Is Not about IF but WHEN - South Sudan EVD Preparedness.

Current Situation in the Democratic Republic of Congo

South Sudan borders the restive provinces of North Kivu and Ituri, located along the eastern border region of the Democratic Republic of Congo (DRC). These regions have reported increasing numbers of Ebola virus disease (EVD) cases by the day during an outbreak that is now reaching towards its tenth month without containment in sight. As of this past Friday June 21, 2019 the Ministry of Health, DRC reported the number of deaths from EVD has now surpassed 1,400 people out of 2,204 reported cases to date and new cases being detected daily,  These numbers still pale in comparison to the Ebola outbreak that began in 2014, during which more than 28,000 people were infected and more than 11,000 died in West Africa, That’s in part because the current outbreak has benefited from a newly available Ebola vaccine and a quicker, better coordinated response from the World Health Organization.

Despite the availability of a vaccine that has been shown to be greater than 97.5% effective in preventing EVD and the vaccination of over 100,000 people, violent conflict in the region and recent attacks on several Ebola treatment centers and hospitals has caused response efforts to nearly come to a halt with some health workers walking out in protest over safety concerns for themselves and the violently ill persons with EVD for which they provide care. In light of the attacks and the violent death of visiting epidemiologist from Cameroon, Dr Richard Valery Mouzko Kiboung in Betembo, a city in North Kivu this past week, agencies are seeking to withdraw resources until the government provides some assistance in halting the violence in the region. Healthcare workers need to be able to proceed safely with case detection, treatment and vaccination efforts. Until then, the slowing response will cause a response gap that will allow for increased EBV transmission until agencies feel safe operating in the region.

On June 18th the DRC's ministry of health said the total number of health workers infected during this outbreak to 118, including 39 deaths. Health workers represent 5.5% of all cases diagnosed since last August 2018

 The amount of shared border between South Sudan and DRC is approximately 714 kilometers. The continuous bi-directional movement of people fleeing civil unrest in both regions and other business opportunity makes South Sudan vulnerable to EVD until the present outbreak in DRC is contained. As was previously stated, the outbreak is not contained, and new cases are being detected daily. People who fled from civil unrest in South Sudan will soon seek to return home for shelter from the violence and the EVD outbreak. The likelihood of EVD making its way to South Sudan through a porous border region is a reality and underscores the need for more EBV disease preparation in South Sudan.

With the current outbreak in Kasese in Uganda has shown how Ebola can escalate across the border within a shorter period without detection

A mass exodus from the Democratic Republic of Congo could be catastrophic.

Hundreds of thousands of people are fleeing the region in response to ethnic violence, potentially carrying the virus far beyond Congo’s borders. The outbreak has already spread into neighboring Uganda; if it reaches South Sudan, a country dotted with refugee camps and teeming with instability, containment could become nearly impossible.

To prevent that from happening, health care workers will have to eradicate the deep mistrust within Congo’s borders. Rumors abound that the virus was brought to the country by aid workers or that it is a hoax devised by the country’s government to prevent certain districts from voting in the recent concluded presidential election. Such suspicions have led many to avoid Ebola treatment centers, hide sick family members from foreign doctors and refuse to cooperate with other control measures.

Hundreds of thousands of people have fled an explosion of ethnic violence in northeastern Democratic Republic of Congo in the past two weeks, the United Nations said on Tuesday, creating a new humanitarian emergency in a region where international agencies are struggling to control an outbreak of Ebola.

The United Nations refugee agency said more than 300,000 people had fled in the face of large-scale clashes between two ethnic groups, the Hema and the Lendu, in Ituri province, which borders Uganda and South Sudan. But officials said that the estimate was conservative.

The mass displacement poses a threat to efforts to tackle an Ebola outbreak in Congo that is the second worst recorded

Though the outbreak is centered in North Kivu, government data shows that around 10 percent of the infections and deaths have occurred in Ituri, and last week it spread into Uganda.

