Ebola Virus Disease Democratic Republic of Congo: External Situation Report 85 / 2020

Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 1 Democratic Republic of the Congo External Situation Report 85 EBOLA VIRUS DISEASE Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 2 Date of issue: 24 March 2020 Data as reported by: 22 March 2020 No new cases of Ebola virus disease (EVD) have been reported since 17 February 2020. The last person confirmed to have Ebola was discharged from an Ebola Treatment Centre on 3 March 2020 after recovering and testing negative for the virus twice. The last 46 contacts finished their follow-up period on 9 March 2020. These developments are significant milestones in this outbreak. There is, however, still a high risk of re- emergence of EVD, and it is critical to maintain response activities to rapidly detect and respond to any new cases, and to continue ongoing support and health monitoring operations for EVD survivors – as outlined in the WHO recommended criteria for declaring the end of the EVD outbreak. Extensive surveillance, pathogen detection, and clinical management activities in previously affected areas continue, including alert validation, rapid diagnosis of suspected cases, and building of partnerships with community members to strengthen investigation of potential community EVD deaths. Last week, nine historical probable cases were validated, whose dates of symptom onset were between October 2018 to July 2019, bringing the cumulative number of probable cases to 143. Further historical probable cases are expected to be validated as investigations into past cases continue. Insecurity remains a challenge, hindering ongoing surveillance activities in some areas, which could delay the detection of potential reintroduction events. From 16 to 22 March 2020, 31 984 alerts were reported and investigated. Of these, 2 555 alerts were validated as suspected cases, requiring specialized care and laboratory testing to rule-out EVD. On average, people stay in these facilities for three days while waiting for EVD to be definitively ruled out (i.e. after two negative polymerase chain reaction tests 48 hours apart), while care is provided for their illness under isolation precautions. Timely testing of suspected cases continues to be provided across 11 laboratories. From 16 to 22 March 2020, 2 747 samples were tested including: 1 479 blood samples from alive, suspected cases; 374 swabs from community deaths; and 894 samples from re-tested patients. Overall, laboratory activity was conducted as similar levels as compared to the prior week. Since the beginning of the outbreak, alert rates steadily climbed as active and passive case finding systems were strengthened and adapted to suit the local context, reaching additional health zones involved in the evolution of the outbreak. As expected, alert rates have begun to decline in some areas as the incidence of confirmed cases decreased and disease surveillance activities gradually transitioned toward routine operations. However, it remains important to maintain appropriate levels of surveillance through the end of outbreak declaration to rapidly detect relapse, reintroduction or new emergence events, thereby providing an opportunity to implement effective control measures and avoid a potential resurgence of the outbreak. Deaths 100 1. Situation update Cases 3453 External Situation Report 85 Deaths 2273 Democratic Republic of the Congo EBOLA VIRUS DISEASE Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 3 As of 21 March 2020, a total of 3 453 EVD cases were reported from 29 health zones (Table 1), including 3 310 confirmed and 143 probable cases, of which 2 273 cases died (overall case fatality ratio=66%). Of the total confirmed and probable cases, 56% (1931) were female, 28% (975) were children aged less than 18 years, and 5% (171) were healthcare workers. WHO has not received funding for the Ebola response in the Democratic Republic of the Congo since December 2019. An urgent injection of US$ 20 million is required to ensure that response teams have the capacity to maintain the appropriate level of operations through to the beginning of May 2020, and are able to rapidly respond to any flare-ups. If no new resources are received, WHO risks running out of funds for the Ebola response before the end of the outbreak. For more information see this recent statement: https://www.who.int/news-room/detail/06-03-2020-end-in-sight-but-flare- ups-likely-in-the-ebola-outbreak-in-the-democratic-republic-of-the-congo *Excludes n=148/3444 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. Non-active health zones indicate health zone that have not reported cases in the last 21 days – see Table 1 for details. 