Ebola Virus Disease Democratic Republic of Congo: External Situation Report 06 / 2018

Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 1 EBOLA VIRUS DISEASE Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 2 Date of issue: 11 September 2018 Data as reported by: 9 September 2018 The Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces, Democratic Republic of the Congo continues to evolve. However, the Ministry of Health, WHO and partners have made progress in response to the outbreak. Recent trends (Figure 1) suggest that control measures are working; however, these trends must be interpreted with caution. The outbreak remains active in Beni, Mabalako and Mandima health zones, and additional risks remain following the movement of several cases from these areas to Butembo and Masereka in recent weeks. Since our last situation report on 4 September 2018 (External situation report 5), an additional 10 new confirmed or probable EVD cases have been reported from Butembo (2), Beni (5) Mabalako (1), Mandima (1), and Masereka (1) and nine new deaths. Currently there are nine suspected cases under investigation (Table 1). As of 9 September 2018, a total of 132 confirmed and probable EVD cases, including 91 deaths and 36 cases who have recovered, have been reported. Among the 132 cases, 101 are confirmed and 31 are probable. Of the 91 deaths, 60 occurred in confirmed cases. Among the 123 cases with known age and sex, 58% (71/123) are female and 59% (56/95) of confirmed cases and females aged 44 years were most affected. Among men, the most affected age group is also 35-44 years (Figure 2). The data available for age and sex among deaths are limited. However, where known (n=38) the distribution is similar to known cases. A total of 17 health workers (16 confirmed and 1 probable) have been affected, three of whom have died. All health workers’ exposures occurred in health facilities outside the dedicated Ebola treatment centres (ETCs). The epicentres of the outbreak remain Mabalako Health Zone and Beni Health Zone in North Kivu Province, reporting 67.46% (n=87/13229) and 18% (n=24) of all confirmed and probable cases, respectively and 70.769% (63/8991) deaths, including 66 confirmed and 21 probable cases (Table 1 and Figure 3). Additionally, six other health zones in North Kivu Province and one in Ituri Province have reported confirmed and probable cases (Table 1 and Figure 2). Since the 17 August 2018, a cumulative total of 5306 contact contacts have been listed. Over the past week, 75-97% of contacts were followed-up daily. Response teams are addressing a delay in establishing fully functional contact tracing activities in Butembo and Masereka, which has resulted in a dip in contact tracing performance in the past two days. Several challenges faced by the teams have been overcome and it is anticipated that contact performance will return to high rates in the coming days. The Ministry of Health (MoH), WHO and partners are monitoring and investigating all alerts in affected areas, in other provinces in the Democratic Republic of the Congo (including Kisangani and Tshopo provinces) and in neighbouring countries. Since the last report was published, alerts were investigated in several provinces of 1. Situation update Cases 132 EBOLA VIRUS DISEASE Deaths 91 Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 3 the Democratic Republic of the Congo as well as in Uganda, Rwanda and the Central African Republic; and to date, EVD has been ruled out in all alerts from neighboring provinces and countries Case classification / status North Kivu Ituri Total Beni Butembo Oicha Mabalako Musienene Masereka Kalunguta Mandima Probable* 4 2 1 21 1 0 0 2 31 Confirmed 20 2 2 66 0 1 1 9 101 Total confirmed and probable 24 4 3 87 1 1 1 11 132 Suspected cases currently under investigation 1 5 1 1 0 0 0 1 9 Deaths Total deaths 19 3 1 63 1 1 0 3 91 Deaths in confirmed cases 15 1 0 42 0 1 0 1 60 *Includes n=27 community deaths, retrospectively identified from clinical records, tentatively classified as probable cases pending further investigation. Table 1: Ebola virus disease cases by classification and health zones in North Kivu and Ituri provinces, Democratic Republic of the Congo, as of 9 September 2018 Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 4 0 5 10 15 20 25 30 35 40 45 3 0- A p r 7 -M ay 1 4 -M ay 2 1 -M ay 2 8 -M ay 4 -J u n 1 1 -J u n 1 8 -J u n 2 5 -J u n 2 -J u l 9 -J u l 1 6 -J u l 2 3 -J u l 3 0 -J u l 6 -A u g 1 3 -A u g 2 0 -A u g 2 7 -A u g* 0 3 -S ep * N u m b er o f ca se s Week starting Confirmed Probable *Illness onset is currently unknown for n=1 cases. Case counts in recent weeks may be incomplete due to reporting details. All trends should be interpreted with caution. *Age/sex is currently unknown for n=9 cases. Figure 1. Confirmed and probable Ebola virus disease cases by week of illness onset, data as of 9 September 2018 (n=131)* Figure 2: Confirmed and probable Ebola virus disease cases