International efforts to combat the outbreak have not brought it under control in the face of community resistance and militia attacks that disrupted critical operations to isolate those infected and trace all those in contact with them.

EBV Preparedness Update for South Sudan

Vaccination of frontline healthcare workers against EVD began in Yambio, on the 28th of January 2019 according to the UN Office for the Coordination of Humanitarian Affairs (OCHA). The vaccinations are also planned to be extended to other high-risk states including Tambura, Maridi and Torit. The completion of two EVD isolation units in Yambio and Yei States at the end of January 2019 marked a major milestone in the preparation for EVD should it spread to South Sudan. Currently, six more locations have been identified as possible isolation centers and nineteen out of the 39 identified EVD screening points in South Sudan are currently operational. It is hoped to increase the number of operational screening points, but the geography of the region with its thick forests and rivers make it difficult to staff the region with the needed amount of immigration officers. At this present time there have been no reports of EVD in the region. The National Ebola Task Force meets twice a week in order to remain updated on EVD preparedness plans. Resources gaps are the primary concern in the preparedness efforts at the moment and efforts are underway to obtain funding in order close these gaps.

South Sudan Ebola Virus Preparedness Assessment

DRC is expansive and shares its borders with nine countries. The countries sharing borders with DRC are also under high alert for EVD outbreak. The countries experiencing a high alert include not only DRC and South Sudan, but also Uganda, Rwanda, Angola, Central African Republic, Burundi and Zambia. Each country with which DRC shares a border was given funding by the United Nations (UN) to work on their preparedness and response plans which are to include the logistics of building isolation units and developing national Standard Operating Procedures (SOPs), and for increasing border surveillance. This assessment was accomplished through the collaborative efforts of several different international and local partners including OCHA, the Public Health Emergency Operations Centre (PHEOC), Ministry of Health, South Sudan (MoH), the World Heath Organization (WHO), the Centers for Disease Control (CDC), and the World Food Programme (WFP) OCHA being the Secretariat of the response. To date, there have been no reported cases of EVD in South Sudan apart from earlier recorded cases reported in 1976, 1979, and 2004 when it was still Sudan.

South Sudan is in the midst of a complex humanitarian crisis and the region has been for many years. Since gaining its independence from Sudan in 2011, South Sudan has been plagued by a series of civil wars that continue to disrupt its already fragile healthcare system which is currently unable to effectively meet the needs of those affected by conflict, much less prepare for a potential outbreak. Only 22% of health centers are completely operational in South Sudan. Although EVD has a high transmission and mortality rate regardless of age, infants and elderly people have a higher risk of contracting the virus and dying from EVD. These two subsets of the population may have additional challenges pertaining to access to rapid care in an appropriate time-frame for both diagnosis and treatment. Both infants and the elderly become easily dehydrated from the high fever, and severe bouts of diarrhea and vomiting that accompany EVD. Dehydration happens quickly in these populations particularly in the tropical climate and getting medical attention in an appropriate amount of time is sometimes not possible in conflict zones and also at night when it becomes dangerous to don PPE and assist possible EVD patients.

Assessments carried out by the WHO taking place from November 2018 - March 2019 show a significant improvement in progress towards EVD outbreak should it reach South Sudan. The WHO found significant improvements to coordination, public awareness, but also noted gaps on both national and state levels and that plans for readiness were not yet at full capacity.

How Ebola Got Its Name…..

The Ebola virus that's currently causing the second biggest devastating outbreak in DR Congo again didn't even have a name just 44 years ago when it first surfaced and caused a mysterious illness among villagers in Zaire, now the Democratic Republic of Congo.

The international team of scientists who were tasked with investigating that 1976 Ebola outbreak  were shocked at the sight of the virus and the disease it caused, Dr. Peter Piot, co-discoverer of the virus, recalls in his memoir "No Time to Lose: A Life in Pursuit of Deadly Viruses." (W. W. Norton & Company, 2012)

The scientists had looked at blood samples sent from Africa under the microscope in a Belgian laboratory, and the virus looked like a worm or a long string, unlike almost all viruses known. And once the team got on the ground in Zaire, they saw how rapidly the virus spread and how quickly it killed its victims. They knew they had to figure out how this mysterious new virus was being transmitted, what it did inside the body, and how it could be stopped.

