Ebola Virus Disease Democratic Republic of Congo: External Situation Report 21

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: 27 December 2018 Data as reported by: 25 December 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. While civil society in general remain supportive of the Ebola response, operations in some outbreak affected areas have been temporarily disrupted due to insecurity. The Organization’s priority is to end the outbreak, and we hope to return to normal operations as soon as possible, while remaining committed to ensuring the safety of all staff deployed. WHO continues to monitor the situation closely and will adapt the response as needed. During the reporting period (data from 17 to 25 December 2018), 46 new confirmed cases were reported from Komanda (11), Katwa (11), Mabalako (6), Butembo (5), Beni (5), Kalunguta (3), Oicha (3), Musienene (1), and Nyankunde (1) – a newly affected area in Ituri province. The case in Nyankunde likely acquired the infection in Komanda, which highlights the high risk of continued spread of the outbreak and the need to strengthen all aspects of the response in Ituri, North Kivu and surrounding provinces and countries. As of 25 December 2018, a total of 585 EVD cases, including 537 confirmed and 48 probable cases (Table 1), were reported from 16 health zones in the two neighbouring provinces of North Kivu and Ituri (Figure 1), of which 13 reported at least one confirmed case in the last 21 days (5-25 December 2018). Over this period, 117 confirmed cases were reported from 13 health zones, the majority of which were concentrated in major urban centres and towns in Katwa (30), Komanda (20), Beni (15), Butembo (15), and Mabalako (15), which remain the main hotspots of this outbreak. Trends in case incidence (Figure 2) reflect the continuation of the outbreak across these geographically dispersed areas. The general decrease in the weekly incidence observed in Beni since late October is continuing; however, the outbreak is intensifying in Butembo and Katwa, and new clusters have emerged in other health zones. Forty-one additional deaths among confirmed and probable cases occurred since our last report on 18 December 2018. Overall, 356 cases have died (case fatality 61%), including 308 among confirmed cases. As of 25 December 2018, 201 patients have recovered and been discharged from ETCs. A healthcare worker from Mabalako has been reported among the new cases, bringing the number of healthcare workers affected to 54, with 18 deaths. 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 Sudan and Uganda. To date, EVD has been ruled out in all alerts outside of the abovementioned outbreak affected areas. Deaths 100 1. Situation update Cases 585 EBOLA VIRUS DISEASE Deaths 356 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 212 9 221 123 132 Biena 1 0 1 0 0 Butembo 39 0 39 26 26 Kalunguta 37 12 49 17 29 Katwa 76 4 80 48 52 Kyondo 6 2 8 3 5 Mabalako 85 16 101 50 66 Masereka 7 1 8 2 3 Musienene 4 1 5 2 3 Mutwanga 3 0 3 2 2 Oicha 11 0 11 4 4 Vuhovi 8 0 8 3 3 Ituri Komanda 28 0 28 15 15 Mandima 17 3 20 10 13 Tchomia 2 0 2 2 2 Nyakunde 1 0 1 1 1 Total 537 48 585 308 356 Figure 1: Geographical distribution of confirmed and probable Ebola virus disease cases in North Kivu and Ituri provinces, Democratic Republic of the Congo, 25 December 2018 (n=585) Table 1: Ebola virus disease cases by classification and health zones in North Kivu and Ituri provinces, Democratic Republic of the Congo, as of 25 December 2018 Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 4 *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. 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, monkeypox and yellow fever across the country. 0 10 20 30 40 50 60 30 -A p r 14 -M ay 28 -M ay 1 1 -J u n 2 5 -J u n 09 -J u l 23 -J u l 06 -A u g 20 -A u g 03 -S ep 17 -S ep 01 -O ct 15 -O ct 29 -O ct 12 -N o v 26 -N o v 10 -D ec N u m b e r o f ca se s Week of illness onset Confirmed Probable Figure 2. Confirmed and probable Ebola virus disease cases by week of illness onset, as of 25 December 2018 (n=585)* 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), (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, (ix) adapting strategies to the context of insecurity and community resistances. The MoH and other national authorities in the Democratic Republic of the Congo, WHO and partners are implementing several outbreak control interventions. After detecting an outbreak of malaria in Beni, MoH and partners ran a malaria prevention campaign which reached 400 000 people with anti-malarial drugs and insecticide-treated mosquito nets for their households. The impact will be fewer lives lost to malaria, and the campaign will curtail transmission of malaria among Ebola-affected populations and health centres. Having fewer people present with malaria will lessen the workload on already stretched Ebola Treatment Centres (ETCs). Teams in the surrounding north-eastern provinces are taking action to being response ready. Some of the latest activities are summarized below: Current risk assessment Strategic