The Impact of Different Types of Violence on Ebola Virus Transmission During the 2018–2020 Outbreak in the Democratic Republic of the Congo

• Published in: The Journal of infectious diseases Vol. 222; no. 12; pp. 2021 - 2029
• Main Authors: Kelly, John Daniel, Wannier, Sarah Rae, Sinai, Cyrus, Moe, Caitlin A, Hoff, Nicole A, Blumberg, Seth, Selo, Bernice, Mossoko, Mathais, Chowell-Puente, Gerardo, Jones, James Holland, Okitolonda-Wemakoy, Emile, Rutherford, George W, Lietman, Thomas M, Muyembe-Tamfum, Jean Jacques, Rimoin, Anne W, Porco, Travis C, Richardson, Eugene T
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 15-12-2020
• Subjects: Aggression; Armed Conflicts - classification; Civil Disorders - classification; Democratic Republic of the Congo - epidemiology; Disease Outbreaks; Ebola virus; Ebolavirus; Geographic Mapping; Hemorrhagic Fever, Ebola - epidemiology; Hemorrhagic Fever, Ebola - transmission; Humans; Major and Brief Reports; Violence; Democratic Republic of the Congo; transmission; Democratic Republic of the Congo; Africa; Ebola virus disease; violence
• ISSN: 0022-1899; 1537-6613
• DOI: 10.1093/infdis/jiaa163

Abstract
Background
Our understanding of the different effects of targeted versus nontargeted violence on Ebola virus (EBOV) transmission in Democratic Republic of the Congo (DRC) is limited.
Methods
We used time-series data of case counts to compare individuals in Ebola-affected health zones in DRC, April 2018–August 2019. Exposure was number of violent events per health zone, categorized into Ebola-targeted or Ebola-untargeted, and into civilian-induced, (para)military/political, or protests. Outcome was estimated daily reproduction number (Rt) by health zone. We fit linear time-series regression to model the relationship.
Results
Average Rt was 1.06 (95% confidence interval [CI], 1.02–1.11). A mean of 2.92 violent events resulted in cumulative absolute increase in Rt of 0.10 (95% CI, .05–.15). More violent events increased EBOV transmission (P = .03). Considering violent events in the 95th percentile over a 21-day interval and its relative impact on Rt, Ebola-targeted events corresponded to Rt of 1.52 (95% CI, 1.30–1.74), while civilian-induced events corresponded to Rt of 1.43 (95% CI, 1.21–1.35). Untargeted events corresponded to Rt of 1.18 (95% CI, 1.02–1.35); among these, militia/political or ville morte events increased transmission.
Conclusions
Ebola-targeted violence, primarily driven by civilian-induced events, had the largest impact on EBOV transmission.
A time-series study of the 2018–2020 Ebola virus disease outbreak in the Democratic Republic of the Congo found both Ebola-targeted and untargeted violence increased transmission, though targeted violence, primarily driven by civilian-involved events, had the largest impact.