But they also had to figure out a name for the new virus. [10 Deadly Diseases That Hopped Across Species]

The story of how Ebola got its name is short and somewhat random, according to Piot's account in his book. Late one night, the group of scientists discussed over Kentucky bourbon what the virus they were hunting should be named.

The virus had surfaced in a village called Yambuku, so it could be named after the village, argued one team member, Dr. Pierre Sureau, of the Institut Pasteur in France, Piot recalls.

But naming the virus Yambuku would run the risk of stigmatizing the village, said another scientist, Dr. Joel Breman, from the Centers for Disease Control and Prevention (CDC). This had happened before, for example, in the case of Lassa virus, which emerged in the town of Lassa in Nigeria in 1969.

It was Karl Johnson, another researcher from the CDC, and the leader of the research team, who suggested naming the virus after a river, to tone down the emphasis on a particular place.

One obvious option would have been the Congo River, which is the deepest river in the world and flows through the country and its rainforest. But there was a problem—another virus with a similar name already existed. That virus was the Crimean-Congo hemorrhagic fever virus.

 So, the scientists looked at a small map, pinned up on the wall, for any other rivers near Yambuku. On the map, it appeared that the closest river to Yambuku was called Ebola, meaning "Black River," in the local language Lingala. "It seemed suitably ominous," Piot writes.

However, the map was inaccurate, and the Ebola river turned out not to be the closest river to Yambuku, Piot says. "But in our entirely fatigued state, that's what we ended up calling the virus: Ebola."

And so, Ebola joined the list of viruses named after rivers. Other members include the mosquito-borne Ross river virus, which causes a debilitating infection and is named after a river in northern Queensland in Australia, and the Machupo virus, which causes Bolivian hemorrhagic fever, or "black typhus," and is named after a Bolivian river.

Many other viruses, too, have been named after a feature of their place of origin, including West Nile virus discovered in 1937, coxsackievirus discovered in 1948 (Coxsackie is a town in New York), Marburg virus discovered in 1967 (Marburg is a town in Germany), and Hendra virus identified 1994 (Hendra is a suburb of Brisbane, Australia).

The tradition continues today. Last year, after months of being called by a number of names, the newly discovered coronavirus finally got an official name -- Middle East respiratory syndrome coronavirus, or MERS-CoV.

Important Facts You Should Know About Ebola

1. Ebola Transmits from Animals to Humans

Ebola virus originates from the Democratic Republic of Congo – a central African nation. The Ebola river runs through the center of the country, snaking through many of the nation’s provinces, and scientists named the virus after this river, which is thought to be the home of the fruit bats which carry the virus.

Animals, such as fruit bats, may carry the virus and shed it through their feces and urine. The fruit bats may shed the virus in feces, that they then drop onto leaves and fruit, which local villagers then consume. After eating the contaminated fruit, the infected person experiences an incubation period that lasts for anywhere between 2 to 21-days before symptoms start to present.

Medical science and investigators still are uncertain about the exact cause or delivery mechanism for the virus, and the fruit theory is the top assumption. However, other researchers state that the infection may also transmit through eating the meat of contaminated animals, such as monkeys, bats, and gorillas.

2. The Virus Spreads through Contact

Once the virus finds a human host, it spreads readily through contact with the body fluids of an infected person. The incubation phase is what makes the virus so deadly and easy to spread. Since infected individuals may not experience symptoms for up to three weeks after initial exposure to the virus, they have the opportunity to infect plenty of people during this phase of the disease before symptoms present.

Since African populations mostly eat with their hands, the risk of consuming contaminated water and beverages is much higher.

African people also have a culture where they bury their dead, with the mourners crying over the body as they reminisce about the times spent with their loved one when they were living. Unfortunately, Ebola remains active for up to a week or more in a dead body, meaning that any contact with a deceased person may result in transmission of the virus.

