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Blog Virology

Ebola Strikes Again in the DRC

A second simultaneous Ebola outbreak has been confirmed in the Democratic Republic of Congo (DRC), (World Health Organization, 2020). This marks the 11th Ebola outbreak in central Africa which comes at a time when the continent also battles the COVID-19 pandemic.

First discovered in 1976, ebola viruses have since re-emerged across the African continent. The virus reached international attention during the longest and most extensive Ebola outbreak in West Africa between 2013 – 2015.

Historical Ebola outbreaks have fatality rates as high as 88%, almost 9 out of 10 people would die as a result of infection. The West Africa outbreak, however, saw a drastic reduction in fatality rate, to around 40%. The reduction in fatality rate was likely a result of the increased basic support, advanced and more appropriate care for those infected and earlier case detection, allowing for better management of both patients and outbreak spread (Baseler et al., 2017).

The most recent outbreak is in Mbandaka in the Équateur region, 600 miles from the ongoing Kivu Ebola epidemic in the North Kivu and Ituri provinces. The cases in Mbandaka are thought to be separate from the Kivu Ebola epidemic and instead the result of a new ‘spillover’ event from an animal reservoir to humans.

As of the 10th of June, a total of 12 cases have been reported; 9 confirmed cases, 3 suspected cases and 6 deaths, (Bujakera, Holland and Heavens, 2020)*. Positive samples were confirmed via testing at the Institut National de Recherche Biomédicale (INRB) – the countries national medical research organisation.

Although case number is relatively small at present, this is likely to rise as contacts are traced and the incubation period of 2-21 days elapses. Whilst the outbreak has presented at an already challenging time, scientists and doctors are on the ground with capacity to trace and diagnose. This service was expanded and refined in 2018 in response to previous outbreaks (World Health Organization, 2020).

The Kivu Ebola epidemic began in August 2018, over 3,400 people have been infected and sadly 2,200 lives lost despite the implementation of aggressive control measures. A number of factors have hindered this operation including; stigmatization, civil unrest and logistical issues.

Community level prevention and outbreak measures are dependent on the public trusting local authorities, however 31.9% of 961 individuals surveyed in North Kivu trusted that local authorities were acting in their best interests. The same survey reported 25.5 % of those surveyed believed the outbreak was a hoax, (Vinck et al., 2019). Complicating this were populist politicians publishing their own doubts on the outbreak validity to gain support in the 2018 elections. The country had not yet had a peaceful transition of power since decolonialisation in 1960, (Moran, 2018).

However, deployment of an experimental vaccine, coupled with rapid diagnostics helped to halt the outbreak. Following emergency use in 2016, the Ervebo vaccine was finally approved for use in 2019, after clinical trial demonstrated safety and efficacy; 97.5% efficacy in preventing Ebola infection compared to no vaccination, (Regules et al., 2015; World Health Organization, 2019).

Although an effective vaccination is now available, this is by no means the end of the problem. Availability, difficulties in contact tracing and public perception are all challenges that must be addressed to manage the outbreak during an already arduous time.

It is hoped that authorities and individuals alike can action their learnings from previous outbreaks, to bring this new outbreak to a swift end.

The DRC is currently contending with outbreaks of cholera, SARS-CoV-2, measles and two separate Ebola clusters. This serves as a stark reminder that whilst the world fights against the SARS-CoV-2 pandemic, Ebola outbreaks will stop for no country and no person.

Viruses emerge, or spillover often in nature, ebola virus is an example of this. Check out our blog on viral emergence here, or our post about bats and viruses.

*Please note that this article is not by a scientific body and reports figures from a WHO press conference which could not be confirmed on WHO.int.

Written by Charlotte Rigby

Citations

Baseler, L. et al. (2017) ‘The Pathogenesis of Ebola Virus Disease’, Annual Review of Pathology: Mechanisms of Disease, 12(1), pp. 387–418. doi: 10.1146/annurev-pathol-052016-100506.

Bujakera, S., Holland, H. H. and Heavens, A. (2020) Up to 12 infected in Congo’s new Ebola outbreak: WHO, Reuters.

Moran, B. (2018) ‘Fighting Ebola in conflict in the DR Congo’, The Lancet. Elsevier, 392(10155), pp. 1295–1296. doi: 10.1016/S0140-6736(18)32512-1.

Regules, J. A. et al. (2015) ‘A Recombinant Vesicular Stomatitis Virus Ebola Vaccine’, New England Journal of Medicine. Massachusetts Medical Society, 376(4), pp. 330–341. doi: 10.1056/NEJMoa1414216.

Vinck, P. et al. (2019) ‘Institutional trust and misinformation in the response to the 2018–19 Ebola outbreak in North Kivu, DR Congo: a population-based survey’, The Lancet Infectious Diseases, 19(5), pp. 529–536. doi: https://doi.org/10.1016/S1473-3099(19)30063-5.

World Health Organization (2019) Preliminary results on the efficacy of rVSV-ZEBOV-GP Ebola vaccine using the ring vaccination strategy in the control of an Ebola outbreak in the Democratic Republic of the Congo: an example of integration of research into epidemic response. doi: 10.1016/j.surfcoat.2019.125084.

World Health Organization (2020) New Ebola outbreak detected in northwest Democratic Republic of the Congo; WHO surge team supporting the response. Available at: https://www.who.int/news-room/detail/01-06-2020-new-ebola-outbreak-detected-in-northwest-democratic-republic-of-the-congo-who-surge-team-supporting-the-response (Accessed: 2 June 2020).

