

The natural transmission cycle of the virus involves certain species of forest-dwelling fruit bats. These act as a reservoir of the virus in nature and this cycle is continuous, ensuring that the virus is maintained in nature over time. The virus may, however, spill over from its natural reservoir either to other forest-dwelling animals or directly to humans to set off an epidemic in the human population.

Read more:
Ebola vaccine is key in ongoing efforts to contain the DRC outbreak

Ebola-infected animals such as non-human primates, monkeys and antelope have been reported before and could present a source of exposure to humans. For example, hunters or people slaughtering these animals come into contact with infected blood and tissues. But, it is also believed that spillover may occur through direct contact from infected bats into humans. The exact mechanism remains to be defined, but contact with infected blood and tissues are likely sources of infection.

The virus is always present in nature and, when circumstances allow for it, may jump from one species to another.

What lessons from previous outbreaks are being applied now?

There are many important lessons but, arguably, swift and sure action will make the difference. In the aftermath of the 2014-2016 outbreak, the apparent lag in the initial responses was a major critique of the response efforts.

It is critical to contain the outbreak early before it spreads beyond ground zero to other locations in Guinea and to neighbouring countries. If this happens, more protracted and complicated efforts for containment will be required.

One feature that sets this outbreak apart is that it is happening against the backdrop of the COVID-19 global pandemic – which has health-care and other resources around the globe under severe pressure.

Read more:
The coping mechanisms the DRC is putting in place as it faces Ebola, measles and COVID-19

International support has been a mainstay in the containment efforts in West Africa, but also in most Ebola outbreaks reported to date. Time will tell how efforts to deal with the COVID-19 pandemic impact on Ebola containment efforts.

Does Guinea have the health infrastructure to manage the disease?

Access to healthcare in Guinea has improved marginally over the years. But the country struggles with one of the worst health-care infrastructures in the world. Most deaths in Guinea remain associated with communicable, maternal and neonatal diseases and nutritional disorders. The Ebola outbreak of 2014-2016 did galvanise intensified efforts towards improving healthcare systems in the country, but progress is slow.

Given that the West Africa Ebola outbreak ended only five years ago, one would assume that some of the infrastructure that was developed during the outbreak remains, and could be rapidly brought back in use. The “muscle memory” for public health response to Ebola gained from the previous outbreak in Guinea will be put to the test in the coming weeks.

What’s the relationship between the outbreak in West Africa and central Africa?

Studies conducted during and following the 2014-2016 outbreak show that the Zaire ebolavirus species was circulating in local bat populations in West Africa before the outbreak. The genomic similarity of the Ebola viruses associated with the West Africa outbreak and Ebola viruses that have caused outbreaks in central Africa since 1976 supports the hypothesis that the virus did at some point spread from central Africa to West Africa.

On the other hand, when analysing the differences between these viruses, there is evidence for separate evolution over space and time. The exact mechanism of spread from central to West Africa remains unclear. But the transfer is plausible given, for example, that many fruit bat species – some of which are implicated as natural reservoirs of Ebola virus – are migratory, and may migrate over large distances.

Efforts are under way to determine the genomic sequence of the virus associated with the recently reported cases. This could point to the potential source of the outbreak and indicate the link between these viruses associated with the recent cases, and the viruses that circulated during the previous outbreak. Another consideration is that currently available Ebola vaccines have not been tested against strains other than Zaire ebolavirus. The efficacy of these vaccines against other species of the virus is, therefore, unsure.

Jacqueline Weyer, Senior Medical Scientist, National Institute for Communicable Diseases

This article is republished from The Conversation under a Creative Commons license. Read the original article.

The index case involved a nurse that died at the end of January 2021. Following her funeral, six additional cases of persons with EVD-like symptoms were identified of which two cases were confirmed. At this stage of the investigations it is not clear how the index case contracted the disease. Laboratory analysis is being informed to determine the Ebola virus species involved in the outbreak.

