Ebola Virus Disease Democratic Republic of Congo: External Situation Report 22

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: 3 January 2019 Data as reported by: 1 January 2019 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, despite security challenges which have temporarily disrupted key response activities in some affected areas, notably Beni and Butembo. These response activities are progressively resuming. On 1 January 2019, six new confirmed cases were reported from Beni (2), Butembo (2) and Katwa (2). Only one case was a known contact; investigations are underway to establish the epidemiological links of the other cases. During the reporting period (26 December 2018 - 1 January 2019), 23 newly confirmed cases were reported from Beni (4), Butembo (4), Kalunguta (2), Katwa (4), Komanda (2), Mabalako (1), and Oicha (6) health zones. As of 1 January 2019, a total of 608 EVD cases, including 560 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 10 health zones reported at least one confirmed case in the last 21 days (12 December 2018 - 1 January 2019). Over this period, 103 confirmed cases were reported from 10 health zones, the majority of which were concentrated in major urban centres and towns in Beni (12), Butembo (13), Mabalako (13), Katwa (22), Komanda (21), and Oicha (10), which remain the main hotspots of this outbreak. As of 1 January 2019, no new cases were reported among healthcare workers, leaving the number of affected healthcare workers at 54, including 18 deaths. Trends in case incidence (Figure 2) reflect the continuation of the outbreak across these geographically dispersed areas. The reported number of cases in epidemiological week 52 (24 - 30 December 2018) has decreased compared to that of week 51 (17 - 23 December 2018), with 19 new confirmed cases in week 52 compared to 35 new confirmed cases in week 51. However, active case finding, laboratory diagnosis, and data reporting were disrupted during week 52, which led to an under-reporting of cases, particularly in Beni and Butembo. During week 52, the number of reported deaths among confirmed cases was 11 of which seven (64%) were community deaths. Community deaths were reported in Beni (1), Butembo (1), Katwa (1), Komanda (1), Mabalako (1), and Oicha (2). As of 1 January 2018, a cumulative total of 368 deaths were reported, including 320 deaths among confirmed cases. The case fatality among confirmed cases is 57% (320/560). 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. To date, EVD has been ruled out in all alerts outside the above-mentioned outbreak affected areas. Deaths 100 1. Situation update Cases 608 EBOLA VIRUS DISEASE Deaths 368 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 216 9 225 128 137 Biena 1 0 1 0 0 Butembo 43 0 43 26 26 Kalunguta 39 12 51 17 29 Katwa 80 4 84 50 54 Kyondo 6 2 8 3 5 Mabalako 86 16 102 52 68 Masereka 7 1 8 2 3 Musienene 4 1 5 2 3 Mutwanga 3 0 3 2 2 Oicha 17 0 17 6 6 Vuhovi 8 0 8 3 3 Ituri Komanda 30 0 30 16 16 Mandima 17 3 20 10 13 Tchomia 2 0 2 2 2 Nyakunde 1 0 1 1 1 Total 560 48 608 320 368 Note: Attributions of cases notified in recent days to a health zone are subjected to changes upon in-depth investigations *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 0 10 20 30 40 50 60 70 30 -A pr 07 -M ay 14 -M ay 21 -M ay 28 -M ay 04 -J un 11 -J un 18 -J un 25 -J un 02 -J ul 09 -J ul 16 -J ul 23 -J ul 30 -J ul 06 -A ug 13 -A ug 20 -A ug 27 -A ug 03 -S ep 10 -S ep 17 -S ep 24 -S ep 01 -O ct 08 -O ct 15 -O ct 22 -O ct 29 -O ct 05 -N ov 12 -N ov 19 -N ov 26 -N ov 03 -D ec 10 -D ec 17 -D ec 24 -D ec N um be r of c as es Week of illness onset Confirmed Probable Figure 1: Confirmed and probable Ebola virus disease cases by week of illness onset, as of , 1 January 2019 (n=608)* Table 1: Ebola virus disease cases by classification and health zones in North Kivu and Ituri provinces, Democratic Republic of the Congo, as of 1 January 2019 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 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. Figure 2. Geographical distribution of confirmed and probable Ebola virus disease cases in North Kivu and Ituri provinces, Democratic Republic of the Congo, 1 January 2019 (n=608) 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 high 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 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. However, response activities are limited in Beni and Butembo because of recent protests, with no alert reporting possible in Beni, Oicha, Mutwanga, Karisimbi, Kiretshe and Nyiragongo. Contact tracing activities continues, with over 35 000 contacts registered to date. Contact tracing was temporary disrupted due to the security situation resulting in a decrease in the proportion of contacts being followed in week 52. As of 1 January 2019, 6 859 contacts remain under surveillance including 6 136 (89%) contacts seen over the past 24 hours. WHO continues to monitor alerts from outbreak-affected areas. In the last week, on average of 116 alerts were received per day, of which an average of 111 (96%) per day could be investigated. 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. Laboratory activities decreased by 43% (555 samples tested) in week 52, 24 - 30 December 2018, compared to week 51. There are two major reasons for this: i) Security issues delayed or prevented sample collection and analysis, in particular in Beni and Butembo and ii) Supply issues in with Xpert Ebola cartridges (Cepheid) limited the number of tests performed in certain sites. Supply issues have been resolved. A total of 5300 cartridges were shipped and distributed to the laboratories. As the Beni laboratory was not operational on 26-27 December 2018 due to protests, only part of the laboratory results were reported for week 52. 