Ebola Virus Disease Democratic Republic of Congo: External Situation Report 68 / 2019

Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 1 Democratic Republic of the Congo External Situation Report 68 EBOLA VIRUS DISEASE Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 2 Date of issue: 19 November 2019 Data as reported by: 17 November 2019 Over the last three months, there has been a steady decrease in the incidence of confirmed Ebola Virus Disease (EVD) cases in Democratic Republic of the Congo (DRC). In the week of 11 to 17 November 2019, nine new confirmed EVD cases were reported from three health zones in two affected provinces, compared to 126 cases reported at the peak of the epidemic in the last week of April 2019. No cases were reported from both Mandima and Mambasa health zones. After over 30 days with no new cases, Oicha Health Zone reported a new confirmed community death with links to Kalunguta, Oicha and Mandima health zones. Following initial resistance from family members and the community, a multidisciplinary team has now commenced investigations around this case. So far, the source of exposure is yet to be identified. All other cases reported in Beni and Mabalako health zones in the past week have been linked to known chains of transmission. Although the number of weekly reported cases is decreasing, it is expected that the outbreak response will encounter more complex circumstances as some transmission continues within rural and hard to reach communities. Multidisciplinary response teams are building on sustained progress by enhancing efforts to thoroughly engage with the community in order to investigate all new cases, to improve contact tracing and access to vaccination and consequently break the remaining transmission chains. In the 21 days from 28 October to 17 November 2019, 12 health areas and five health zones have reported cases (Table 1, Figure 2). During this period, a total of 31 confirmed cases were reported, with Mabalako (45%; n=14 cases), Beni (29%; n=9) and Mandima (19%; n=6) cases as the principal hot spots. As of 17 November 2019, a total of 3296 EVD cases were reported, including 3178 confirmed and 118 probable cases, of which 2196 cases died (overall case fatality ratio 67%). Of the total confirmed and probable cases, 56% (1854) were female, 30% (996) were children aged less than 18 years, and 5% (162) were healthcare workers. Deaths 100 1. Situation update Cases 3296 External Situation Report 68 Deaths 2196 Democratic Republic of the Congo EBOLA VIRUS DISEASE Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 3 *Excludes n=184 cases for whom onset dates not reported. Data in recent weeks are subject to delays in case confirmation and reporting, as well as ongoing data cleaning. Other health zones include: Alimbongo, Ariwara, Biena, Bunia, Goma, Kalunguta, Kayna, Komanda, Kyondo, Lolwa, Lubero, Manguredjipa, Masereka, Musienene, Mutwanga, Mwenga, Nyankunde, Nyiragongo, Oicha, Pinga, Rwampara, Tchomia, and Vuhovi. Figure 1: Health zone of reported Ebola virus disease cases by week of illness onset, as of 17 November 2019 Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 4 Cumulative cases by classification Cumulative deaths Province Health Zone Health areas reporting at least one case in previous 21 days / total number of health areas Confirmed cases in the last 21 days Confirmed cases Probable cases Total cases Deaths among confirme d cases Total deaths South Kivu Mwenga 0/18 0 6 0 6 3 3 North Kivu Alimbongo 0/20 0 5 0 5 2 2 Beni 5/18 9 688 9 697 449 458 Biena 0/16 0 18 2 20 12 14 Butembo 0/15 0 285 3 288 350 353 Goma 0/10 0 1 0 1 1 1 Kalunguta 0/18 0 193 19 212 71 90 Katwa 0/18 0 651 23 674 470 493 Kayna 0/21 0 28 0 28 8 8 Kyondo 0/22 0 25 4 29 15 19 Lubero 0/19 0 31 2 33 4 6 Mabalako 3/12 14 397 17 414 309 326 Manguredjipa 0/10 0 18 0 18 12 12 Masereka 0/16 0 50 6 56 17 23 Musienene 0/20 0 84 1 85 33 34 Mutwanga 0/19 0 32 0 32 12 12 Nyiragongo 0/10 0 3 0 3 1 1 Oicha 1/26 1 63 0 63 29 29 Pinga 0/18 0 1 0 1 0 0 Vuhovi 0/12 0 103 14 117 37 51 Ituri Ariwara 0/21 0 1 0 1 1 1 Bunia 0/20 0 4 0 4 4 4 Komanda 0/15 0 56 10 66 44 54 Lolwa 0/8 0 6 0 6 1 1 Mambasa 1/17 1 78 3 81 27 30 Mandima 2/15 6 339 5 344 160 165 Nyankunde 0/12 0 2 0 2 1 1 Rwampara 0/13 0 8 0 8 3 3 Tchomia 0/12 0 2 0 2 2 2 Total 12/471 31 3178 118 3296 2078 2196 Note: Attributions of cases notified in recent days to a health zone are subjected to changes upon in-depth investigations Table 1: Ebola virus disease cases by classification and health zones in North Kivu and Ituri provinces, Democratic Republic of the Congo, as of 17 November 2019 Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 5 *Data are subject to delays in case confirmation and reporting, as well as ongoing data cleaning and reclassification – trends during recent weeks should be interpreted cautiously. Figure 2: Geographical distribution of confirmed and probable Ebola virus disease cases by health area, North Kivu and Ituri provinces, Democratic Republic of the Congo, 17 November 2019 Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 6 The Government and the Ministry of Health (MOH) and other national authorities in the Democratic Republic of the Congo, WHO, and partners are implementing outbreak control interventions together with teams in the surrounding provinces, who are taking measures to ensure that they are response-ready. An overview of key activities is summarized below: Over 234 000 contacts have been registered to date, and 4823 are currently under surveillance as of 17 November 2019. On average, 90% of contacts were followed daily in the last seven days in health zones with continued operations. An average of 4290 alerts were received per day over the past seven days, of which 4217 (98%) were investigated within 24 hours of reporting. There are 11 field laboratories with Ebola virus diagnostic capacity operational in the Democratic Republic of the Congo, located in Beni, Biakato, Butembo, Bukavu, Bunia, Goma, Kasindi, Katwa, Komanda, Mambasa, and Mangina. All the laboratories are using GeneXpert as the primary diagnostic tool. Central laboratory support is provided by the Institute of Biomedical Research (INRB) laboratory in Kinshasa. Capacity to sequence whole virus genome has been established in Katwa field laboratory to support virus transmission chain analysis. Sequencing support is also available at the Kinshasa INRB laboratory. The Institut National Pour la Recherche Biomedicale (INRB) laboratory tested 4208 samples from 11 to 17 November 2019. The number of samples tested in this time period decreased by 4% compared to the previous week and the proportion of positive cases among new samples is less than 1%” From 8 August 2018 to 16 November 2019, 253 545 persons were vaccinated. 3191 persons were vaccinated in the week of 11 to 17 November 2019, compared to 3530 during the week of 4 to 10 November 2019. Vaccination with the Johnson & Johnson vaccine (Ad26.ZEBOV/MVA-BN-Filo) continued in the Krisimbi Health Zone, with 54 people vaccinated on 16 November 2019, bringing the cumulative total of people vaccinated with this vaccine to 147 since its introduction on 14 November 2019. There are currently 11 operational Ebola treatment centres (ETCs) and 24 Ebola transit centres located in the provinces of North Kivu, South Kivu and Ituri. Three transit centres are in the development phase: Kalunguta HGR, Mukulya and Mambasa. The current intra-ETC mortality remains around 35%. Surveillance and Laboratory 2. Actions to date Vaccines Case management Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 7 Points of Entry (PoE) Infection prevention and control (IPC) and Water, Sanitation and Hygiene (WASH) IPC and WASH activities continue in health facilities and in Ebola-affected communities. Activities in health facilities include facility assessments, training and briefing health workers on basic and EVD- specific IPC principles, decontamination when necessary, providing supplies, evaluating adherence to key IPC indicators (e.g. EVD screening, PPE availability, isolation, and referral), developing improvement action plans based on gaps identified and followed-up by supportive supervision and mentorship. A standardized IPC/WASH package phased rollout training is ongoing; at national level with 65 IPC specialists trained, across all of the target sub-commissions (Goma, Butembo, Beni, Bunia, Komanda, Mambasa and Mangina) 294 IPC supervisors trained, ongoing training this week at Biakato. The next level which targets facility-based IPC focal persons, is being planned across most of the sub- commissions, with a minimum target of 800 IPC participants. The National IPC/WASH package will strengthen the quality of IPC/WASH interventions throughout the Ebola Response as well as addressing nosocomial infections, through standardization of training modules, SOPS, and tools through implementation of evidence-based best practices. Meanwhile, the Phase 4 pilot, which aims to train supervisors on supportive supervision and mentorship, has been completed in Goma and is undergoing revision prior to the planned rollout to the target sub-commissions. The cumulative probable nosocomial infection rate is 16% (529/3296 - this includes 162 healthcare workers infections) During the week ending 17 November 2019, 2 596 211 screenings were