by age and sex, North Kivu and Ituri provinces, Democratic Republic of the Congo, 6 September 2018 (n=123) Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 5 Context North Kivu and Ituri are among the most populated provinces in the Democratic Republic of the Congo. North Kivu shares borders with Uganda and Rwanda. The provinces have been experiencing intense insecurity and a worsening humanitarian crisis, with over one million internally displaced people and a continuous efflux of refugees to neighbouring countries, including Uganda, Burundi and Tanzania. The Democratic Republic of the Congo is also experiencing multiple disease outbreaks, including three separate outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2) in the provinces of Ituri, Mongola, Maniema and Haut Lomami, Tanganyika and Haut Katanga, and outbreaks of cholera, measles and monkeypox spread across the country. Figure 3: Geographical distribution of confirmed and probable Ebola virus disease cases in North Kivu and Ituri provinces, Democratic Republic of the Congo, 9 September 2018 (n=132) Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 6 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 the transportation links between the affected areas, the rest of the country, and neighbouring countries; the internal displacement of populations; and the displacement of Congolese refugees to neighbouring countries. The country is concurrently experiencing other epidemics (e.g. cholera, vaccine- derived poliomyelitis), and a long-term humanitarian crisis. Additionally, the security situation in North Kivu and Ituri may hinder the implementation of response activities. Based on this context, the public health risk was assessed to be high at the national and regional levels, and low globally. As the risk of national and regional spread remains high, it is important for neighbouring provinces and countries to enhance surveillance and preparedness activities. WHO will continue to work with neighbouring countries and partners to ensure health authorities are alerted and are operationally ready to respond. WHO recommends the implementation of proven strategies for the prevention and control EVD outbreaks. These include (i) strengthening the multi-sectoral coordination of the response, (ii) enhanced surveillance, including active case finding, case investigation, contact tracing and surveillance at Points of Entry (PoE), (iii) strengthening diagnostic capabilities, (iv) case management, (v) infection prevention and control in health facilities and communities, including safe and dignified burials, (vi) risk communication, social mobilization and community engagement, (vii) psychosocial care (viii) vaccination of risk groups and (ix) research, and ix) operational support and logistics. The sub-national Health Cluster Coordinator originally deployed in Kananga through the Standby Partner (SBP) with NORCAP, has been reassigned to North Kivu to support the EVD response. Efforts are ongoing to backfill positions through additional SBP deployments. SBPs are also prepared to support and deploy health professionals for EVD preparedness and response activities. As of 10 September, 166 experts have been deployed through WHO to support response activities including logisticians, epidemiologists, laboratory experts, communicators, clinical care specialists, community engagement specialists, and emergency coordinators. Global Outbreak Alert and Response Network (GOARN) partner institutions continue to support the response as well as readiness and preparedness activities in non-affected provinces and in neighbouring countries. Strategic approach to the prevention, detection and control of EVD Current risk assessment 2. Actions to date Coordination of the response Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 7 Surveillance teams continue to enhance active case search, case investigation and contact tracing activities across the affected and neighbouring areas. In-depth reviews are being undertaken of all confirmed and probable cases to elucidate the chains of transmission and identify risks and potential gaps in response for improving interventions (such as delays in ETC referral of newly identified suspected cases, unsafe burials, etc.). This past week, surveillance capacities were extended to Butembo and Masereka health zones, where teams continue to strengthen operations. Systematic monitoring and rapid investigation of all alerts continues in all provinces of the Democratic Republic of the Congo, and in neighbouring countries. This past week between 16–26 alerts per day were investigated in the outbreak affected areas. In addition, Burundi, the Central African Republic, Rwanda and Uganda detected, investigated and ruled out EVD in alert and suspected viral haemorrhagic fever cases; a strong sign that surveillance systems are working. There is continued strengthening of surveillance through training health personnel on EVD and the early warning