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  1. 1. Patient with Ebola Hemorrhagic Fever, Bumba Zone, Equateur Province, DR Congo (Zaire), October 1976
  2. 2. Active Surveillance for EHF Cases, Equateur Province, DR Congo (Zaire), November-December 1976
  3. 3. Investigations of EHF Cases in Villages, Equateur Province, DR Congo (Zaire), October-December 1976 Dr. M. Mbuyi & Nurse Sukato interviewing mourning family member
  4. 4. Ebola Hemorrhagic Fever in Democratic Republic of the Congo (Zaire), 1976-1977 Selected Events Aug 26 First patient presents with fever in Yambuku, Equateur Province, receives chloroquine injection; fever resolves in 4 days Sept 1 EHF begins in first patient 16 Local clinician reviews 17 patients; reports unknown disease to Kinshasa 23-25 First medical team visit from Kinshasa; typhoid fever suspected, vaccination; evacuation of Belgian nun to capital 30 Yambuku hospital closed, 11 of 17 staff members dead Sept 30/ Oct 20 Three nurses die in Kinshasa
  5. 5. Ebola Hemorrhagic Fever in Democratic Republic of the Congo (Zaire), 1976-1977 Selected Events Oct 2-6 Second medical visit from Kinshasa; specimens collected 3 Health zone quarantined by Minister 8-12 Transmission occurring in Kinshasa hospital 13-14 Filovirus seen on EM in Belgium, UK and USA 14 New virus (Ebola) identified at CDC 18 International Commission formed 19-27 Survey team to Yambuku; reports active cases in 8 villages 30 Airlift of surveillance teams to NE DR Congo, covers DRC-Sudan frontier
  6. 6. Nov 2 Plasmapheresis program begins with convalescent patients 4 Widespread surveillance in epidemic zone 5 Last case dies 16 Surveillance, research and clinical care support arrives in Yambuku Dec 16 Emergency officially over Jan 28 Plasmapheresis program ends Selected Events (cont’d) EHF in DR Congo (Zaire), 1976-1977
  7. 7. Ebola Hemorrhagic Fever in Democratic Republic of the Congo (Zaire), 1976-1977 International Commission Discoveries Virology <ul><li>Isolation and characterization of Ebola virus </li></ul><ul><li>Differentiation from Marburg virus </li></ul><ul><li>Immunology </li></ul>
  8. 8. Ebola Hemorrhagic Fever in Democratic Republic of the Congo (Zaire), 1976-1977 Clinical <ul><li>Described symptoms and signs including </li></ul><ul><ul><ul><li>Hemorrhagic manifestations </li></ul></ul></ul><ul><ul><ul><li>Pancreatitis </li></ul></ul></ul><ul><li>Incubation period </li></ul>International Commission Discoveries
  9. 9. Patient Management and Control Ebola Hemorrhagic Fever in Democratic Republic of the Congo (Zaire), 1976-1977 <ul><li>Isolation of patients effective </li></ul><ul><li>Surveillance of households, villages </li></ul><ul><li>Plasmapheresis of convalescents </li></ul>International Commission Discoveries
  10. 10. Ebola Hemorrhagic Fever in Democratic Republic of the Congo (Zaire), 1976-1977 Epidemiology <ul><li>Mode of transmission </li></ul><ul><li>Risk groups </li></ul><ul><li>Attack rates; individuals, families, villages </li></ul><ul><li>Geographic distribution and spread </li></ul>International Commission Discoveries
  11. 11. Ebola Hemorrhagic Fever in Democratic Republic of the Congo (Zaire), 1976-1977 Immunology <ul><li>Developed IFA test for Ebola </li></ul><ul><li>Found evidence of previous infection </li></ul>International Commission Discoveries
  12. 12. Ebola Hemorrhagic Fever in Democratic Republic of the Congo (Zaire), 1976-1977 <ul><li>Epidemic in northern DR Congo (Zaire) </li></ul><ul><ul><ul><li>100% of villages affected </li></ul></ul></ul><ul><ul><ul><li>100% of persons in villages affected </li></ul></ul></ul><ul><ul><ul><li>100% of affected persons in villages dead </li></ul></ul></ul>Initial Information