performed, bringing the cumulative total to over 119 million. This week, a total of 289 alerts were notified, of which 113 (39%) were validated as suspect following investigation; one was subsequently confirmed with EVD following laboratory testing. This brings the cumulative number of alerts to 4181 with 1842 validated as suspect, and 30 subsequently confirmed with EVD following laboratory testing. On 17 November 2019, a group of travellers in a car and motorbikes passed through PoC Mavivi refusing health screening; they were moving southward. PoC Mavivi staff alerted other PoCs around Beni, and the convoy was subsequently stopped at PoC Mukulya. The convoy included a deceased 35-year old male, who died in Oicha. His family had the intention of burying him in Kabasha, where the family lives. The body was confirmed with EVD. Following negotiations with the family, a safe and dignified burial was performed in Kabasha. Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 8 Three contacts of EVD cases were also identified at two PoCs this week: on 13 November 2019, two contacts were identified at PoC Kanyabanyonga on their way to Goma, and on 14 November, one contact who was lost to follow up for 17 days was identified at PoC PK5 between Beni and Kasindi, on her way to Nzanga in the Mutwanga Health Zone. Analysis of screening patterns from the week prior to this reporting period showed similar population movement trends: travel was more pronounced eastward from Mambasa to Komanda and Bunia and increased north of Bunia; it is equally pronounced southward between Mambasa and Mangina, and further south and south-east through Beni all the way to Kasindi into Uganda, and southwards from Beni into and through Butembo. More than 10 000 screenings are done daily around Beni, Butembo, north of Bunia and at the Kasindi border. The number is lower south of Butembo but increases again on the road entering Goma from the north through OPRP (more than 10 000 screenings daily), and leaving Goma to the west through Mubambiro (more than 20 000 screenings daily) and at the Petite Barrière and Grande Barrière PoE in Goma reaching over 40 000 screenings daily. Figure 3: Travel itinerary of EVD case (M, 35 (†) ) from Pasala to Kabasha through POC Mavisi and POC Mukulya Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 9 Figure 4: Daily screening at PoEs and PoCs in/ around EVD transmission areas, Week 45, 2019 Figure 5: Daily screening at PoEs and PoCs in/ around Goma, Week 45, 2019 Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 10 Safe and Dignified Burials (SDB) Preparedness and Operational Readiness As of 15 November 2019, a total of four PoCs were deactivated from Mwenga Health Zone; where the first positive case in South Kivu Province was recorded on 16 August 2019. Further, two new PoCs (Teturi Bridge and Biakato Mine) which were recently activated in Ituri Province (current hotspots of Mambasa and Mandima) were integrated. This brings a total of 110 PoE/PoC participating in the EVD response in North Kivu, Ituri and South Kivu Provinces. As of 18 November 2019, there have been a total of 17 884 SDB alerts notified through the Red Cross SDB database, of which 15 086 (84%) have been responded to successfully by Red Cross and Civil Protection SDB teams and community harm reduction burial teams. During the week ending 18 November 2019, there were 627 SDB alerts recorded in 29 health zones. Of these, 582 (93%) were responded to successfully. During this period, three health zones fell below the 70% success benchmark: Lubero, Lolwa and Nyankunde SDB in current hotspots (cases in last 7 days): Hotspot ZS Cases in last 7 days (data as of 17 Nov) # SDB alerts # Success Mabalako 5 33 88% Beni 3 62 90% OichaOicha 1 48 98% Three days training for local journalists conducted in Beni together with the MoH and the UNPC (national Congolese press union) Strengthening of activities around confirmed cases, engaging with contacts, and communities affected to negotiate the implementation of the different components: surveillance. Contact tracing, vaccination, referral to CTE and SDB. Operational readiness in the Democratic Republic of the Congo: Readiness teams are rolling out a standard package of readiness activities in non-affected health zones (HZs) of North Kivu Province (6 HZs), Ituri Province (2 HZs), Tshopo Province (Kisangani plus 6HZs) and South Kivu Province (Bukavu plus 3 HZs). Tshopo Province has created an alert management cell and has investigated a total of 777 alerts to date, all negative for EVD. They have trained 3 Rapid Response Teams of 30 people each and are screening approximately 3000 people per week in 10 Points of Entry