0 20 40 60 80 100 120 30 -A pr 14 -M ay 28 -M ay 11 -J un 25 -J un 9- Ju l 23 -J ul 6- A ug 20 -A ug 3- Se p 17 -S ep 1- O ct 15 -O ct 29 -O ct 12 -N ov 26 -N ov 10 -D ec 24 -D ec 7- Ja n 21 -J an 4- Fe b 18 -F eb 4- M ar 18 -M ar 1- A pr 15 -A pr 29 -A pr 13 -M ay 27 -M ay 10 -J un 24 -J un 8- Ju l 22 -J ul 5- A ug 19 -A ug 2- Se p 16 -S ep 30 -S ep 14 -O ct 28 -O ct 11 -N ov 25 -N ov 9- D ec 23 -D ec 6- Ja n 20 -J an 3- Fe b 17 -F eb 2- M ar 16 -M ar N um be r of c as es Week of onset Beni Other HZs Figure 1: Health zone of reported Ebola virus disease cases by week of illness onset, as of 22 March 2020 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 1 6 2 3 Beni 0/18 0 721 9 730 465 474 Biena 0/16 0 19 2 21 12 14 Butembo 0/15 0 295 7 302 353 360 Goma 0/10 0 1 0 1 1 1 Kalunguta 0/18 0 198 23 221 71 94 Katwa 0/18 0 653 24 677 471 495 Kayna 0/21 0 28 1 29 8 9 Kyondo 0/22 0 25 6 31 15 21 Lubero 0/19 0 31 2 33 4 6 Mabalako 0/12 0 463 18 481 334 352 Manguredjipa 0/10 0 18 3 21 12 15 Masereka 0/16 0 50 6 56 17 23 Musienene 0/20 0 85 1 86 33 34 Mutwanga 0/19 0 32 0 32 12 12 Nyiragongo 0/10 0 3 0 3 1 1 Oicha 0/26 0 65 0 65 30 30 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 0/17 0 82 5 87 27 32 Mandima 0/15 0 347 10 357 166 176 Nyakunde 0/12 0 2 0 2 1 1 Rwampara 0/13 0 8 1 9 3 4 Tchomia 0/12 0 2 0 2 2 2 Total 0/471 0 3310 143 3453 2130 2273 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 22 March 2020 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, 22 March 2020 Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 6 Infection prevention and control (IPC) and Water, Sanitation and Hygiene (WASH) 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: A total of 249 395 contacts have been registered to date. None were under surveillance as of 17 March 2020. All contacts of confirmed cases completed follow-up. As of March 17, an average of 4704 alerts were reported per day over the past seven days, of which 4650 (99%) were investigated within 24 hours of reporting. Testing of suspected cases continues to be provided across 11 operational laboratories. From 16 to 22 March, 2747 samples were tested. As of 16 March 2020, 301 785 people were vaccinated with the rVSV-ZEBOV-GP Ebola vaccine. Vaccination with the Ad26.ZEBOV/MVA-BN-Filo vaccine continued in two health areas near Goma, with 20 339 people vaccinated since its introduction on 14 November 2019, as of 29 February 2020. Ebola treatment centres (ETCs), transit centres (TCs), and decentralized transit centres continue to operate across outbreak affected areas, providing timely care and diagnoses for suspected EVD cases. On 21 March 2020, 188 patients with no confirmed cases of EVD were hospitalized in the 22 operational TC/ETCs who are reporting. In the past 21 days, no new cases of nosocomial infections were reported. 2. Actions to date Surveillance and Laboratory Case management Vaccines Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 7 Points of Entry (PoE) Preparedness and Operational Readiness Safe and Dignified Burials (SDB) Risk communication, social mobilization and community engagement Between 16 and 22 March, 2 716 603 screenings were performed, bringing the cumulative number of screenings to over 166 million. From this week’s screenings, 261 alerts were notified, of which 35 (14%) were validated as suspect cases. None were subsequently confirmed with EVD following laboratory testing. The cumulative number of EVD positive cases identified at PoEs and PoCs remains at 30. The average number of operational PoEs and PoCs that are reporting daily screening information is 103 out of 109 (94%). The International Organization for Migration (IOM) continued to monitor the movements of the general population and internally displaced persons (IDPs) in North Kivu and Ituri Provinces. In previous weeks, IOM reported significant flows of people fleeing violence in Biakato through the PoCs of Bango and Somé to Mambasa Territory. This week, a reverse flow of people was observed back into the territory. As of 1 March 2020, there have been a total of 26 139 SDB alerts notified through the Red Cross SDB database, of which 22 762 (87%) have been successfully responded to by Red Cross and Civil Protection SDB teams and community harm reduction burial teams During the week ending 1 March 2020, there were 401 SDB alerts recorded in 28 health zones. Of these, 361 (90%) were responded to successfully. During this period all reporting health zones surpassed the 70% success benchmark, except Biena (3/5, 60%), Kalunguta (3/6, 50%), Lubero (6/10, 60%), Manguredjipa (2/3, 67%), Nyiragongo (1/2, 50%) and Vuhovi (2/6, 33%) Health Zones Beni saw 50 SDB alerts, with 