3. The Worst Ebola Outbreaks

The outbreak of Ebola in the Western African country, in 2014 was the worst on record to this date, resulting in more than 28,000 infections, and more than 11,000 deaths. The Zaire-Ebola strain was responsible for this contagion, and unfortunately, this is the deadliest and most infectious form of the virus.

Many medical experts believe that the severity of the outbreak was so bad because of the remote locations of the epidemic, along with a lack of preparation and medical staff trained to deal with the virus. As a result, many people experienced infection due to the burial practices and lack of understanding of how the disease spreads in the community.

4. Early Symptoms of the Ebola Virus

As previously mentioned, it can take up to 21-days to manifest symptoms of the Ebola virus. When the signs of Ebola do eventually start to display in infected persons, they take on the initial appearance of influenza infection, with patients experiencing a fever, cough, chills, cramps, and body ache.

Because of the general symptoms presented by the virus, many people receive a misdiagnosis in the early stages of infection. However, depending on the strain of Ebola responsible for the infection, the symptoms may rapidly escalate, leading to bleeding from the eyes, ears, and mouth, which are the characteristic symptoms associated with the disease.

People infected with the virus should seek immediate treatment for their symptoms or run the risk of contaminating other people, as well as the haemorrhagic fever killing them, in as little as a few days after developing symptoms – depending on how aggressive the strain of Ebola is on the body.

5. Ebola Induces Bleeding

Ebola falls under the category of haemorrhagic fevers, such as the Marburg virus. Ebola is also incredibly infectious and highly contagious, especially when the person reaches the advanced stages of the disease.

When Ebola is in the final stages of the disease, it causes blood vessels to rupture, forcing massive internal bleeding of the organs. The person’s eyes turn red, and their tear ducts swell with blood – the digestive system starts to haemorrhage, and the patients begin to vomit and cough up blood as it attacks the respiratory system.

If left untreated, the patient’s chances of surviving the advanced stages of the disease are limited, depending on what type of strain of Ebola is responsible for the infection. The Zaire-Ebola strain will cause death in almost every example that reaches this stage of the disease, as is the case with the unfortunate victims of the 2014 West African outbreak.

6. Ebola can be Fatal if Untreated

Data from the World Health Organization (WHO), shows that the chances of dying from Ebola virus infection are about 50-percent, with variations between 25 to 90-percent, depending on the strain and the origin of the outbreak. Ebola outbreaks have occurred mostly in villages in central and Western Africa, where medical care is limited, and most of the regions are unprepared, undersupplied, or under-staffed to handle a massive outbreak of infectious disease.

Instead, these countries rely on WHO and International NGO’s to swoop in and save the day, administering the medical care they need to beat the virus. However, where the virus is left to spread uncontrolled and unabated, it becomes a huge problem for communities. 

Medical science is still at a loss to explain why some people get infected, while others don’t – as well as why some survive the disease while others perish. While it largely remains a mystery, initial research shows that it may have something to do with the health of the immune response, as well as the health of the gut biome bacteria found in the digestive system.

7. There is No Cure

Like most other haemorrhagic fevers, there is no cure for the Ebola virus. The best health professionals and patients can hope for is a system of “supportive care,” where infected patients receive hydration fluids and medications.

Various drugs are on trial in the current DRC outbreak to see if science can find a solution to the Ebola puzzle. So far, the best that the teams have managed to create is a vaccine against the virus, known as rVSV-ZEBOV. So far studies on the vaccine show promise with vaccinated candidates not showing signs of infection.

However, various village leaders and politicians are trying to fool the people into thinking that WHO workers are merchants of death and that if they allow themselves vaccination, they will contract the disease. Unfortunately, in rural Africa, people’s opinion is easily swayed by those in power, and the outbreak continues.

8. A Recent Disease

The first documented cases of the Ebola virus appear in 1976, with outbreaks coinciding in the Democratic Republic of Congo, and South Sudan. There are five different strains, with the Zaire type of Ebola being the most aggressive, carrying the highest mortality rate – of over 90-percent.