including the Kisangani Airport. Priority 1 countries There have been over 2300 alerts investigated from 39 countries and EVD was systematically ruled out in all except Uganda. Four confirmed EVD cases have been imported from Democratic Republic of the Congo to Uganda since June 2019, with no transmission or secondary cases in Uganda. A total of 14 600 health workers have been vaccinated in the four priority 1 countries (Uganda, Burundi, Rwanda and South Sudan). Risk communication, social mobilization and community engagement Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 11 Priority 2 countries Angola, Central African Republic, Congo, Tanzania and Zambia have not reported any cases of EVD related to the Democratic Republic of the Congo outbreak to date. However, financial support for implementing emergency preparedness activities in these countries remains insufficient to allow them to reach optimal IHR core compliance. WHO is currently providing technical support for investigational EVD vaccination approvals and training in priority 2 countries. Under Pillar 1, the public health pillar of the Strategic Response Plan, the estimated funding requirement for all partners for the period July to December 2019 is US$ 287 million, including US$ 140 million for WHO. As of 19 November 2019, US$ 85.6 million has been received by WHO, with additional funds committed or pledged. Under Pillar 5, the Regional Preparedness pillar, the funding requirement for all partners is US$ 66 million, of which WHO requires US$ 21 million. As of 19 November 2019, WHO has received US$ 7.3 million. WHO currently has no further pledges in the pipeline for preparedness. Increased funding for preparedness in neighbouring countries is urgently needed. A summary of funding received by WHO since the start of this outbreak can be found here. Under the overall leadership of the Government of the Democratic Republic of the Congo and in support of the Ministry of Health, WHO is supporting public health operations and regional preparedness as outlined in the Strategic Response Plan. WHO is working intensively with wide- ranging, multisectoral and multidisciplinary national, regional and global partners and stakeholders for EVD response, research and preparedness. Various international organizations and UN agencies, specialized agencies and non-governmental organizations are involved in response and preparedness activities; the organizations and their specific contributions have been previously reported. WHO continues to engage the 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. WHO encourages wider coverage of partner operations via this report. 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 to, and trade with, the Democratic Republic of the Congo based on the currently available information. Any requirements for certificates of Ebola vaccination are not a reasonable basis for restricting movement across borders or the issuance of visas for travellers to/from the affected countries. WHO continues to closely monitor and, if necessary, verify travel and trade measures in relation to this event. Currently, no country has IHR travel measures and cross border health Operational partnerships Finance Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 12 implemented travel measures that significantly interfere with international traffic to and from the Democratic Republic of the Congo. Travelers should seek medical advice before travel and should practice good hygiene. Further information is available in the WHO recommendations for international traffic related to the Ebola Virus Disease outbreak in the Democratic Republic of the Congo. In order to monitor the travel and trade situation around this event, a new dashboard Ebola outbreak in the Democratic Republic of the Congo: Travel and trade health measures has been established. The dashboard can also be accessed from Strategic Partnership for International Health Regulations (2005) and Health Security (SPH) page under ‘Resources’ tab, and then click on ‘IHR Travel and Trade Measures’ tab. The dashboard shows all countries where WHO is aware that travel and trade measures have been implemented, and the type of measure, and will be updated as and when any measure is confirmed to be in place. The decline in the number of new confirmed EVD cases is encouraging, although transmission is still occurring in Mabalako and Beni. However, a high level of vigilance is still required, with particular attention to contact tracing and case recognition. While movement of symptomatic cases continues, it is critical that all areas of the response remain effective, engaged and fully resourced. 3. Conclusion