Ebola Virus Disease Democratic Republic of Congo: External Situation Report 17 / 2018

Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 1 EBOLA VIRUS DISEASE Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 2 Date of issue: 28 November 2018 Data as reported by: 26 November 2018 The Ministry of Health (MoH), WHO and partners continue to respond to the Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo, and remain confident that the outbreak can be contained, despite ongoing challenges. Since our last report dated 21 November 2018 (External Situation Report 16), there have been a total of 48 new confirmed cases from Katwa (n=16), Beni (n=13), Kalunguta (n=9), Butembo (n=6), Oicha (n=2), Kyondo (n=1) and Mutwanga (n=1), and 24 new deaths. As of 26 November 2018, a total of 421 EVD cases, including 374 confirmed and 47 probable cases (Table 1) have been reported from 14 health zones in the two neighbouring provinces of North Kivu and Ituri (Figure 2). Kalunguta, Beni, Butembo and Katwa remain the principle hotspots of the outbreak. Of the 421 cases, 241 have died, including 194 among confirmed cases (case fatality ratio 52%). Females account for 60% of all confirmed and probable cases. A total of 41 health workers have been infected to date, including 12 deaths. A total of 74 new suspected cases were reported on 26 November 2018 from the affected health zones, and are being investigated. A total of 125 patients have been cured since the beginning of the outbreak and have been reintegrated into their communities. The MoH, WHO and partners continue to monitor and investigate all alerts in affected areas, in other provinces in the Democratic Republic of the Congo and in neighbouring countries. Since the last report was published, alerts were investigated in several provinces of the Democratic Republic of the Congo as well as in South Soudan and Uganda. To date, EVD has been ruled out in all alerts from neighbouring provinces and countries. Deaths 100 1. Situation update Cases 421 EBOLA VIRUS DISEASE Deaths 241 Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 3 Case classification Deaths Province Health zone Confirmed cases Probable cases Total cases Deaths in confirmed cases Total deaths North Kivu Beni 180 9 189 96 105 Butembo 17 0 17 15 15 Katwa 39 3 42 18 21 Kalunguta 33 12 45 11 23 Kyondo 3 2 5 1 3 Mabalako 67 16 83 36 52 Masereka 6 1 7 1 2 Musienene 2 1 3 2 3 Mutwanga 2 0 2 1 1 Oicha 4 0 4 1 1 Vuhovi 2 0 2 1 1 Ituri Komanda 1 0 1 0 0 Mandima 16 3 19 9 12 Tchomia 2 0 2 2 2 Total 372 47 421 194 241 * Case counts in recent weeks may be incomplete due to reporting delays. Figure 1. Confirmed and probable Ebola virus disease cases by week of illness onset, data as of 25 November 2018 (n=419)* Table 1: Ebola virus disease cases by classification and health zones in North Kivu and Ituri provinces, Democratic Republic of the Congo, as of 26 November 2018 Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 4 Context North Kivu and Ituri are among the most populated provinces in the Democratic Republic of the Congo. The provinces are affected by intense insecurity and a worsening humanitarian context, with over one million internally displaced people and continuous movement of refugees to neighbouring countries, including Uganda, Burundi and Tanzania. The Democratic Republic of the Congo is concurrently responding to multiple disease outbreaks, including three separate outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2) in the provinces of Ituri, Mongala, Maniema and Haut Lomami, Tanganyika and Haut Katanga, and outbreaks of cholera, measles and monkeypox across the country. Figure 2: Geographical distribution of confirmed and probable Ebola virus disease cases in North Kivu and Ituri provinces, Democratic Republic of the Congo, 25 November 2018 (n=419) Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 5 This outbreak of EVD is affecting north-eastern provinces of the Democratic Republic of the Congo, which border Uganda, Rwanda and South Sudan. Potential risk factors for transmission of EVD at the national and regional levels include: transportation links between the affected areas, the rest of the country, and neighbouring countries; internal displacement of populations; and displacement of Congolese refugees to neighbouring countries. Additionally, the security situation in North Kivu and Ituri continues to hinder the implementation of response activities. On 28 September 2018, based on the worsening security situation, WHO revised its risk assessment for the outbreak, elevating the risk nationally and regionally from high to very high. The risk globally remains low. WHO continues to advise against any restriction of travel to, and trade with, the Democratic Republic of the Congo based on currently available information. Given the context, including the volatile security situation, sporadic incidents of community reluctance, refusal or resistance, continued reporting of confirmed cases, and the risk of spread to neighbouring countries, an International Health Regulations (IHR) Emergency Committee (EC) on the EVD outbreak in North Kivu, Democratic Republic of the Congo, was convened on 17 October 2018. The EC advised that the EVD outbreak does not constitute a public health emergency of international concern. The EC did, however, express their deep concern emphasising the need to intensify response