47 successfully completed (94%) All health areas that have gone more than 141 days without cases have stopped SDB activities. The Commission continues to engage in talks and community dialogues with target groups to encourage increased vigilance as of 21 March 2020. Operational readiness in the Democratic Republic of the Congo: Readiness actions are being implemented in 42 non-affected health zones in North Kivu, South Kivu and Ituri Provinces and in the non-affected Provinces of Tshopo and Maniema. An immersion training programme was implemented for the national preparedness workforce to gain hands-on skills in the affected areas, and a simulation exercise was conducted in Kinshasa. Priority 1 countries There have been over 2400 alerts investigated from 40 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. Uganda was successful in stopping the spread of EVD and preventing outbreaks by investing USD 18 million in EVD preparedness efforts. A total of 14 600 health workers have been vaccinated in the four priority 1 countries (Burundi, Rwanda, South Sudan and Uganda). All Priority 1 countries are finalizing updated national contingency plans for 2020. The Burundi National Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 8 EVD Plan for January – June 2020 has a requirement of about $7M. The focus is on IPC and strengthening district level coordination, surveillance, and risk communication. The Rwanda National EVD Plan for January – June 2020 is pending endorsement. The focus is on scaling up surveillance, strengthening district level capacities, and a full-scale simulation exercise for EVD readiness. In South Sudan the National EVD Plan for January – June 2020 has a $3.2M requirement. The focus is to fold EVD readiness into the National Action Plan for Health Security (NAPHS) and MoH systems and to expand laboratory capacity to crossover EVD readiness with novel coronavirus readiness. IOM continues with EVD prevention and preparedness activities in the 17 POEs in Morobo, Kajo Keji, Yei, Nimule, Juba and Wau. In epidemiological week 11, 58 866 inbound travelers were screened, bringing the cumulative number of travelers screened to 1 998 612. There was one alert reported, verified and discarded by the team at the Nimule docking site in week 8. There was a decrease of 60% in the number of travelers undergoing secondary screening from 58 in week 10 to 35 in week 1. All travelers with common non-EVD illnesses were treated in nearby health facilities. IOM continued to strengthen the capacity to detect and refer EVD suspected cases to three health facilities (Kaya, Kerwa and Khorijo) and this reporting week. A total of 288 people were provided health promotional information on EVD and 39 people were screened for EVD in the health facilities. The IOM South Sudan EVD weekly report (week 10) is available here: https://southsudan.iom.int/media-and-reports/other-reports/iom-south- sudan-evd-weekly-report-friday-13-march-2020 Uganda’s National EVD Plan for January – June 2020 is pending endorsement. The Plan focuses on sustained regional capacities, mentoring health care workers in IPC and mainstreaming activities into the NAPHS. 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 Angola, Central African Republic, Republic of Congo and Zambia remains insufficient to allow them to reach optimal International Health Regulations (IHR) core compliance. Tanzania has continued to implement regular coordination meetings to update partners and strategies for EVD preparedness as well as activities in the technical pillars. WHO’s financial need for the Ebola Response for January to June 2020 (SRP 4.1) is US $83 million. WHO currently requires US$ 40 million to ensure continuity of activities. 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. Operational partnerships Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 9 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 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 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. Given the challenges related to continued insecurity and population displacement in previous hotspots, limited access to some affected communities, and potential shortages of resources required to carry out response activities, there remains a high risk of re-emergence of the virus in the period leading up to the declaration of the end of the outbreak, as well as for several months following that declaration. In order to mitigate the risk of re-emergence, it is essential to maintain surveillance and rapid response capacities, prioritize survivor care, and maintain cooperative relationships with survivors’ associations. 3. Conclusion IHR travel measures and cross border health