The WHO reports that efforts are underway to deploy Ebola vaccines, contact tracing and treatment structures to contain the outbreak. The WHO reports that as of 15 February nearly 200 contacts have been identified, but that none of these have travelled to neighbouring countries. The containment responses will strongly hinge on the in-country experience gained during the West Africa EVD outbreak of 2013-2016 and the availability of antiviral treatment and Ebola vaccines.

Currently the WHO is not recommending any restrictions on travel and trade to Guinea due to the EVD outbreak. At this stage of the outbreak the risk of exportation to South Africa is low. On 18 February 2021, there are no confirmed or suspected cases of EVD in South Africa.

For more information on EVD visit the NICD and WHO websites.

Update on the DRC outbreak

A third case was identified in Goma in the DRC on 31 July 2019. This is the daughter of the second case who came from a mine some distance from Goma. Contacts are being identified and will be vaccinated.  There have been no secondary cases related to the first imported cases in Goma.  There have also been no secondary cases related to the imported cases in Uganda, and more than 21 days have passed.

The Democratic Republic of Congo (DRC) has been experiencing an Ebola Virus Disease (EVD) outbreak since August 2018. To date, 2512 cases and 1676 deaths were reported. The outbreak is limited to the zones of the North Kivu and Ituri Provinces, located towards the eastern border of the DRC. This is a remote location in the DRC, more than 3000 km from the capital Kinshasa.

The ongoing nature of the outbreak despite best efforts of the DRC, WHO and Partners to control it, prompted the World Health Organization (WHO) to convene the 4^th International Health Regulations (IHR) Emergency Committee meeting. On Wednesday, 17 July 2019, the WHO Director-General Dr Tedros Adhanom Ghebreyesus declared the EVD outbreak in the DRC to be a Public Health Emergency of International Concern (PHEIC).

The WHO expressed concern for the spread of the disease to other parts of DRC and countries neighbouring it. There has been importation of cases to Uganda in June 2019 which were swiftly identified, with no further cases reported in the country since then. In addition, a case was reported in the DRC city of Goma (situated near the border of Rwanda), which was promptly isolated and treated.

The declaration of the PHEIC is an extraordinary measure that will enable the DRC to gain access to much needed international support and resources. In addition, control strategies will be reviewed and coordinating mechanisms will be strengthened within the DRC.

To become infected, an individual has to have direct contact with an infected person. Persons who are at risk of becoming infected need to have been in the North Kivu area, and have contact with infectious patients there.  There are no trade links nor tourist destinations in the North Kivu area. In addition, there are no commercial flights between South Africa and the epicentre of the outbreak including Goma, further limiting the risk of an imported case.

Despite the low risk to South Africa, the health systems are on high alert to rapidly detect and manage imported cases should these occur. Since the commencement of the outbreak, the South African Department of Health has worked with stakeholders to develop and implement a preparedness plan. The plan includes co-ordination meetings amongst stakeholders, risk communication, screening of returning travellers and other high-risk persons including military personnel, infection prevention and control training and provision of equipment, strengthening of laboratory diagnostic capacity and simulation exercises amongst stakeholders. South Africa has a great deal of experience in diagnosing and managing viral haemorrhagic fevers and has the only BSL-4 high-security laboratory on the continent.

The National Department of Health in collaboration with the NICD and WHO will continue to monitor the level of risk to the country and implement appropriate measures as required.

The WHO does not recommend that any travel or trade restrictions be applied to DRC or neighbouring countries.

Persons who have travelled to the DRC to the affected area, particularly the North Kivu region are advised to monitor themselves for symptoms including vomiting, diarrhoea, fever and or bleeding and to contact their health care practitioners should they be concerned.  Health care workers should note that malaria is a very important and far more common cause of febrile illness in travellers from these areas and must be considered when assessing any such patients.

Click here for more information on Ebola virus disease, guidelines and other useful resources

For Medical/clinical related queries: Contact the NICD Hotline +27 82 883 9920 (for use by healthcare professionals only).