activities and strengthen vigilance whilst noting the challenging security situation and providing a series of public health recommendations to further strengthen the response. The EC commended the Government of the Democratic Republic of the Congo, WHO, and all response partners for the progress made under difficult circumstances. WHO recommends implementation of strategies for the prevention and control EVD outbreaks. These include (i) strengthening multi-sectoral coordination of the response, (ii) enhancing surveillance, including active case finding, case investigation, confirmation of cases by laboratory testing, contact tracing and surveillance at Points of Entry (PoE), including adapting strategies to the context of insecurity and high community resistances(iii) strengthening diagnostic capabilities, (iv) improving the effectiveness of case management, (v) scaling up infection prevention and control support to health facilities and communities, (v) adapting safe and dignified burials approach to the context with the support of anthropologists, (vi) adapting and enhancing risk communication, social mobilization and community engagement strategies, (vii) enhancing psychosocial support to the affected population (viii) improving coverage of risk groups by the ring vaccination. The MoH and other national authorities in the Democratic Republic of the Congo, WHO and partners are implementing several outbreak control interventions, some of the latest activities are summarized below: Strategic approach to the prevention, detection and control of EVD Current risk assessment 2. Actions to date Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 6 Infection prevention and control (IPC) and Water, Sanitation and Hygiene (WASH) Cleaning of the database, line listing and contact follow-up continue, with intensified active case finding in health facilities and communities, particularly in Beni, Kalunguta, Butembo and Katwa health zones. Over 22 000 contacts have been registered since the onset of the outbreak. As of 26 November 2018, 4767 were still under follow-up in 10 health zones, of whom 4521 (95%) were seen in the previous 24 hours. Over the past week, between 88-100% of contacts were followed-up daily. There were 490 new contacts identified on 26 November 2018. Most contacts lost to follow-up are in Beni. Surveillance and vaccination teams are continuing to enhance the process of identifying case contacts and potential gaps to overcome the challenges. A total of 222 alerts from affected areas were received on 26 November 2018, of which 218 were investigated. Of these, 99% (217/220) were investigated within 24 hours, and 52 were validated as suspected cases, including 16 deaths out of ETCs. Diagnostic testing capacity has continued to expand as cases spread to new geographic areas. Six field Ebola laboratories providing near-patient testing have been established in Beni, Bunia, Butembo, Goma, Mangina and Tchomia; these are in addition to the national reference laboratory in Kinshasa. Since the beginning of the response, close to 5000 samples have been tested (including repeat samples). In the week ending 25 November 2018, 756 samples (including repeat samples) were tested in North Kivu and Ituri. The ETCs continue to provide therapeutics under the monitored emergency use of unregistered and experimental interventions (MEURI) protocol, in collaboration with the MoH and the Institut National de Recherche Biomédicale (INRB) together with supportive care measures. WHO is providing technical clinical expertise on-site and is assisting with the creation of a data safety management board. New patients continue to be treated in ETCs. As of 26 November 2018, 34 patients were being treated with a therapeutic under the MEURI framework after evaluation by clinical expert committee. All hospitalized patients received food and psychological support. Additional capacity is being put into place to support IPC activities, including, but not limited to, the deployment of additional experts to provide support to existing teams and review current strategies, review and enhance training materials and review key messaging for consistency with WHO recommendations. IPC activities continue with decontamination of five households of confirmed cases and 10 health facilities in Beni, Butembo, Katwa and Oicha; distribution of personal protective equipment to 14 Surveillance and Laboratory Case management Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 7 Safe and Dignified Burials (SDB) Points of Entry (PoE) health facilities, including six in Beni; briefing of 116 health workers, including 67 in Beni; and formative supervision of IPC activities in 16 health facilities, including 11 in Beni; and follow-up to check 223 handwashing points, including 104 in Beni. Monitoring and sanitary control activities continue at the 67 PoEs in North Kivu and Ituri. As of 25 November 2018, 16.8 million travellers have been screened and 114 alerts were notified, of which 30 were validated and one was confirmed for EVD. Data collection tools, hand washing kits and risk communication materials are available in all PoEs. A PoE in Goma was visited by the response coordination team managed by the Director General of Health. A sensitization session for drivers and managers of transport companies on the importance of health screening is being organized. International