system, as well as community contact relay training and supervision. Health screening has been established at 45 Points of Entry (PoE) with health declaration forms, temperature checking, hand washing and risk communications. More than two million travellers have been screened at these PoEs since the beginning of screening during this outbreak . A committee for Points of Entry at Beni is being established to conduct a mid-term review of their response so far with partners including International Organization for Migration (IOM), Japan International Cooperation Agency (JICA) and CDC. Laboratory testing capacity for Ebola has been established in hospital facilities in Beni, Goma and Mangina to facilitate rapid diagnosis of suspected cases. The US CDC and other partners are providing technical assistance and training for laboratory testing for Ebola in neighbouring countries. Ebola Treatment Centres (ETC) are fully operational in Beni and Mangina with support from The Alliance for International Medical Action (ALIMA) and Médecins sans Frontières (MSF) respectively. In Beni, ALIMA are planning to expand treatment capacity over the next two weeks. An ETC is being constructed in Makeke (Ituri Province) with the support of International Medical Corps (IMC), which is expected to be operational this week. A seven bed MSF transit centre is already operational in Makeke. Samaritan's Purse continue to support the isolation unit in Nyankunde with infection, IPC and isolation training. Surveillance Laboratory Case management Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 8 Infection prevention and control and water, sanitation and hygiene (IPC and WASH) Safe and Dignified Burials 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). WHO is providing technical clinical expertise onsite and is assisting with the creation of a data safety management board. As of 6 September 2018, 29 patients have received investigational Ebola therapeutics, including: mAb114 (14 patients), Remdesivir (9 patients) and ZMapp (6 patients). Of the 20 patients, 14 have been discharged and nine have died. All the deaths were among patients with advanced organ failure on admission. Médicines sans Frontièrs (MSF) Swiss and the Ministry of Health are building a 10 bed ETC in Butembo, which is expected to be operational by the end of this week. A team of IPC specialists is holding daily training with healthcare and frontline workers, assessing and decontaminating facilities, and providing essential hand hygiene solutions and personal protective equipment. A team of experts deployed by WHO are supplementing local capacity, working with dozens of healthcare centres to see where there are gaps, and providing training and supplies as needed. They are assisting the health centres to set up triage to ensure that patients with suspected EVD can be separated and treated away from other patients, to decrease transmission risks. WHO, CDC, and other partners are working with the Ministry of Health staff to conduct healthcare facility assessments and training on IPC in neighbouring countries. Red Cross IPC activities are progressing well in six health facilities in Tamende health area (Beni Health Zone). This includes training of healthcare workers in infection control practices, providing support to improve WASH mechanisms and processes in targeted health facilities and supporting waste management measures at the health facilities. Routine water, sanitation and hygiene (WASH) teams are continuing activities in all areas: supplying water for hand hygiene, providing chlorination points, and installing and monitoring the operation of hand hygiene devices. Red Cross Safe and Dignified burial (SDB) teams are operational in Beni (3), Mangina (4) and Butembo (2). Initial training for SDB teams in Bunia (1) and Mambasa (1) has been conducted. The SDB alert system is up and running in Butembo, Red Cross will increase the numbers of SDB volunteers, with training planned for this week. As of 10 September 2018, these teams have responded to a total of 135 SDB alerts and successfully completed 121 SDBs. The main reason for unsuccessful SDBs has been community refusals/burial done by the community before arrival of the team. There is continuing work on strengthening the community engagement approach within the SDB, along with increased efforts to increase community acceptance and support. The SDB sub-commission is meeting daily to strengthen coordination. Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 9 Implementation of ring vaccination protocol The SDB Commission plan for hard-to-reach areas started training on civil protection teams on 9 September 2018 with, the support of the Red Cross. As of 10 September 2018, 48 vaccination rings have been defined, in addition to 13 rings of healthcare and other frontline workers. These rings notably include the contacts (and their contacts) of the confirmed cases from the last three weeks. To date, 8229 people consented and were vaccinated, including 2526 healthcare and front line workers, and 1968 children. There is one area in Ndindi, where the implementation of vaccination is hampered by community resistance. The ring vaccination teams are currently active in three health areas in North Kivu and one in Ituri. Psychosocial support is being provided to surveillance teams by care and communication teams, during epidemiological investigations and water, sanitation and hygiene (WASH) teams in order to help in situations of community resistance. Routine psychosocial activities include interviews and individual psychological support, psychological follow up and community reintegration of cured patients and those designated as non-cases, and their caregivers. The MoH, WHO, the United Nations Children's Fund (UNICEF), the Red Cross and partners are intensifying activities to engage with local communities in Beni, Butembo and Mangina. Local leaders, religious leaders, opinion leaders, and community networks such as youth groups and motorbike taxi drivers are being engaged to support community outreach for Ebola prevention and early care seeking through active dialogues on radio and interpersonal communication. Local frontline community outreach workers are working closely with Ebola response teams to strengthen community engagement and psychosocial support in contact tracing, patient care and safe and dignified burials (SDBs). As of 8 September 2018, Red Cross has reached 52 614 people through door-to-door education/mass sensitisation in Mangina, Beni, Oicha. Currently, the risk communication and community engagement team is being strengthened by an increasing number of volunteers. A community feedback system has been established and is active in Beni and Mangina through regular reporting of volunteers regarding community questions, concerns, beliefs and rumours. An additional 1916 members of influential leaders and groups were reached through advocacy, community engagement, and interpersonal communication activities including 120 youth leaders in Mangina health area, which represent 20 youth associations from eight surrounding health areas. Common questions addressed among leaders are questions related to the ‘source’ of Ebola: ‘How can a bat bring all of this? Are bats the real origin? How do animals in the forest get Ebola?’ Risk communication, social mobilization and community engagement Psychosocial care Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 10 In Ndindi, from where most of the recent confirmed cases were reported, partners, including UNICEF, Oxfam, WHO have engaged 77 ‘chefs d’avenue’ (street chiefs) and 30 community leaders (religious, youth leaders and women's associations) have been briefed on the EVD risks, preventive measures, community monitoring and resistance/conflict management and are already holding community dialogue sessions. For re-establishing trust towards response interventions, visits to ETCs are planned for community leaders and chiefs of wards and streets. EVD survivors have also been recruited to provide testimonials during dialogue sessions in the community to promote early care seeking. A total of 35 households presenting resistance/reluctance to Ebola vaccination benefited from personalized house visits to address general concerns, including refusals of secure and dignified burials practices. An operations hub has been established in Butembo with dedicated coordination support from WHO, partners, and the MoH. The Emergency Operations Center (EOC) is expected to be operational within the coming days. Four additional ambulances have been purchased and are expected to arrive this week. Additional logistics support is being deployed to North Kivu to support scaling of operations in Beni and Butembo. Implementation of and resource mobilization for the joint strategic response plan, approved by the Minister of Health of the Democratic Republic of the Congo, is progressing well, in collaboration with the national authorities and all partners. In addition to the ongoing response activities within outbreak affected areas, the MoH, WHO and partners have begun implementing a 30-day strategic plan to ensure operational readiness measures against EVD are strengthened in all provinces of the Democratic Republic of the Congo. The WHO Regional Office for Africa has updated the regional preparedness plan and reprioritized neighbouring countries based on proximity to North Kivu, the current EVD epicentre. The new prioritizations are as follows: Priority 1: Rwanda, Uganda, South Sudan and Burundi; Priority 2: Angola, Congo, Central African Republic, Tanzania, Zambia. These countries were prioritised based on their capacity to manage EVD and viral haemorrhagic fever (VHF) outbreaks, and their connections and proximity to the areas currently reporting EVD cases. WHO and partners have deployed Preparedness Support Teams to these countries and other neighbouring countries, as was done during the