COVID-19 Research Summaries

Report Summary: Features of 20,133 UK patients in hospital with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study

Written by Rebekah Penrice-Randal and Lucia Livoti

Features of 20,133 UK patients in hospital with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study 1 was published in The British Medical Journal (BMJ) this week. This report defines clinical characteristics of patients in hospital in the UK, using the ISARIC WHO Clinical Characterisation Protocol. We have written a brief summary to define what this means, discuss the report itself and highlight the key findings to aid public understanding.


What is ISARIC?

ISARIC is the acronym for International Severe Acute Respiratory and emerging Infections Consortium. ISARIC are a global federation of clinical research networks, with a core goal of generating evidence to improve clinical care and public health responses. They provide a “proficient, coordinated and agile research response to outbreak-prone infectious diseases”.

You can follow the study on twitter for more updates: @CCPUKstudy


What is the ISARIC WHO Clinical Characterisation Protocol?

A research protocol is the set of documents that includes the instructions for conducting a study, the participant information sheets and consent forms. A clinical research protocol has to be approved by an independent Research Ethics Committee to ensure patient safety and dignity, and in the UK, by the Health Research Authority to ensure that health care resources are used appropriately.

 The ISARIC WHO Clinical Characterisation Protocol for Severe Emerging Infection (ISARIC WHO CCP-UK) was designed in 2012 to understand the clinical characteristics  of “any severe or potentially severe acute infection of public health interest”.

In other words, the study was set up in advance of an outbreak to ask the “who, what and why” of a new disease. Who is affected means, age, sex, ethnicity and underlying medical problems. What means, what does the disease cause any of: breathing problems, diarrhoea, vomiting, sepsis or bleeding.

The ISARIC WHO CCP allows for the collecting of clinical data and biological samples, and their analysis and processing to be done in a globally-harmonised manner. This protocol has been curated by multidisciplinary experts across the world 2, and employed in response to outbreaks such as:

  • Middle Eastern Respiratory Virus Syndrome coronavirus (MERS-CoV) in 2012,
  • Influenza in 2013,
  • Ebola virus in 2014,
  • Monkeypox and MERS-CoV in 2018,
  • Tick-borne encephalitis virus (TBEV) in 2019 and
  • SARS-CoV-2 in 2020.

The ISARIC WHO CCP has been central to the swift and cohesive research response to COVID-19. As a free, readily available resource it has been instrumental in the standardised collection of samples and data for the COVID-19 outbreak. This in turn has allowed clinical investigation to progress as quickly as possible. Global generic documents can be accessed here. Countries are also encouraged to develop “localised” instructions and seek local research permissions. The documents pertaining to UK protocols are available here.


Definitions:

Cohort: a cohort of patients are a group of individuals affected by a common factor, such as a disease, treatments or environmental factors.

Cohort study: cohort studies are central to the study of epidemiology and are often used in the fields of medicine, nursing, psychology and social sciences.

Comorbidity: presence of one or more medical conditions in addition to the condition being studied.

Epidemiology: the study and analysis of factors contributing to disease and health outcomes. In this case it may refer to the frequency and pattern of COVID-19 infection, risk factors, super-spreader events and study of specific populations. 

Median: the median is defined as the ‘middle’ value of a data set, such that other values are equally likely to be above or below.

Risk factor: a factor that increases an individual’s risk or susceptibility to a disease.


Aim of the study:

  • To rapidly understand the clinical characteristics of people severely affected by COVID-19. Severely affected, meaning those who need hospital care.


Why is this work important?

This work is essential to appreciate the clinical features of patients that present with COVID-19 and identify risk factors associated with poor outcome. It is only through the understanding of such aspects that public policy can be informed, particularly around shielding of vulnerable groups and planning of resources such as oxygen and ventilator provision.   


Who took part?

20,133 hospital in-patients with COVID-19 from 208 acute care hospitals across the UK were enrolled into the study. Clinical data was collected from patients admitted to hospital between 6th February and 19th April 2020. Patient outcomes are described as known on 3rd May 2020, as people admitted on the 19th April need at least 14 days to complete their admission or “declare the nature of their illness”.


The Results


Conclusions

The ISARIC WHO CCP-UK is a large ongoing study of patients hospitalised with COVID-19. This study found that the mortality rate was high in those admitted to hospital. Certain risk factors were associated with higher mortality rate such as; increasing age, male sex, and chronic comorbidity, including obesity. This report provides the first clinical insight of hospital patients with COVID-19 in the UK. The data gathered throughout this study will assist decision-making in the management of COVID-19, from patient to nation.

This report acknowledges the 2648 frontline NHS clinical and research staff, volunteer medical students and many researchers, who have worked tirelessly to make this study happen. Thank you to all involved and congratulations from The Science Social.


A note on ‘open access’

Open access journal articles are available to everyone and are not behind a pay wall. This article is freely available to all, if you would like to read the original article click here.

References

1          Docherty, A. B. et al. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. BMJ 369, m1985, doi:10.1136/bmj.m1985 (2020).

2          Dunning, J. W. et al. Open source clinical science for emerging infections. The Lancet Infectious Diseases 14, 8-9, doi:10.1016/S1473-3099(13)70327-X (2014).

Thank you to Professor Calum Semple (@tweediechap), an ISARIC investigator and co-author of the original article for permission to write this blog, and for the valuable comments.

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