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 Alliance for International Medical Action (ALIMA) Ebola treatment centre (ETC) in Beni, where patients are enrolled in the study after obtaining voluntary informed consent. MSF treatment centres are also preparing to launch the trial at their sites in the near future. Until other ETCs are ready to launch the trial, they will continue to provide therapeutics under the Monitored Emergency Use of Unregistered Interventions (MEURI) (compassionate use) protocol, in collaboration with the MoH and the INRB, together with supportive care measures. WHO continues to provide technical clinical expertise on-site at all treatment centres. UNICEF is providing nutritional treatment and psychological support for all hospitalized patients. As of 1 January 2019, a total of 88 patients are hospitalized in ETCs, of which 30 are confirmed cases, receiving compassionate therapy. Surveillance and Laboratory Case management Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 7 Infection prevention and control (IPC) and Water, Sanitation and Hygiene (WASH) Points of Entry (PoE) 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 consumables items such as personal protective equipment 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. Destruction of some health facilities has interrupted WASH and IPC activities in some areas. Since the beginning of the outbreak as of 1 January 2019, 24 448 717 travellers have been screened, with two confirmed cases detected among them. Minimal service was possible at many PoE/Points of Control (POCs) during the reporting period, as a result of security incidents related to the elections, with protests affecting activities at PoCs in Beni, Kasindi, and Mangina, as well as destruction of buildings at many PoE/PoC facilities. At least eight PoCs in Beni and Butembo were destroyed or vandalized this week, which are Disruptions to the communication network have also hampered the reporting of PoE/PoC activities. Preparations are progressing for the roll-out of a series of trainings for field staff and supervisors on the revised Standard Operating Procedures (SOPs) for traveller screening and other public health measures at PoEs and PoCs. These trainings aim to strengthen the effectiveness and efficiency travellers’ 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. Within this scheme, the International Organization for Migration (IOM) supported a one day refresher training for 36 staff members of the National Program of Hygiene at Borders (PNHF)staff at N’djili International Airport on 28 December 2018. PoE/PoC activities continue to be strengthened around Goma, in response to increased risks of Ebola spread into the capital of the province through travel and trade channels. 11 locations have been identified in the northern, eastern and western perimeters of Goma through a population movement mapping exercise, where PoE/PoCs need to be put in place. 10 are established, and the last one, located on the western periphery will follow shortly. . Seven additional PoE/PoCs will also be established at strategic locations on road connections, four in the North Kivu Province (Kasindi Frontiere, Mukulya, Kanyabayonga and OPRP) , and three in the Ituri Province (Komanda Foner, Gombe Nyama and Pont Ituri). Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 8 Implementation of ring vaccination protocol Safe and Dignified Burials (SDB) As of 3 of January, a total of 1 091 SDB alerts have been received, of which 937 were responded to successfully (86%) by Red Cross and Civil Protection SDB teams. Between 24 of December 2018 and 2 of January 2019 , a total of 97 SDB alerts were received, of which 47 (49%) came from Beni Health Zone, followed by Butembo (3), Katwa (20), Komanda (6), Mabalako (15), Mabasa (1), Mandima (3), and Oicha (2). SDB teams performed 79 (81%) of safe and dignified burials successfully. Scale up of the Community Emergency Harm Reducation Burials *(CEHRBU) Strategy: Two teams trained and operational for Vighole and Vuhika in Katwa Health Zone since 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 related to the elections have been noted and data may be missing due to the ‘ville morte’ in Beni and general instability due to the elections. Vaccination activities were interrupted in Beni, Butembo, Goma, Katwa, Komanda and Mabalako as a result of protests. The cumulative number of people vaccinated was 54 153 as of 1 January 2019. Risk communication, social mobilization and community engagement field activities were suspended for several days at Beni, Katwa, Lubero, Mabalako, Oicha, as a result of insecurity. However, activities have now resumed with meetings with community leaders and community dialogue recommencing. Awareness raising about the Ebola response has been carried out at voting stations in Komanda. Eleven people classified as non-cases were reintegrated into the community in Aloya (7), Katanga (1), Mabalako (1), and Ngoyo (2). 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. 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 Risk communication, social mobilization and community engagement Operational partnerships Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 9  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. 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. Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 10  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. 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. The Ebola outbreak in DRC is occurring in one of the most complex settings possible. Five months following the confirmation of the first case of EVD the outbreak in North Kivu and Ituri provinces is still ongoing. The intensification of response activities has shown promising results, in particular in Beni where a decline in case incidence has been observed since late October. However, the recent security challenges during end of December could compromise the achievement reached so far. Despite the challenges regarding the security situation, WHO and partners, under the government’s leadership, continue to respond to the EVD outbreak and remain committed to ending it. Vaccination, contact tracing, and community engagement activities have resumed with the support of local community relays, and WHO is supporting local health authorities to undertake other critical surveillance functions where possible. 3. Conclusion IHR travel measures and cross border health