Genomic sequencing of Ebola viruses associated with the two outbreaks confirmed that the outbreaks were unlinked. By 17 February 2019, total of 840 cases of hemorrhagic fever have been identified, of which 537 had a fatal outcome. Laboratory testing confirmed EVD for 775 of the cases investigated, with 65 cases remaining probable (i.e. not laboratory confirmed) (https://www.who.int/ebola/situation-reports/drc-2018/en/).  By 10 February 2019, 68 confirmed cases involved health care workers, of which 18 had a fatal outcome.

The cases have been reported from the health zones of the North Kivu and Ituri Provinces, located towards the eastern border of the DRC. This is a remote and conflicted location in the DRC, located more than 3000 Km from the capital Kinshasa (https://www.afro.who.int/news/who-calls-free-and-secure-access-responding-ebola-outbreak-democratic-republic-congo), but in close proximity to borders with Uganda, South Sudan and Rwanda. According to the WHO situation report dated 12 February 2019, there are no confirmed cases of cross-border spread associated with this outbreak yet. More than 34 million travelers have been screened since the start of containment efforts up to 10 February 2019 in the attempt to prevent exportation of the disease. Containment efforts, including ring vaccination and strengthening of cross-border surveillance, continues to be mobilized and strengthened (https://apps.who.int/iris/bitstream/handle/10665/281194/SITREP_EVD_DRC_20190212-eng.pdf?ua=1).

By 10 February 2019, nearly 78 000 persons have been vaccinated using an experimental Ebola vaccine. In addition, several experimental therapeutics are being used to treat patients under monitored emergency use protocols (https://apps.who.int/iris/bitstream/handle/10665/281194/SITREP_EVD_DRC_20190212-eng.pdf?ua=1 and https://www.who.int/ebola/drc-2018/treatments-approved-for-compassionate-use-update/en/).

Challenges to the containment efforts include ongoing violent conflict with displacement of large numbers of the local population and the wide-spread expanse of the outbreak in the affected region of the DRC (https://apps.who.int/iris/bitstream/handle/10665/281194/SITREP_EVD_DRC_20190212-eng.pdf?ua=1). WHO advises against any restriction of travel and trade to the Democratic Republic of the Congo based on the currently available information. WHO continues to monitor travel and trade measures in relation to this event. The regulations for evidence of a valid yellow fever vaccination certificate apply. Precautions against malaria should be applied as per routine practice. Malaria must be considered a high priority in the investigation and management of any febrile traveler.

On 19^th February 2019, there has been no suspected or confirmed cases of EVD related to this outbreak in South Africa. The followed is emphasized at all levels to maintain epidemic preparedness and response capacity in the country, in the event of inadvertent cases being detected.

1. Coordination

• Maintain activation of Provincial Outbreak Response Teams and ensure capacity for preparedness and response is developed and sustained in accordance with the IHR (2005).

2. Laboratory services

• Ensure that key laboratories (NHLS laboratories linked to prioritized EVD hospitals, and private laboratories) have ongoing training and competency evaluations for VHF protocols and able to receive and handle such cases currently and in the foreseeable future.

3. Case management, Infection prevention and control (IPC)

• Ensure availability of appropriate PPEs
• Maintain and monitor designated isolation facilities
• Ensure ongoing IPC preparedness training

4. Environment and Port Health Services

• Alert all key stakeholders in the Port environment. Port Health must take a lead role on all health related incidents at the Ports and respond to public health risks
• Ensure adequate staffing (trained) at POEs with the required equipment needed.

5. Emergency Medical Services

• Assess Ebola PPE availability as per national guidelines and assist to source PPE
• Assess training needs and facilitate training through various platforms
• Develop SOP for disinfection of ambulance, contaminated areas etc.

 Follow these links to read more about EVD:

National Institute for Communicable Diseases: https://www.nicd.ac.za/index.php/ebola-virus-disease/

World Health Organization, Ebola virus disease webpage: http://www.who.int/ebola/en/.