Organization for Migration (IOM) completed a Population Flow Monitoring (FMP) exercise in Goma. Findings revealed that there are three main origins for people coming to and from Goma: Kinshasa, South Kivu and Rwanda. Of the five PoEs currently monitored, Goma airport and Port Kituku are the only two PoEs with travel connections to and from the epicentre. IOM will expand its support on the road connecting Butembo with Goma, which is currently being managed by the National Program of Hygiene at Borders (PNHF), in the coming week. Multiple security incidents were reported at PoEs in Beni and Butembo over the last week. Mutsanga PoE in Butembo City was attacked and two huts were burnt down after this PoE reported an alert for a suspected EVD patient, who was tested positive for EVD on 22 November 2018. IOM supported the deployment of 20 PNHF supervisors to North Kivu and Ituri. Supervisors were briefed by IOM staff in Kinshasa and at the field. As of 26 November 2018, there were 670 SDB alerts reported, of which 85% have been responded to successfully. 40% of the reported alerts have come from communities, 33% from hospitals and 26% from ETCs. Between 20 and 26 November 2018, a total of 92 SDB alerts were reported, of which 55 (70%) came from Beni Health Zone followed by Butembo (14), Mabalako (14), Mandima (4), Oicha (2), Katwa (2) and Mutwanga (1). The number of SDB alerts that continue to be officially reported, especially from Butembo, remains notably low in relation to the population of the affected areas. A community burial approach to mitigate the risk of transmission from unsafe burials in areas non- accessible by SDB teams is being piloted in three health areas of the Kalunguta Health Zone with close cooperation with the respective communities, MoH (local health centre), Red Cross, MSF and WHO. Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 8 Implementation of ring vaccination protocol Vaccination continued on 25 November 2018 in Beni, Oicha, Katwa and Butembo. As of 25 November 2018, 569 persons were vaccinated in 14 rings in affected health zones, bringing the cumulative number of people vaccinated to 35 958. The door-to-door advocacy activities continue, with 3781 door-to-door outreach sessions in affected areas. There has been an intensification of awareness activities in Beni with the launch of a programme of outdoor educational films on Ebola and the continued intensification of communication in Kanyihunga, Kalunguta Health Zone. A total of 59 media outlets have broadcast messages, placed inserts in magazines and provided spot messages about response activities Risk communication, social mobilization and community engagement support across the response pillars continues including strengthened community involvement in surveillance with Public Transit Authority leaders in Butembo, sensitization of contacts in Katwa and Vutetse on vaccination and decontamination of health facilities and households and engaging in dialogue to address concerns during safe and dignified burials in the community. Teams are also working with leaders of Lucha and Ujamaa groups to reduce misunderstandings and tensions in Katwa. WHO and partners are supporting community leadership and ownership of the Ebola response activities by working with local civil society organizations, women at all levels of the community structure and youth groups through community engagement and peace building activities. Community feedback and anthropological insights are regularly evaluated to support the adaptation of the response strategy. Under the overall leadership of the MoH, WHO is supporting all major pillars of the EVD preparedness and response. WHO is working intensively with wide-ranging, multisectoral, and multidisciplinary national, regional and global partners and stakeholders for EVD response, research, and preparedness. WHO has deployed a total 285 experts in various disciplines to support the EVD outbreak response in the Democratic Republic of the Congo. Several international organizations and UN agencies are involved in response and preparedness activities; the organizations and specific contributions are noted below.  European Civil Protection and Humanitarian Aid Operation (ECHO): MEDEVAC, logistics and operational support  International Organization for Migration (IOM): cross-border preparedness  UK Public Health Rapid Support Team: supporting deployments through GOARN (see below)  United Nations Children’s Fund (UNICEF): risk communication, social mobilization and community engagement, WASH, child protection and psycho-social support, supplies and logistics. Risk communication, social mobilization and community engagement Operational partnerships Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 9  UN High Commission on Refugees (UNHCR): cross-border preparedness and PoE  World Bank and regional development banks: medical support  World Food Programme (WFP) and UN Humanitarian Air Service (UNHAS): nutrition assistance; logistical and operational support  UN mission: logistical assistance and, together with UN Department of Safety and Security (UNDSS), ensuring the safety of staff on the ground  Additional UN agencies include the Inter-Agency Standing Commission, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), and the United Nations Population Fund (UNFPA). WHO is engaging Global Outbreak Alert and Response Network (GOARN), Emerging and Dangerous Pathogens Laboratory Network (EDPLN), Emerging Disease Clinical Assessment and Response Network (EDCARN), and the Emergency Medical Team (EMT) initiative – as well as regional operational partners and collaboration centres in Africa – to deploy experts and multidisciplinary teams for the response, and to support intensive preparedness and readiness activities in neighbouring and at-risk countries. Specialized agencies participating in Ebola response include:  Africa Centres for Disease Control: Deployment of health professionals (of various professional categories and seniority levels) to support surveillance and contact tracing, training of local health workers in IPC and social mobilization activities; laboratory services; Central Coordination in Kinshasa; and support with laboratory diagnostic equipment.  US Centers for Disease Control (CDC): Supporting deployments via GOARN; supporting incident management operations through staff deployments.  UK Department for International Development (DFID): Supporting surveillance, IPC, risk communication, and community engagement.  United States Agency for International Development (USAID): Supporting surveillance, infection protection and control, risk communication and community engagement, safe and dignified burials, coordination. Non-governmental organizations involved in Ebola response are:  Adeco Federación (ADECO): Supporting IPC, risk communication, and community engagement.  Association des femmes pour la nutrition à assisse communautaire (AFNAC): Supporting IPC, risk communication, and community engagement.  Alliance for International Medical Action (ALIMA): Supporting patient care and vaccination.  CARITAS DRC: Supporting vaccination, risk communication, and community engagement.  CARE International: Supporting surveillance, IPC, risk communication, and community engagement in the Democratic Republic of the Congo; CARE International is also supporting Ebola preparedness in Uganda.  Centre de promotion socio-sanitaire (CEPROSSAN): Supporting surveillance, infection prevention and control, risk communication, and community engagement.  Cooperazione Internationale (COOPE): Supporting infection prevention and control, risk communication, and community engagement.  Catholic Organization for Relief and Development Aid (CORDAID/PAP-DRC): Supporting infection prevention and control, risk communication, and community engagement.  International Medical Corps: supporting surveillance, infection prevention and control, and patient care.  International Rescue Committee (IRC): Supporting infection prevention and control, risk communication, and community engagement.  INTERSOS: Supporting surveillance, and infection prevention and control.  MEDAIR: Supporting surveillance, and infection prevention and control. Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 10  Médecins Sans Frontièrs (MSF): Supporting infection prevention and control, and patient care.  Oxfam International: Supporting vaccination, community engagement and social mobilization, infection prevention and control, and patient care.  Red Cross of the Democratic Republic of Congo, with the support of the International Federation of Red Cross and Red Crescent Societies (IFRC) and International Committee of the Red Cross (ICRC): Supporting infection prevention and control, safe and dignified burials, risk communication, and community engagement.  Samaritan’s Purse: Supporting infection prevention and control as well as risk communication and community engagement.  Save the Children International (SCI): Supporting surveillance, infection prevention and control, risk communication, and community engagement. WHO encourages wider coverage of partner operations via this report in response to demand from our planning teams. If you would like to see the activities of your agency or organization appears in the report, please send an email to goarn@who.int. WHO advises against any restriction of travel and trade to the Democratic Republic of the Congo based on the currently available information. WHO continues to closely monitor and, if necessary, verify travel and trade measures in relation to this event. The EVD outbreak in the Democratic Republic of the Congo remains serious and unpredictable, with emergence of new confirmed cases and continued deaths. While insecurity remains a major underlying hindrance, there are other important factors contributing to the continuation of the outbreak. One of these key drivers is inadequate infection prevention and control practices in healthcare settings. Informal health facilities have been found to be a major source of infections. While health workers are vulnerable to being infected by Ebola (being the first point of contact), they also amplify spread of the disease (as they have contact with many patients) in the event of inadequate precautionary measures. Additionally, there are ongoing negative and risky practices in the community, fuelled by rumours, misinformation and mistrust. Efforts have now been directed to reinforce measures that aim to eliminate these key known risk factors for EVD transmission, including improving infection prevention and control measures in healthcare settings and working closely with community leaders and local structures to address the misinformation, rumours and mistrust. IHR travel measures and cross border health 3. Conclusion