previous EVD outbreak in Équateur Province. Logistics Resource mobilization Preparedness Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 11 Extensive preparedness efforts are underway by the respective Ministries of Health, national partners and stakeholders, and global partners. Activities conducted include national multisectoral training in 8 out of the 9 countries. GOARN partners have provided 56 offers of technical support for preparedness and readiness activities in non-affected provinces of Democratic Republic of the Congo and in neighbouring countries. Burundi, CAR, Congo, Rwanda, Uganda, South Sudan and Zambia have been able to investigate all EVD alerts received. The regional office and headquarters are supporting Uganda and Rwanda with preparations for the vaccination of healthcare and frontline workers, as well as ring vaccination should there be a confirmed case in either country. Vaccination supplies and the ultra-cold chain have been shipped to Uganda. Under the overall leadership of the Ministry of Health, WHO is supporting all major pillars of the EVD response. WHO is working intensively with wide-ranging, multisectoral and multidisciplinary regional and global partners and stakeholders for EVD response, research, and preparedness including:  UN secretariat and sister agencies, OCHA, Inter-Agency Standing Committee (IASC), multiple clusters, and peacekeeping operations;  World Bank and regional development banks;  African Union, and Africa CDC and regional agencies;  GOARN, technical networks, including Emerging and Dangerous Pathogens Laboratory Network (EDPLN), and Emerging Diseases Clinical Assessment and Response Network (EDCARN), operational partners and WHO collaborating centres;  Emergency Medical Team (EMT) initiative;  Standby Partnership. WHO is engaging GOARN, EMT and regional partners in Africa to deploy experts and multidisciplinary teams for the response, and to support intensive preparedness and readiness activities in the neighbouring and at-risk countries of the Democratic Republic of the Congo. The International Federation of Red Cross and Red Crescent Societies (IFRC), UNICEF and CDC have deployed liaisons to WHO headquarters to ensure optimal coordination of activities, as these organizations have extensive presence on the ground, working closely with Ministries of Health. United Nations Children’s Fund (UNICEF)  WASH teams supported the joint efforts between humanitarian actors to provide basic services in Ndindi, Beni city, where community resistance has limited the Ebola response. In close coordination with the local committee of key leaders, UNICEF provided WASH hygiene kits in all schools (23) and in 13 health facilities in Ndindi.  With new confirmed cases in Butembo, a UNICEF WASH team collaborated with WHO to identify a list of priority health facilities and schools in the affected zones of the city. UNICEF and WHO will join efforts to simultaneously cover WASH and IPC activities in the priority Operations partnership Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 12 health structures identified. As schools officially opened on 3 September 2018, UNICEF continued to scale-up WASH interventions in schools, reaching a total of 255 (81% coverage) schools. In addition to assessment and training to school staff, WASH hygiene kits (which contains infrared thermometers, handwashing stations, and soap) were distributed. These activities will reach an estimated 115 000 children registered in the schools covered.  During the reporting period, five families affected by EVD received psycho-social support and material assistance, including food assistance, in Beni, Mandima (Makeke area), and Mambasa Health zones, reaching a total of 132 (100% coverage) out of the targeted 132 families. It is important to note that the target of affected families also includes the assistance to suspected cases/discharged patients (who have been tested negative for EVD), so the total figure may be higher than the total number of EVD cases.  Eight new separated/orphan children due to the Ebola epidemic has been identified and received appropriate care; a total of 129 (86% coverage) out of the targeted 150. NFI and food assistance have been distributed to the caregivers of seven separated/orphan children previously identified.  Eight family members visiting their relatives received psychosocial support in the ETC of Mangina and in the transit ETC of Makeke.  As of 8 September 2018, the ETC in Beni Health Zone had eight hospitalized patients and four recovering patients, of whom two are lactating women. Given the risk of transmission of EVD virus to their infants, the infants were separated from their mothers and were provided with breastmilk substitutes and complementary feeding. Three women affected by Ebola were counselled on Infant and Young Child Feeding (IYCF) practices. In addition, 530 pregnant and breastfeeding women were counselled on IYCF practices at the Regional Hospital in Beni Health Zone.  