Ebola Virus Disease Democratic Republic of Congo: External Situation Report 23 / 2019

Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 1 Democratic Republic of the Congo External Situation Report 23 EBOLA VIRUS DISEASE Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 2 Date of issue: 8 January 2019 Data as reported by: 6 January 2019 The Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces, Democratic Republic of the Congo persists and continues to be closely monitored. Since our last report on 1 January 2019, 17 newly confirmed cases have been reported. From the beginning of the outbreak through 6 January 2019, a total of 625 EVD cases, including 577 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 ten health zones reported at least one confirmed case in the last 21 days (17 December 2018 – 6 January 2019). Over this period, 80 confirmed cases were reported from ten health zones, the majority of which were concentrated in major urban centres and towns in Beni (12), Butembo (15), Kalunguta (6), Katwa (19), Komanda (4), Kyondo (1), Mabalako (9), Musienene (1), Nyankunde (1), and Oicha (12). 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 1 (31 December 2018 - 6 January 2019) has increased with 27 new confirmed cases compared to 19 new confirmed cases in week 52 (24 - 30 December 2018). During week 1, the number of reported deaths among confirmed cases was 13, of which three (23%) were community deaths. Promising declines in case incidence in areas such as Beni have continued. However, here and elsewhere, these trends must be interpreted cautiously, as delayed detection of cases is expected following recent temporary disruption in response activities due to insecurity. The outbreak remains highly active across all areas listed above. Hard-earned progress could still be lost from prolonged periods of insecurity hampering containment efforts. As of 6 January 2018, a cumulative total of 377 deaths were reported, including 329 deaths among confirmed cases. The case fatality ratio among confirmed cases is 57% (329/577). An additional health worker was identified retrospectively among the cases, and the number of healthcare workers infected to date is now 55, with 18 deaths. Deaths 100 1. Situation update Cases 625 External Situation Report 23 Deaths 377 Democratic Republic of the Congo EBOLA VIRUS DISEASE Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 3 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, Uganda, South Sudan, and a traveller returning from Burundi to Sweden. To date, EVD has been ruled out in all alerts outside the above-mentioned outbreak affected areas. International travellers who may have come into contact with the virus, including a doctor who returned to the United States of America after providing medical assistance in the Democratic Republic of the Congo, are also being followed closely; all remain asymptomatic to date. Case classification Deaths Province Health zone Confirmed cases Probable cases Total cases Deaths in confirmed cases Total deaths North Kivu Beni 218 9 227 130 139 Biena 1 0 1 0 0 Butembo 46 0 46 27 27 Kalunguta 40 12 52 17 29 Katwa 87 4 91 56 60 Kyondo 8 2 10 3 5 Mabalako 89 16 105 52 68 Masereka 7 1 8 2 3 Musienene 4 1 5 2 3 Mutwanga 3 0 3 2 2 Oicha 23 0 23 6 6 Vuhovi 8 0 8 3 3 Ituri Komanda 23 0 23 16 16 Mandima 17 3 20 10 13 Tchomia 2 0 2 2 2 Nyakunde 1 0 1 1 1 Total 577 48 625 329 377 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 6 January 2019 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 Figure 1: Confirmed and probable Ebola virus disease cases by week of illness onset, as of 6 January 2019 (n=625)* Figure 2. Geographical distribution of confirmed and probable Ebola virus disease cases in North Kivu and Ituri provinces, Democratic Republic of the Congo, 6 January 2019 (n=625) 0 10 20 30 40 50 60 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 31 -D ec N um be r of c as es Week of illness onset Confirmed Probable 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. Teams in the surrounding north-eastern provinces are taking measures 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. However, active case finding has been disrupted in Beni and Butembo since 26 December 2018 and is gradually resumed. Contact tracing activities continues, with over 35 000 contacts registered to date. As of 6 January 2019, 4 350 contacts remain under surveillance including 4 058 (93%) contacts seen over the past 24 hours. WHO continues to monitor alerts from outbreak-affected areas. In the last week, on average of 267 alerts were received per day, of which an average of 259 (97%) 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. As of 6 January 2019, 141 samples were analysed, with 128 negative and 13 positive for EVD. 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) 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 6 January 2019, a total of 151 patients are hospitalized in ETCs, of which 29 are confirmed cases, receiving compassionate therapy. As of 4 January 2019, Katwa ETC has been opened and admitted three suspected cases. 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 the Democratic Republic of the Congo, 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 Surveillance and Laboratory Case management Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 7 Points of Entry (PoE) Safe and Dignified Burials (SDB) protective equipment, are ongoing in healthcare facilities. IPC activities are gradually resuming in health facilities where confirmed cases were reported, along with training and provision of IPC kits and the resumption of healthcare activities. Destruction of some health facilities interrupted WASH and IPC activities in some areas during recent protest actions. Activities in four Points of Control (PoC) in Kasindi have resumed and a total of 152 160 travellers have been screened. Members of the Congolese National Police deployed to Beni and Kasindi PoE/PoC facilities have been briefed in order to reinforce screening activities. A new PoC in Kiwandja was opened and started activities on 5 January 2019. The PoC in Beni has been destroyed for a second time. As on 6 of January 2019, 64 of 74 PoE/PoCs are in operation. 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. Eleven 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. Ten 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). From 31 December through 7 January, a total of 88 SDB alerts were received, of which 46 (52%) came from Beni Health Zone followed by Komanda (15), Mabalako (11), Katwa (6), Butembo (4), Oicha (4), Mandima (1) and Musienne (1). From 31 December through 7 January 2019 a total of 87 SDB alerts were received, of which 46 (53%) came from Beni Health Zone followed by Komanda (15), Mabalako (11), Katwa (6), Butembo (4), Oicha (4), Mandima (1) and Musienne (1). Scale up of the Community Emergency Harm Reduction 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. Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 8 Implementation of ring vaccination protocol Risk communication, social mobilization and community engagement As of 6 January 2019, a total of 56 509 individuals have been vaccinated since the start of the outbreak. Risk communication, social mobilization and community engagement field activities have now resumed with meetings with community leaders and community dialogue recommencing in Beni and Oicha. The monitoring and evaluation work undertaken by the communication team working in Musienene is ongoing to improve risk communication and community engagement in the area. 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. 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. See this link. 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 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. IHR travel measures and cross border health Operational partnerships Health Emergency Information and Risk Assessment WHO Health Emergencies Programme Page 9 The Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo is in a critical phase as it enters its sixth month since the declaration of the outbreak. The outbreak continues to evolve in a particularly complex and challenging environment, marked by a volatile security context, which continues to hinder the implementation of key response activities. The persistence of insecurity threatens to reverse recent progress achieved around disease hotspots such as Beni and Butembo. Nevertheless, WHO and partners, under the government’s leadership, continue to respond to the EVD outbreak and remain committed to ending it. The progressive resumption of key response activities following recent security challenges is encouraging; however, it is vital to ensure their continuation and intensification. 3. Conclusion