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Introduction: In August 1976, an outbreak of Ebola virus disease occurred in Zaire (now the Democratic Republic of the Congo). The first recorded case was from Yambuku, a small village in Mongala District,[1] 1,098 kilometres (682 mi) northeast of the capital city of Kinshasa.

The virus responsible for the initial outbreak, named after the relatively (sounds unprofessional) nearby Ebola River, was first thought to be Marburg virus but was later identified as a new type of virus related to the genus Marburgvirus.[2]

A total of 318 cases and 280 deaths (an 88% fatality rate) resulted from this outbreak, which, along with an outbreak in Sudan that had begun a few weeks previously, were the first outbreaks of Ebola ever recorded.[3]

Background:

The people of the north-central Zaire area were most heavily affected by this specific epidemic. This area is located within the Bumba Zone that is in the Equator Region which consists mostly of tropical rainforests in biome, as the villages were established along the Zaire river. Over this region, there were approximately 35,000 Zarieans and 275,000 people in the entire Bumba Zone and three quarters of the Zaire population lived in forest villages. Each of the forest villages had approximately less than 5,000 people in population, and the even smaller villages had less than 500. The topography of the river runs along the border on the South side of the country, and this was important in the context of the Ebola epidemic, as it separated the areas geographically. The people of Zaire were usually hunters, or in contact with hunters that were exposed to an array of wild animals.[1] This was not the suspected cause for the outbreak, but was considered for a possible outbreak cause for some time.[2] The area was susceptible to a variety of different ailments that could look like the beginning symptoms of Ebola Hemorrhagic Fever including: Malaria and Yellow Fever, as many doctors initially did suspect the ailments of the patients being.

History: Mabalo Lokela, the headmaster of a local school in Yambuku, was the first case of the 1976 outbreak in Zaire.[4] Lokela had toured with a Yambuku mission in August 1976 near the Central African Republic border and along the Ebola River.[5]

Lokela was initially diagnosed with malaria at the Yambuku Mission Hospital and given quinine. However, Lokela returned to the mission hospital on 1 September with a high fever.[5] Rest was recommended, and he returned home to his village of Yalikonde, about one kilometer from the mission complex. By 5 September, Lokela was in a critical condition with profuse bleeding from all orifices, vomiting, acute diarrhea, chest pains, headache, fever and in an agitated and confused state.[5] Lokela died shortly afterwards on 8 September.[6] On 28 August, a second man presented symptoms, claiming he was from the nearby village of Yandongi.[5] He left the hospital on 30 August, as no clear cause could be identified from his symptoms, and was not seen again. On the same day, Yombe Ngongo, a patient at the hospital receiving treatment for anemia, checked out of the hospital and returned to her village. She soon fell seriously ill, and was tended to by her younger sister Euza. Yombe Ngongo died on 7 September, and her sister Euza followed on 9 September.[5]

Soon after Lokela's visit, a number of other cases were presented at the Yambuku Mission Hospital. A report from the World Health Organization (WHO) noted that "almost all subsequent infections had either received injections at the hospital or had had close contact with another case."[6] Shortly after family members prepared his body for burial, in accordance with local customs, 21 of Lokela's friends and relatives fell seriously ill and 18 later died.[5] The mission hospital's reuse of unsterilized needles also contributed to the spread of infection.[7] (mentioned later)

Yambuku Mission Hospital was a remote Catholic hospital and had no doctors and no laboratory facilities to aid in diagnosis.[5] This, as well as the lack of communication ability, contributed to this Mission Hospital being isolated from Kinshasa, and unable to receive more resources, until the Minister of Health sent out an International Commission to investigate further.[2] Treatment of the disease, was conducted by four Belgian nuns, a priest, one female nurse from Zaire, and seven male Zaireians.[5] Urgent pleas for assistance were sent out on 12 September. On 15 September, the first doctor to arrive, Mgoi Mushola, prepared a report in which he noted that none of the many treatments provided met with success; this was the first formal description of Ebola virus disease.[5]

Epidemiology:

The International Commission team worked with the nurses for interpreting and processing standardized pre-coded forms. These forms included clinical questionnaires, as well as, many epidemiological features such as: asking for the sex and age of the person, and asking to list out relatives that would also fill out a form. Through this form, the team was able to construct a control group to compare with the Ebola patients, by matching similar traits, thus helping them construct their epidemiological study.[1]

The team needed to figure out how this disease was spreading in order to make a plan of attack against the deadly virus.  Because of the uncertainty of the infection route, the team placed a quarantine over the region of the Bumba Zone that was most concerning within two days after the hospital’s closure in October. The motivation for this quick quarantine was largely due to the intense nature of the symptoms and rapid progression of this disease. Unfortunately, there was a lot of resistance from people to help out the team and situation because of the fear associated with the unknown infection route of this disease. Since all of the infection route possibilities were in contention, they had to start narrowing down the potential infection pathways. The team noted that the cases had distinct patterns when drawn out into an epidemic curve that showed a clear correlation between the disease and women between the age of 18-25.[2] The image below shows the team’s data that they collected from this region.[1]

The Mission Hospital had only 120 beds available and a staff of just 17 nurses that were directed by a paramedical assistant, not a doctor. This hospital primarily saw patients from the Yandongi country, but they had also attracted patients from the outer Bumba Zone because this hospital was considered relatively well stocked and supplied with a good amount of staff for the area. They were already very limited in disease containment abilities because of these factors, but they also generally saw anywhere between 6,000 and 12,000 patients a month for general care. This is another reason why the quarantine was so necessary during the time of the Ebola epidemic at this hospital.

Peter Piot, a microbiologist and physician who investigated the ensuing epidemic, concluded that it was inadvertently caused by the Sisters of Yambuku Mission Hospital, who had given unnecessary vitamin injections to pregnant women in their prenatal clinic without sterilizing the needles and syringes.[8][9] There were five total syringes and needles that were being used by this nursing staff for multiple days. These medical materials were rinsed between uses with the use of only warm water. Then, at the end of their shift, the nurses would boil the needles and syringes in water, and no other sterilization methods were utilized.[1] This was not an effective enough sterilization process as the Ebola virus was able to be spread from an possible infected man in the Sudan region during their own Ebola epidemic and spread through this hospital.[3] The International Commission team was able to back up this theory by their epidemiological study showing a correlation between injection history and Ebola cases and then consequently the spreading through person to person.[1]

In all, 318 cases of Ebola were identified in Zaire, and 280 resulted in death. An additional 284 cases and 151 deaths occurred in nearby South Sudan in an unrelated outbreak. Yambuku Mission Hospital was closed after 11 of its 17 staff members died. Belgian nuns serving the community were also infected, and two of them died, along with Mayinga N'Seka, a Zairean nurse, after the group was transported to Kinshasa. With assistance from the WHO, the outbreak was eventually contained by quarantining local villagers in their communities, sterilizing medical equipment, and providing protective clothing to medical personnel. The small Congolese Air Force provided helicopters to allow the outbreak team to visit 550 villages in the area.[5]