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Ebola Epidemiology

The first known outbreak of Ebola virus disease (EVD) was identified only after the fact, occurring between June and November 1976 in Nzara, South Sudan (then part of Sudan) and was caused by Sudan virus (SUDV). The Sudan outbreak infected 284 people and killed 151. The first identifiable case in Sudan occurred on 27 June in a storekeeper in a cotton factory in Nzara, who was hospitalized on 30 June and died on 6 July. While the WHO medical staff involved in the Sudan outbreak were aware that they were dealing with a heretofore unknown disease, the actual "positive identification" process and the naming of the virus did not occur until some months later in the Democratic Republic of the Congo.

On 26 August 1976, a second outbreak of EVD began in Yambuku, Zaire, a small rural village in Mongala District in northern Democratic Republic of the Congo (then known as Zaire). This outbreak was caused by Ebola virus (EBOV), formerly designated Zaire ebolavirus, which is a different member of the genus Ebolavirus than in the first Sudan outbreak. The first person infected with the disease was village school headmaster Mabalo Lokela, who began displaying symptoms on August 26, 1976. Lokela had returned from a trip to Northern Zaire near the Central African Republic border, having visited the Ebola River between 12–22 August. He was originally believed to have malaria and was given quinine. However, his symptoms continued to worsen, and he was admitted to Yambuku Mission Hospital on September 5. Lokela died on September 8, fourteen days after he began displaying symptoms.

Soon after Lokela's death, others who had been in contact with him also died, and people in the village of Yambuku began to panic. This led the country's Minister of Health along with Zaire President Mobutu Sese Seko to declare the entire region, including Yambuku and the country's capital, Kinshasa, a quarantine zone. No one was permitted to enter or leave the area, with roads, waterways, and airfields placed under martial law. Schools, businesses and social organizations were closed. Researchers from the CDC, including Peter Piot, co-discoverer of Ebola, later arrived to assess the effects of the outbreak, observing that "the whole region was in panic." The outbreak lasted 26 days, with the quarantine lasting two weeks. Among the reasons that researchers speculated caused the disease to disappear, were the precautions taken by locals, the quarantine of the area, and possibly most important, the discontinuance of reusing needles by local nurses.

The virus responsible for the initial outbreak, first thought to be Marburg virus, was later identified as a new type of virus related to marburgviruses. Virus strain samples isolated from both outbreaks were named as the "Ebola virus" after the Ebola River, located near the originally identified viral outbreak site in Zaire. Reports conflict about who initially coined the name: either Karl Johnson of the American CDC team or Belgian researchers. Subsequently a number of other cases were reported, almost all centered on the Yambuku mission hospital or having close contact with another case. 318 cases and 280 deaths (a 88% fatality rate) occurred in the DRC. Although it was assumed that the two outbreaks were connected, scientists later realized that they were caused by two distinct ebolaviruses, SUDV and EBOV. The Zaire outbreak was contained with the help of the World Health Organization and transport from the Congolese air force, by quarantining villagers, sterilizing medical equipment, and providing protective clothing.

Figure 1: First Ebola outbreaks till 2010. Source: WHO.

1995 to 2014
The second major outbreak occurred in 1995 in the Democratic Republic of Congo, affecting 315 and killing 254. The next major outbreak occurred in Uganda in 2000, affecting 425 and killing 224; in this case the Sudan virus was found to be the ebolavirus species responsible for the outbreak. In 2003 there was an outbreak in the Republic of Congo that affected 143 and killed 128, a death rate of 90%, the highest to date.

In August 2007, 103 people were infected by a suspected hemorrhagic fever outbreak in the village of Kampungu, Democratic Republic of the Congo. The outbreak started after the funerals of two village chiefs, and 217 people in four villages fell ill. The 2007 outbreak eventually affected 264 individuals and resulted in the deaths of 187. On 30 November 2007, the Uganda Ministry of Health confirmed an outbreak of Ebola in the Bundibugyo District in Western Uganda. After confirmation of samples tested by the United States National Reference Laboratories and the Centers for Disease Control, the World Health Organization confirmed the presence of a new species of Ebolavirus, which was tentatively named Bundibugyo. The WHO reported 149 cases of this new strain and 37 of those led to deaths.

The WHO confirmed two small outbreaks in Uganda in 2012. The first outbreak affected 7 people and resulted in the death of 4 and the second affected 24, resulting in the death of 17. The Sudan variant was responsible for both outbreaks. On 17 August 2012, the Ministry of Health of the Democratic Republic of the Congo reported an outbreak of the Ebola-Bundibugyo variant in the eastern region. Other than its discovery in 2007, this was the only time that this variant has been identified as the ebolavirus responsible for an outbreak. The WHO revealed that the virus had sickened 57 people and claimed 29 lives. The probable cause of the outbreak was tainted bush meat hunted by local villagers around the towns of Isiro and Viadana.

In 2014, an outbreak of Ebola virus disease occurred in the Democratic Republic of the Congo (DRC). Genome-sequencing has shown that this outbreak was not related to the 2014–15 West Africa Ebola virus outbreak, but was of the same EBOV species, the Zaire species. It began in August 2014 and was declared over in November of that year with a total of 66 cases and 49 deaths. This is the 7th outbreak in the DRC, three of which occurred during the period when the country was known as Zaire.