World Health Organization, Ebola frequently asked questions: http://www.who.int/csr/disease/ebola/faq-ebola/en/

World Health Organization, Ebola vaccines frequently asked questions: http://www.who.int/ebola/drc-2018/faq-vaccine/en/

The cases have been reported from the health zones of the North Kivu and Ituri Provinces, located towards the eastern border of the DRC. This is a remote and conflicted location in the DRC, located more than 3000 Km from the capital Kinshasa (https://www.afro.who.int/news/who-calls-free-and-secure-access-responding-ebola-outbreak-democratic-republic-congo), but in close proximity to borders with Uganda, South Sudan and Rwanda. Cases reported from the Beni health zone, North Kivu Province account for nearly half of the cases reported to date.

Containment efforts, including ring vaccination and strengthening of cross-border surveillance, continues to be mobilized and strenghtened (https://www.who.int/ebola/situation-reports/drc-2018/en/), despite many challenges faced. By 6 January 2019, nearly 60 000 persons have been vaccinated using an experimental Ebola vaccine. According to the WHO situation report dated 8 January 2019, there are no confirmed cases of cross-border spread associated with this outbreak. In addition, several experimental therapeutics are being used to treat patients under monitored emergency use protocols (http://apps.who.int/iris/bitstream/handle/10665/278978/SITREP_EVD_DRC_20190108-eng.pdf?ua=1 and http://www.who.int/ebola/drc-2018/treatments-approved-for-compassionate-use-update/en/ and http://www.who.int/news-room/detail/26-11-2018-democratic-republic-of-the-congo-begins-first-ever-multi-drug-ebola-trial). Challenges to the containment efforts include ongoing violent conflict with displacement of large numbers of the local population (http://www.who.int/news-room/detail/17-11-2018-who-statement-on-latest-attacks-in-the-democratic-republic-of-the-congo).

WHO advises against any restriction of travel and trade to the Democratic Republic of the Congo based on the currently available information. WHO continues to monitor travel and trade measures in relation to this event. The regulations for evidence of a valid yellow fever vaccination certificate apply. Precautions against malaria should be applied as per routine practice. Malaria must be considered a high priority in the investigation and management of any febrile traveler.

On 18 January 2019, there has been no suspected or confirmed cases of EVD related to this outbreak in South Africa. The followed is emphasized at all levels to maintain epidemic preparedness and response capacity in the country, in the event of inadvertent cases being detected.

1. Coordination

• Maintain activation of Provincial Outbreak Response Teams and ensure capacity for preparedness and response is developed and sustained in accordance with the IHR (2005).

2. Laboratory services

• Ensure that key laboratories (NHLS laboratories linked to prioritized EVD hospitals, and private laboratories) have ongoing training and competency evaluations for VHF protocols and able to receive and handle such cases currently and in the foreseeable future.

3. Case management, Infection prevention and control (IPC)

• Ensure availability of appropriate PPEs
• Maintain and monitor designated isolation facilities
• Ensure ongoing IPC preparedness training

4. Environment and Port Health Services

• Alert all key stakeholders in the Port environment. Port Health must take a lead role on all health related incidents at the Ports and respond to public health risks
• Ensure adequate staffing (trained) at POEs with the required equipment needed.

5. Emergency Medical Services

• Assess Ebola PPE availability as per national guidelines and assist to source PPE
• Assess training needs and facilitate training through various platforms
• Develop SOP for disinfection of ambulance, contaminated areas etc.

Follow these links to read more about EVD:

National Institute for Communicable Diseases: https://www.nicd.ac.za/index.php/ebola-virus-disease/

World Health Organization, Ebola virus disease webpage: http://www.who.int/ebola/en/.

