Ebola returns to Beni—survivor transmission suspected

In a disappointing development today, the Democratic Republic of the Congo (DRC) health ministry reported a new Ebola case in Beni, coming just 2 days after the former outbreak epicenter had reached the hopeful mark of going a full 21-day incubation period without new illness.

Today's announcement also noted five other new cases, including four from two current hot spots.

In other Ebola developments, a research team from the United Kingdom and Guinea that conducted a detailed epidemiological investigation paired with antibody testing in the Guinea community where West Africa's outbreak began found evidence of eight more survivors and two probable deaths from the virus.

Survivor contact suspected

The newly confirmed patient from Beni was apparently exposed to the body fluids of an Ebola survivor, the ministry said in its statement today, adding that a thorough investigation and genetic sequencing is underway to determine the epidemiological links between the cases.

In the waning months of West Africa's Ebola outbreak, sexual transmission linked to survivors was strongly suspected in many recurrence events. Immune-protected areas of the body such as the testes and the eyes can harbor the virus, perhaps for as long as 1 year.

Of the five other new cases today, two are from Katwa, two are from Butembo, and one is from Kalunguta. Authorities are also investigating 179 suspected Ebola cases. Today's six new cases lift the outbreak total to 859 cases, which includes 794 confirmed and 65 probable infections.

The health ministry reported five more deaths, three of which occurred in the community—two in Katwa and one in Butembo. The other two people died in Ebola treatment centers, one in Katwa and one in Butembo. So far, 536 fatalities have been reported in the DRC's outbreak.

In other developments, the health ministry said the Ebola strategic coordination office today began its move from Beni to Goma, the capital of North Kivu province. Health minister Oly Ilunga Kalenga, MD, in late November decided to relocate the office to Goma to separate planning and supervision activities from field operations. According to the statement, the move to Goma will make it easier for the ministry's partners to get security clearances to work on the Ebola response. It added that the move won't disrupt daily response activities in Beni, which will still have a subcoordination center as for other main hot spots such as Butembo and Katwa.

"It is important to note that this move to Goma in no way means that the Ebola outbreak has reached the city, although it remains exposed," the ministry said, noting that placing the coordinating office in an area not affected by the outbreak allows it to focus on supervision, monitoring, and planning.

More clues from Guinea's first outbreak

In an effort to reconstruct early Ebola transmission in Meliandou, Guinea, the remote heavily forested area where West Africa's outbreak began in December 2013, researchers from the United Kingdom and Guinea conducted detailed interviews with all households in the village and used a validated oral test detect Ebola IgG antibodies. The described their findings yesterday in The Lancet Infectious Diseases.

The group conducted the study in June and July of 2017, enrolling 237 participants from 27 Meliandou households. All adults who agreed to be interviewed were provided oral fluid for the tests, and 224 samples were suitable for testing.

They found that illnesses were more widespread than the 11 cases originally reported from the area, which includes a 2-year-old boy thought have been the first case and to have been exposed to the virus by a bat.

Researchers identified two more probable deaths and eight previously unrecognized IgG-positive survivors, including one person who had mild illness and another who was asymptomatic, for a case fatality of 55.6% for adults, much lower than originally reported 100%.

When they looked at epidemiological connections among the village's cases, healthcare work and exposure level stood out as independent risk factors.

For example, the 2-year-old boy spread the virus to his sister and mother who was pregnant and had a spontaneous abortion the night she died. Over that period, family members and healthcare workers cared for her, which the researchers said was an amplification event that spread Ebola to other households.

The team said the noninvasive oral test was acceptable to the community and has the potential to reveal more about mild and symptomatic infection and transmission patterns within communities.

'Brilliant' epi sleuthing

In a related commentary in the same journal issue, two experts from Harvard Medical School's Department of Global Health and Social Medicine called the study "a brilliant piece of epidemiological sleuthing" that pairs classic field investigation with an oral Ebola antibody test. The authors are Eugene Richardson, MD, PhD, and Mosoka Fallah, PhD, MPH.

They wrote that the study shows almost double the number of people infected with Ebola and that mild infections may have been common in West Africa's outbreak.

Though the study uncovers important insights into the start of the outbreak, they said it's important to keep in mind that a combination of social factors is the real cause of the outbreak, which include the legacy of slavery, colonial exploitation, illicit financial transactions, poverty, gender violence, and civil war.

See also:

Feb 22 DRC statement

Feb 21 Lancet Infet Dis abstract

Feb 23 Lancet Infect Dis commentary

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