F75, F100 milk, and Ready to Use Therapeutic Food (RUTF) was provided to patients in ETCs.  On 10 September 2018, an agreement between UNICEF and the national nutrition programme of the Government of DRC (PRONANUT) was signed at the Goma office to support training on Integrated Management of Acute Malnutrition (IMAM) including Severe Acute Malnutrition case management, coordination of nutrition activities in health zones affected by EVD. World Food Program (WFP)  Food distribution (maize meal, pulses, oil and salt) started on 29 August 2018 and has already reached 6100 beneficiaries, including contacts, health workers and EVD survivors, along with deployment of surge response teams, prefab buildings, temporary warehouses, IT support and staff health supplies to augment this response in support of WHO and partners.  Further distribution by the Psychosocial Committee and CARITAS of 10 MT of food is taking place in Butembo for 100 identified contacts.  WFP is providing augmented logistics support (common warehousing, transport and offloading aircraft) to support WHO and response partners in Goma and Beni.  Preparedness actions include regular vulnerability assessments and mapping in Mangina have suggested deteriorating food security and possible future crop failure, resulting in joint WHO- WFP logistics assessments in Mangina to anticipate potential supply chain needs. UNHAS support  Ebola evacuation training for UNHAS staff in the use of specialised medevac operations was conducted in Goma on 30 August 2018.  An additional 19 seater aircraft dedicated to the Ebola response was positioned at Goma on 3 September 2018 and one aircraft from Goma is serving Oicha twice a week.  There is continued close cooperation between UNHAS/MONISCO/EVHO FLIGHT/CICR/MAF and this past week UNHAS has transported vaccines, medicines and personal protective equipment, as well as government officials and UNICEF staff to affected areas. Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 13  From 2 August 2018 to 6 September 2018, UNHAS has transported 902 passengers and 17 MT of cargo to and from Beni in support of EVD response operations. Red Cross  The Red Cross of the Democratic Republic of the Congo, with the support from IFRC and ICRC, is supporting SDBs and community engagement/risk communication activities. IPC interventions to support non-ETC health facilities has also started in Beni  Red Cross SDB teams are operational in Beni (3), Mangina (4) and Butembo (2). Training for SDB teams in Bunia (1) and Mambasa (1) has been conducted.  Red Cross IPC team are progressing well in implementing IPC support to Tamende health area in Beni.  Red Cross has trained total of 142 community volunteers to conduct risk communication/ community engagement activities in Butembo, Beni, Mangina and Oicha. A community feedback system has been established as of 18 August 2018.  As of 8 September 2018, Red Cross volunteers have reached over 50 000 people in the above- mentioned health areas. IRC  IRC has a team of 18 staff on the ground, with ongoing recruitment of an additional 30 local clinical and support staff. IOM  Following the confirmation of EVD cases in Butembo, IOM is assessing the population mobility, including various routes, their distances, traffic volume and location of health facilities in order to identify the health screening points. 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. As investigations continue to establish the full extent of this outbreak, it is important for neighbouring provinces and countries to enhance surveillance and preparedness activities1. The EVD outbreak in the Democratic Republic of the Congo has been ongoing for six weeks since its declaration and a lot of progress has been made to limit the spread of the disease to new areas. The number of new confirmed EVD cases and new deaths recorded during the reporting week declined significantly, compared to the last weeks. The situation in Mangina (Mbalako health zone), is stabilizing, while Beni has become the new hotspot, and teams must continue to enhance response activities to mitigate potential clusters in the city of Butembo and Masereka Health Zone. 1 http://origin.who.int/ith/en/ IHR travel measures and cross border health 3. Conclusion Health Emergency Information and Risk Assessment WHO Health Emergency Program Page 14 While these gains have been made, there are still significant threats for further spread of the disease, reluctance by some communities to adopt public health prevention measures, weak infection prevention and control practices in healthcare facilities, and risk of the virus spreading into an insecure area. The coming few days will be critical in determining the trajectory of the outbreak. The priority remains strengthening all components of the response in all affected areas, as well as enhancing preparedness in the non-affected provinces of the Democratic Republic of the Congo and neighbouring countries.