2013–2016 West African
In March 2014, the World Health Organization (WHO) reported a major Ebola outbreak in Guinea, a West African nation. Researchers traced the outbreak to a one-year-old child who died December 2013. The disease rapidly spread to the neighboring countries of Liberia and Sierra Leone. It was the largest Ebola outbreak ever documented, and the first recorded in the region. On 8 August 2014, the WHO declared the epidemic an international public health emergency. Urging the world to offer aid to the affected regions, its Director-General said, "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible." By mid-August 2014, Doctors Without Borders reported the situation in Liberia's capital, Monrovia, was "catastrophic" and "deteriorating daily". They reported that fears of Ebola among staff members and patients had shut down much of the city's health system, leaving many people without medical treatment for other conditions. In a 26 September statement, WHO said, "The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long."

Intense contact tracing and strict isolation techniques largely prevented further spread of the disease in the countries that had imported cases. As of 8 May 2016, 28,646 suspected cases and 11,323 deaths have been reported; however, the WHO has said that these numbers may be underestimated. Because they work closely with the body fluids of infected patients, healthcare workers have been especially vulnerable to catching the disease; in August 2014, the WHO reported that ten percent of the dead have been healthcare workers. 2014 Ebola virus epidemic in West Africa.

In September 2014, it was estimated that the countries' capacity for treating Ebola patients was insufficient by the equivalent of 2,122 beds; by December there were a sufficient number of beds to treat and isolate all reported Ebola cases, although the uneven distribution of cases was causing serious shortfalls in some areas. On 28 January 2015, the WHO reported that for the first time since the week ending 29 June 2014, there had been fewer than 100 new confirmed cases reported in a week in the three most-affected countries. The response to the epidemic then moved to a second phase, as the focus shifted from slowing transmission to ending the epidemic. On 8 April 2015, the WHO reported a total of only 30 confirmed cases, the lowest weekly total since the third week of May 2014.

On 29 December 2015, 42 days after the last person tested negative for a second time, Guinea was declared free of Ebola transmission. At that time, a 90-day period of heightened surveillance was announced by that agency. "This is the first time that all three countries – Guinea, Liberia and Sierra Leone – have stopped the original chains of transmission ...", the organization stated in a news release. A new case was detected in Sierra Leone on 14 January 2016. However, the outbreak was declared no longer an emergency on 29 March 2016.

2014 spread outside West Africa
On 19 September, Eric Duncan flew from his native Liberia to Texas; 5 days later he began showing symptoms and visited a hospital but was sent home. His condition worsened and he returned to the hospital on 28 September, where he died on 8 October. Health officials confirmed a diagnosis of Ebola on 30 September – the first case in the United States.

In early October, Teresa Romero, a 44-year-old Spanish nurse, contracted Ebola after caring for a priest who had been repatriated from West Africa. This was the first transmission of the virus to occur outside Africa. Romero tested negative for the disease on 20 October, suggesting that she may have recovered from Ebola infection.

On 12 October, the Centers for Disease Control and Prevention (CDC) confirmed that a nurse in Texas, Nina Pham, who had treated Duncan was found to be positive for the Ebola virus, the first known case of transmission in the United States. On 15 October, a second Texas health-care worker who had treated Duncan was confirmed to have the virus. Both of these people recovered.An unrelated case involved a doctor in New York City, who returned to the United States from Guinea after working with Doctors Without Borders and tested positive for Ebola on 23 October. The person recovered and was discharged from Bellevue Hospital Center on 11 November. On 24 December 2014, a laboratory in Atlanta, Georgia reported that a technician had been exposed to Ebola.

On 29 December 2014, Pauline Cafferkey, a British nurse who had just returned to Glasgow from Sierra Leone, was diagnosed with Ebola at Glasgow's Gartnavel General Hospital. After initial treatment in Glasgow, she was transferred by air to RAF Northolt, then to the specialist high-level isolation unit at the Royal Free Hospital in London for longer-term treatment.

2017 other outbreaks
On 11 May 2017, the DRC Ministry of Public Health notified the WHO about an outbreak of Ebola. Four people died, and four people survived; five of these eight cases were laboratory-confirmed. A total of 583 contacts were monitored. On 2 July 2017, the WHO declared the end of the outbreak.

On 14 May 2018, the World Health Organization reported that "the Democratic Republic of Congo reported 39 suspected, probable or confirmed cases of Ebola between 4 April and 13 May, including 19 deaths." Some 393 people identified as contacts of Ebola patients were being followed up. The outbreak centered on the Bikoro, Iboko, and Wangata areas in Equateur province, including in the large city of Mbandaka. The DRC Ministry of Public Health approved the use of an experimental vaccine. On 13 May 2018, WHO Director-General Tedros Adhanom Ghebreyesus visited Bikoro. Reports emerged that maps of the area were inaccurate, not so much hampering medical providers as epidemiologists and officials trying to assess the outbreak and containment efforts.The 2018 outbreak in the DRC was declared over on 24 July 2018.

On 1 August 2018, the 10th Ebola virus outbreak was declared in North Kivu province. In contrast to prior outbreaks, this one has occurred in a military conflict zone, with thousands of refugees in the area. By November 2018, nearly 200 Congolese had died of Ebola, about half of them from the city of Beni, where armed groups are fighting over the region's mineral wealth, impeding medical relief efforts.

By March 2019, the Democratic Republic of Congo outbreak became the second largest Ebola outbreak ever recorded, with more than 1,000 cases and insecurity continuing to being the major resistance to providing an adequate response. As of 4 June 2019, WHO reported 2025 confirmed and probable cases with 1357 deaths. In June 2019, two people died of Ebola in neighbouring Uganda.

In July 2019, an infected man travelled to Goma, home to more than 2 million people. One week later, on 17 July 2019, the WHO declared the Ebola outbreak a global health emergency, the fifth time such a declaration has been made by the organization. A government spokesman said that half of the Ebola cases are unidentified, and he added that the current outbreak could last up to three years.

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