  13. 13. Ebola Hemorrhagic Fever in Democratic Republic of the Congo (Zaire), 1976-1977 <ul><li>Cause? </li></ul><ul><ul><li>Typhoid </li></ul></ul><ul><ul><li>Lassa fever </li></ul></ul><ul><ul><li>Yellow fever </li></ul></ul>Initial Information <ul><li>Sources of Information </li></ul><ul><ul><li>International plantation manager (confidential) </li></ul></ul><ul><ul><li>World Health Organization (limited) </li></ul></ul><ul><ul><li>US Embassy (limited) </li></ul></ul><ul><ul><li>Scientists in Belgium and France </li></ul></ul>
  14. 14. Ebola Hemorrhagic Fever in DR Congo (Zaire), 1976 Risk Factors Associated with Person to Person Spread Person to Person Family Contacts (non-infected) Risk Factor Cases % Yes Cases % Yes P Touched cases Attended burial Cared for case Slept in same room Prepared cadaver Aided in delivery of child from sick patient 126 126 119 116 116 104 86 86 71 69 59 18 91 98 84 86 58 74 84 86 71 68 58 9 ns ns ns ns ns p<0.001
  15. 15. Ebola Hemorrhagic Fever in DR Congo (Zaire), 1976 Distribution of Cases in Villages Cases Number of Villages % of Villages Cumulative % 1 2-5 6-9 10-14 15-19 20-29  30 17 18 12 4 1 1 2 55 31 33 22 7 2 2 4 31 64 86 93 95 97 101
  16. 16. Family Contact Attack Rate by Generation of Illness Generation 1* 2 3 4 Total No. of Families of Cases 61 62 18 5 146 No. of Family Exposures 496 459 117 29 1103 No. of Subsequent Cases 38 20 3 1 62 Attack Rate (%) 7.5 4.4 2.6 3.4 5.6 * persons acquiring disease by injection Ebola Hemorrhagic Fever in DR Congo (Zaire), 1976
  17. 17. Distribution of Ebola Hemorrhagic Fever Cases by Transmission Type, Yambuku, DR Congo (Zaire), 1976 Injection Person-to-person Both possible Unknown Neonatal Cases No. 85 149 43 30 11 318 % 27 47 14 9 3 100 Survivors No. 0 30 4 4 0 38 % 0 79 11 11 0 101 Transmission History Ebola Hemorrhagic Fever in DR Congo (Zaire), 1976
  18. 18. Ebola Hemorrhagic Fever, DR Congo (Zaire), 1977 Case Definitions <ul><li>Probable: </li></ul><ul><li>Living in epidemic area </li></ul><ul><li>Died after  1 days with  2 of the following: </li></ul><ul><ul><li>headache, fever, abdominal pain, nausea/vomiting, </li></ul></ul><ul><ul><li>bleeding </li></ul></ul><ul><li>With 3 preceding weeks received an injection or had </li></ul><ul><li>contact with a probable or proven case </li></ul><ul><li>No other diagnosis </li></ul>
  19. 19. Ebola Hemorrhagic Fever, DR Congo (Zaire), 1977 Case Definitions <ul><li>Proven: </li></ul><ul><li>Ebola virus isolated or shown by EM </li></ul><ul><li>Or IFA titer of  1:64 after 3 weeks of symptom onset </li></ul>
  20. 20. Ebola Hemorrhagic Fever, DR Congo (Zaire), 1977 Case Definitions <ul><li>Infection: </li></ul><ul><li>IFA titer  1:64 with no symptoms/signs August 15- </li></ul><ul><li>November 19, 1976 </li></ul><ul><li>Possible: </li></ul><ul><li>Headache and/or fever for  24 hours with or without other signs/symptoms </li></ul><ul><li>Contact with a probable or proven case, within 3 weeks </li></ul><ul><li>Treated with antimalarials, antibiotics, antipyretics </li></ul><ul><li>Bled and checked for antibodies </li></ul><ul><li>Any case of fever and bleeding anywhere in DR Congo </li></ul><ul><li>Neonatal: </li></ul><ul><li>Newborns of probable cases if died within 28 days </li></ul>
  21. 21. Ebola Hemorrhagic Fever, DR Congo (Zaire), 1977 Case Definitions <ul><li>Primary Contact: </li></ul><ul><li>Face to face contact with a probable or proven case </li></ul><ul><li>Between 2 days before symptom onset and death or recovery </li></ul><ul><li>Surveillance 21 days from last contact </li></ul><ul><li>Secondary Contact: </li></ul><ul><li>Face to face contact with primary contact </li></ul>
  22. 22. Ebola Hemorrhagic Fever, DR Congo (Zaire), 1976-77 Major Gaps and Challenges <ul><li>Natural history undefined </li></ul><ul><li>Surveillance and response weak </li></ul><ul><li>No specific treatment or precaution </li></ul><ul><li>Limited application of modern technologies </li></ul><ul><li>Few laboratories involved </li></ul><ul><li>Filovirus and other “orphan” diseases receive </li></ul><ul><li>low priority </li></ul>

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