Case Definitions Used During the First 6 Months of the 10th Ebola Virus Disease Outbreak in the Democratic Republic of the Congo - Four Neighboring Countries, August 2018-February 2019.

Alexandra Medley ,Aimee Geissler,Richard Lako,Sudhir Bunga,Adeline Kabeja,Raimi Ewetola,Issa Makumbi,Trevor Shoemaker,Felicien Nizeyemana,Pratima L Raghunathan,Allan Muruta,Amanda Macgurn,Yona Kenyi Manoah,Sarah Ward,Shahrokh Roohi,Jaco Homsy,Kimberly Singler,Angela Umutoni,Oscar Mavila,Vance Brown,Joseph Ojwang,Hélène Balisanga,Glen C Macdonald ,Léopold Lubula ,Rebecca D Merrill

doi:10.15585/mmwr.mm6901a4

Abstract

On August 1, 2018, the Democratic Republic of the Congo (DRC) declared its 10th Ebola virus disease (Ebola) outbreak in an area with a high volume of cross-border population movement to and from neighboring countries. The World Health Organization (WHO) designated Rwanda, South Sudan, and Uganda as the highest priority countries for Ebola preparedness because of the high risk for cross-border spread from DRC (1). Countries might base their disease case definitions on global standards; however, historical context and perceived risk often affect why countries modify and adapt definitions over time, moving toward or away from regional harmonization. Discordance in case definitions among countries might reduce the effectiveness of cross-border initiatives during outbreaks with high risk for regional spread. CDC worked with the ministries of health (MOHs) in DRC, Rwanda, South Sudan, and Uganda to collect MOH-approved Ebola case definitions used during the first 6 months of the outbreak to assess concordance (i.e., commonality in category case definitions) among countries. Changes in MOH-approved Ebola case definitions were analyzed, referencing the WHO standard case definition, and concordance among the four countries for Ebola case categories (i.e., community alert, suspected, probable, confirmed, and case contact) was assessed at three dates (2). The number of country-level revisions ranged from two to four, with all countries revising Ebola definitions by February 2019 after a December 2018 peak in incidence in DRC. Case definition complexity increased over time; all countries included more criteria per category than the WHO standard definition did, except for the "case contact" and "confirmed" categories. Low case definition concordance and lack of awareness of regional differences by national-level health officials could reduce effectiveness of cross-border communication and collaboration. Working toward regional harmonization or considering systematic approaches to addressing country-level differences might increase efficiency in cross-border information sharing.

Highlights

The low level of concordance in case definitions among countries, when case definitions are critical to many outbreak response and preparedness activities, indicates the need for routine evaluation of regional differences in case definitions and implementation of systematic approaches to advance harmonization
Case contact Person was in the same household Had direct contact Shared the same room or bed Direct contact with a person with Ebola, alive or dead Touched body fluids Direct contact with the body of a person with Ebola at a funeral Attended a burial ceremony of a person with suspected or confirmed Ebola Gave patient care Touched soiled linen Was breastfed Shared transport Had animal contact Ate bushmeat Had a laboratory exposure
There was variation among countries in case definition sensitivity, this analysis did not evaluate the effect of discordance on surveillance; cases with in-country transmission have been limited to DRC

Summary

Morbidity and Mortality Weekly Report

Case Definitions Used During the First 6 Months of the 10th Ebola Virus Disease Outbreak in the Democratic Republic of the Congo — Four Neighboring Countries, August 2018–February 2019. The World Health Organization (WHO) designated Rwanda, South Sudan, and Uganda as the highest priority countries for Ebola preparedness because of the high risk for cross-border spread from DRC (1). Countries might base their disease case definitions on global standards; historical context and perceived risk often affect why countries modify and adapt definitions over time, moving toward or away from regional harmonization. CDC worked with the ministries of health (MOHs) in DRC, Rwanda, South Sudan, and Uganda to collect MOH-approved Ebola case definitions used during the first 6 months of the outbreak to assess concordance (i.e., commonality in category case definitions) among countries.

DRC Rwanda South Sudan Uganda WHO

Clinician suspects Ebola

Discussion

What are the implications for public health practice?

Case contact