World Health Organization, Ebola frequently asked questions: http://www.who.int/csr/disease/ebola/faq-ebola/en/

World Health Organization, Ebola vaccines frequently asked questions: http://www.who.int/ebola/drc-2018/faq-vaccine/en/

The cases have been reported from the health zones of the North Kivu and Ituri Provinces, located towards the eastern border of the DRC. This is a remote and conflicted location in the DRC, located more than 3000 Km from the capital Kinshasa (https://www.afro.who.int/news/who-calls-free-and-secure-access-responding-ebola-outbreak-democratic-republic-congo), but in close proximity to borders with Uganda, South Sudan and Rwanda. Cases reported from the Beni health zone, North Kivu Province account for 45% of the cases reported to date.

Containment efforts, including ring vaccination and strengthening of cross-border surveillance, continues to be mobilized (https://www.who.int/ebola/situation-reports/drc-2018/en/), despite many challenges faced. At 28 November 2018, nearly 36 000 persons have been vaccinated using an experimental Ebola vaccine. Since the start of the outbreak until 25 November, nearly 17 million travelers at 67 points of entry to the North Kivu and Ituri Provinces have been screened. Of 30 possible cases identified in these travelers, only one case of EVD was confirmed.  According to the WHO situation report dated 28 November, there are no confirmed cases of cross-border spread associated with this outbreak. In addition, several experimental therapeutics are being used to treat patients under monitored emergency use protocols (http://apps.who.int/iris/bitstream/handle/10665/276198/SITREP_EVD_DRC_20181128-eng.pdf?ua=1 and http://www.who.int/ebola/drc-2018/treatments-approved-for-compassionate-use-update/en/ and http://www.who.int/news-room/detail/26-11-2018-democratic-republic-of-the-congo-begins-first-ever-multi-drug-ebola-trial). Challenges to the containment efforts include ongoing violent conflict with displacement of large numbers of the population (http://www.who.int/news-room/detail/17-11-2018-who-statement-on-latest-attacks-in-the-democratic-republic-of-the-congo).

WHO advises against any restriction of travel and trade to the Democratic Republic of the Congo based on the currently available information. WHO continues to monitor travel and trade measures in relation to this event. The regulations for evidence of a valid yellow fever vaccination certificate apply. Precautions against malaria should be applied as per routine practice. Malaria must be considered a high priority in the investigation and management of any febrile traveler.

On 3 December 2018, there has been no suspected or confirmed cases of EVD related to this outbreak in South Africa. The followed is emphasized at all levels to maintain epidemic preparedness and response capacity in the country, in the event of inadvertent cases being detected.

1. Coordination

• Maintain activation of Provincial Outbreak Response Teams and ensure capacity for preparedness and response is developed and sustained in accordance with the IHR (2005).

2. Laboratory services

• Ensure that key laboratories (NHLS laboratories linked to prioritized EVD hospitals, and private laboratories) have ongoing training and competency evaluations for VHF protocols and able to receive and handle such cases currently and in the foreseeable future.

3. Case management, Infection prevention and control (IPC)

• Ensure availability of appropriate PPEs
• Maintain and monitor designated isolation facilities
• Ensure ongoing IPC preparedness training

4. Environment and Port Health Services

• Alert all key stakeholders in the Port environment. Port Health must take a lead role on all health related incidents at the Ports and respond to public health risks
• Ensure adequate staffing (trained) at POEs with the required equipment needed.

5. Emergency Medical Services

• Assess Ebola PPE availability as per national guidelines and assist to source PPE
• Assess training needs and facilitate training through various platforms
• Develop SOP for disinfection of ambulance, contaminated areas etc.

Follow these links to read more about EVD:

National Institute for Communicable Diseases: https://www.nicd.ac.za/index.php/ebola-virus-disease/

World Health Organization, Ebola virus disease webpage: http://www.who.int/ebola/en/.

World Health Organization, Ebola frequently asked questions: http://www.who.int/csr/disease/ebola/faq-ebola/en/

World Health Organization, Ebola vaccines frequently asked questions: http://www.who.int/ebola/drc-2018/faq-vaccine/en/