approach to the prevention, detection and control of EVD 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) There is intensified active case finding in health facilities and communities, as well as line listing and follow-up of contacts in health zones with recently reported confirmed cases. Contact tracing activities continue, with over 34 000 contacts registered to date. As of 25 December 2018, 8 128 contacts remained under surveillance. The daily follow-up rate among listed contacts by health zones ranged from 81-92% over the reporting period (data from 16-25 December 2018). Surveillance teams continue to enhance the processes of identifying case contacts and resolving potential gaps. The number of alerts reported from outbreak-affected areas has increased over the past two weeks. Over the reporting period, on average of 204 alerts were received each day, of which 89 per day were validated as suspected cases for further investigation and testing. Field teams are reviewing and reinforcing active case finding activities to ensure surveillance is maintained across areas, and new cases are detected as quickly as possible. During the last reporting week (17-23 December), a total of 981 samples were tested; a 7% increase compared to the previous week. Since the beginning of the outbreak, 8 206 samples have been laboratory-tested. On 24 November 2018, MoH announced the launch of a randomized control trial for Ebola therapeutics. This first-ever multi-drug randomized control trial within an outbreak setting, is an important step towards finding an effective evidence-based treatment for Ebola. The trial is coordinated by WHO and led and sponsored by the Democratic Republic of the Congo’s National Institute for Biomedical Research (INRB) which is the principal investigator. The trial has begun in the ALIMA Ebola treatment center (ETC) in Beni, where patients are enrolled in the study after obtaining voluntary informed consent. Other ETCs continue to provide therapeutics under the MEURI (compassionate use) protocol, in collaboration with the MoH and the 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. UNICEF is providing nutritional treatment and psychological support for all hospitalized patients. As of 25 December 2018, a total of 131 patients were hospitalised in transit centres and ETCs, of whom 29 were laboratory confirmed. The United Nations Children’s Fund (UNICEF) supports hygiene and sanitation in more than 400 facilities in all affected areas, including IPC training. Extensive IPC activities are ongoing throughout DRC, which include but are not limited to: decontamination of households and health facilities with confirmed cases; briefings and trainings of healthcare providers, including those working in private healthcare facilities and tradi-modern facilities. Distribution of IPC kits, which include consumable items such as personal protective 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) equipment and non-consumable items such as chairs, etc. are ongoing in healthcare facilities. Continued monitoring of handwashing facilities is ongoing; in Beni formative supervision of IPC activities in 21 health facilities and performance evaluations in 34 health facilities is ongoing as part of an integrated IPC project; and five-day training of 37 healthcare workers in Goma was completed in the past week, with three facilities participating in practical sessions. Training of hygienists in decontamination techniques in health facilities and households in the Vuhovi region was completed. Performance-based funding is ongoing in Beni and first payments based on initial scores and assessments are in progress. Increased IPC needs are required in Komanda and are being addressed. As of 25 December 2018, 67 of the 74 PoEs and points of control (PoCs) were functional and reporting information. A total of 23 449 694 travellers have been screened and 162 alerts notified. Sixty-eight alerts were validated as suspect cases, of which two were confirmed positive for EVD. The Standard Operating Procedures (SOPs) for traveller screening and other public health measures at PoEs and PoCs have been revised and endorsed, and a series of training for field staff and supervisors is under preparation, for roll-out in early January 2019. The revision of the SOPs aims to increase effectiveness and efficiency of health screening to identify symptomatic travellers, as well as those with a history of exposure, while at the same time limit barriers to travel and trade to the extent possible. With the revised SOPs, new standards for supervision have been agreed upon as well. Screening activity has been strengthened around Komanda and Oicha, given the increased number of confirmed EVD cases in the areas. Damaged PoCs have been repaired and re-stocked, and operations have resumed. PoCs have also been expanded to the north of Goma, along the Lubero- Rutshuru- Goma axis. However, these activities may be hampered by the non-payment of screeners. Spot checks at Goma airport confirmed that exit screening of departing passengers is implemented. Entry screening of incoming internal flights from the Ebola affected areas is also in place. Following a rapid field evaluation, IOM is working to improve traveller flow management and risk communication at the Kinshasa domestic airport. As of 24 December, a total of 1 011 SDB alerts have been received, of which 870 were responded to successfully (86%) by Red Cross and Civil Protection SDB teams. Between 17 and 24 of December a total of 107 SDB alerts were received (23% more than the last reporting period), of which 59 (55%) came from Beni Health Zone, followed by Mabalako (18), Butembo area (18), Komanda (5), Oicha (4), Mandima (2) and Nyankunde (1). Scale up of the CEHRBU Strategy: Two teams trained for Vighole and Vuhika in Katwa Health Zone. Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 8 Implementation of ring vaccination protocol The teams are currently on ‘’on-the-job-training’’ in Katwa, close to their communities. The teams are planned to be operational from 1 January 2019. The scale up plan includes training teams in Mabalako (two in Aloya Health Areas) and in Komanda. Community reluctance remains the main challenge facing the SDB teams. Several security incidents have been noted. On 25 December 2018, 138 contacts were vaccinated, along with 201 contacts of contacts and 62 front line workers in 12 vaccination centres. From 17 to 26 December 2018, 5 491 new people were vaccinated, The cumulative number of people vaccinated as of 26 December 2018 was 53 610. Vaccination rings were opened around confirmed cases in Vutetse, Kanzulinzuli, Keyshero, Matanda, Muchanga, Vungi, Nyankunde, Wanamahika, and Aloya. Risk communication, community engagement, and social mobilization is being strengthened in Butembo and Katwa through community dialogues with groups of women, community leaders, religious leaders, youth groups and marginalized groups. The aim is to address community concerns in order to help response teams to work more closely with communities. Feedback and suggestions from the community are being collected, analysed and used to improve all aspects of the response. Patients who are discharged from Ebola treatment centres are being supported with community reintegration activities, along with psychoeducation sessions to strengthen community engagement and collaboration with the response. UNICEF 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. In addition, there are community awareness and mobilization sessions, with educational talks; youth awareness through a football tournament; daily door-to-door outreach activities in households of affected areas; and awareness activities through the involvement of community leaders and local media. There are continued community reintegration activities for patients discharged from ETCs, along with psychoeducation sessions to strengthen community engagement and collaboration in the response. 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 total 285 experts in various disciplines to support the EVD outbreak response in the Democratic Republic of the Congo. Risk communication, social mobilization and community engagement Operational partnerships Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 9 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.  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): CDC continues to provide technical expertise and support countries bordering the outbreak region (Rwanda, Uganda, and South Sudan) in their efforts to prepare for possible introduction of Ebola cases.  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. Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 10 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.  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. Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 11 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. Preparedness activities continue in neighbouring countries. South Sudan is set to join Uganda in vaccinating most at-risk health care and frontline workers. Almost six months following the confirmation of the first case of EVD the outbreak is still ongoing, with a fifth of the total case load reported in the past 21 days. Intensified population mobility during the holiday season will likely increase the complexity of the situation and further hamper response activities. The continued decline in case incidence in Beni is a promising sign that proven control measures, alongside new preventive and therapeutic tools, are working. However, the control of EVD transmission in emerging and re-emerging hotspots such as Nyakunde, Butembo, Katwa, Komanda and Mabalako remains a key challenge. Insecurity in some outbreak affected areas have resulted in disruptions to response. As the timeliness and completeness of case detection, isolation and control measures are negatively impacted, continued transmission and potentially increases in cases may be anticipated. Nevertheless, together with the MoH and partners, WHO continues to respond and remains committed to ending the outbreak. 3. Conclusion IHR travel measures and cross border health