This fact means that the Ebola virus is a relatively new disease when compared to pathogens like smallpox, that have documented cases dating back hundreds of years. However, unlike smallpox, there is no known cure for Ebola, and medical science is still experimenting with several vaccines in the ongoing outbreak in the DRC.

While that outbreak was the first documented case of the disease, some medical experts believe that Ebola may have had outbreaks in the past, but there was no way to report it to health authorities due to the lack of infrastructure available on the African continent during the early parts of the 1900s.

9. Ebola Vs. Marburg

While many people have heard about the Ebola virus, not as many are aware of its close relatives that are just as deadly. The Marburg virus is another haemorrhagic fever that’s often confused with Ebola. The virus has all of the same bleeding and influenza symptoms, but it is not as aggressive as the Zaire Ebola strain.

However, Marburg can still do extensive internal damage to the body, and all 100 of the patients involved in the first recorded outbreak of Marburg in Angola died as a result of the infection. Other reports show that Marburg is only fatal in 50 to 60-percent of all documented cases.

Both viruses cause severe internal bleeding and haemorrhaging of the organs. Patients require immediate medical assistance to ensure they have the best chance of surviving the infection. As is with Ebola, there is no known cure or vaccine for the deadly Marburg virus.

10. Ebola Is Not Airborne or Waterborne

The Ebola virus is the stuff of nightmares – a fast-acting haemorrhagic fever that causes you to bleed from the eyeballs and orifices. It’s no wonder that Hollywood finds it so appealing as a subject for disaster movies.

Fantasy can sometimes become a reality and start a panic in people. In the 1995 movie, “Outbreak,” the character played by Dustin Hoffman becomes terrified when he learns that the virus causing the epidemic has gone airborne.

An airborne virus means that the pathogen can float through the air and infect any person that breathes in the virus or bacteria. Since these pathogens are microscopic, the patient does not realize they have an infection until symptoms start to present.

The same goes for a waterborne pathogen that can spread through contact with bodies of water. The virus swims up your nose and infects the body.

Fortunately, Ebola infection is limited to contact with the body fluids of an infected person only.

11. Confusion with other Diseases

One of the reasons why Ebola spreads so readily – is because it’s mistaken for other diseases in the early stages of infection. Ebola is not a common disease, and if there is no current outbreak, then doctors may confuse the initial symptoms of the disease with others such as malaria, cholera, typhoid fever, shingles, or leptospirosis.

There are dozens of other conditions that have similar symptoms as Ebola in the early stages. The bleeding symptoms do not occur until the advanced stages of the disease, so it’s easy for a doctor to misdiagnose a patient and send them back to their family.

As a result of the misdiagnoses, the patient infects the rest of their family, and everyone in the household gets sick. Guidelines set by the World Health Organization for treating infected patients in hot zones requires that doctors first rule out all other possible sources of infection before diagnosing the patient with Ebola.

My Conclusions

At this current point in time South Sudan has demonstrated adequate preparedness by setting up isolation units and implementing IPC/WASH training, however there are still substantial resource gaps that must be addressed. First and foremost, Community engagement and social mobilization, followed by risk communication, more IPC/WASH supplies to be distributed to health care facilities

Also taking lessons from the current ongoing outbreak in DRC on mistrust from community means South Sudan can start community engagement now by training community healers, religious leaders, village elders and involving them in decision making not forgetting updating them on the current status.

References:

https://www.afro.who.int/sites/default/files/2019-04/Weekly%20Update%20on%20Ebola%20Virus%20Disease%20%28EVD%29%20%20Preparedness_%23%2034.pdf

https://extranet.who.int/sph/news/south-sudan-readiness-scales-face-drc-ebola-outbreak

https://reliefweb.int/report/south-sudan/south-sudan-ebola-preparedness-and-response-dashboard-january-2019

https://www.aljazeera.com/news/2019/03/ebola-defence-south-sudan-steps-border-checks-