DRC – Ebola/Cholera/Polio/Measles
Editor’s Note:
The complex challenges faced in DRC across a range of health and security fronts continue. We include extensive coverage of the decision to declare the Ebola outbreak as a PHEIC below.
Summary of new polio viruses this week:
:: Democratic Republic of Congo (DRC)
Five cases of circulating vaccine-derived poliovirus type 2 (cVDPV2) have been reported this week in the Democratic Republic of the Congo (DR Congo): three from Malemba-Nkulu district, Haut Lomami province; one each from Tshumbe and Wembo-Nyama districts, Sankuru province. The onset of paralysis was on 10 February, 30 May, 26 May, 23 May, 3 June 2019 respectively. There are 11 reported cases of cVDPV2 in 2019. The total number of cVDPV2 cases reported in 2018 is 20. DRC is currently affected by seven separate cVDPV2 outbreaks; one each originated in Haut Katanga, Mongala, Sankuru and two in Haut Lomami and Kasai provinces.
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Ebola outbreak in the Democratic Republic of the Congo declared a Public Health Emergency of International Concern
17 July 2019 News release Geneva
WHO Director-General Dr. Tedros Adhanom Ghebreyesus today declared the Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo (DRC) a Public Health Emergency of International Concern (PHEIC).
“It is time for the world to take notice and redouble our efforts. We need to work together in solidarity with the DRC to end this outbreak and build a better health system,” said Dr. Tedros. “Extraordinary work has been done for almost a year under the most difficult circumstances. We all owe it to these responders — coming from not just WHO but also government, partners and communities — to shoulder more of the burden.”…
“It is important that the world follows these recommendations. It is also crucial that states do not use the PHEIC as an excuse to impose trade or travel restrictions, which would have a negative impact on the response and on the lives and livelihoods of people in the region,” said Professor Robert Steffen, chair of the Emergency Committee…
“This is about mothers, fathers and children – too often entire families are stricken. At the heart of this are communities and individual tragedies,” said Dr. Tedros. “The PHEIC should not be used to stigmatize or penalize the very people who are most in need of our help.”
Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 17 July 2019
[Excerpts]
The meeting of the Emergency Committee convened by the WHO Director-General under the International Health Regulations (IHR) (2005) regarding Ebola virus disease in the Democratic Republic of the Congo (DRC) took place on Wednesday, 17 July 2019, from 12:00 to 16:30 Geneva time (CEST).
Proceedings of the meeting
…The current situation in the Democratic Republic of the Congo was reviewed. There are increased numbers of cases in Butembo and Mabalako; the epicentre has moved from Mabalako to Beni; and there is one imported case in Goma. Factors affecting the outbreak include population movement in highly densely populated areas; weak infection and prevention control practices in many health facilities; complex political environment; continued reluctance in the community; and the ongoing unstable security situation, which led to the recent murders of two community health workers. More than 70 entry points are being monitored and 75 million screenings have been conducted, with 22 cases detected in this manner. Beni is the main hotspot; cases in other areas are decreasing. There are 2512 confirmed or probable cases, including 136 health workers affected, with 40 deaths among them.
Beni remains the epicentre of the outbreak, with 46% of the cases over the last 3 weeks. Mangina has 18% of the cases, and one new case in Goma came from Beni, with diagnosis confirmed within one hour of the patient’s arrival at a health facility. The patient, who was not known to be a contact, traveled to Goma with several other people in a bus. When the vehicle broke down, he went to a health facility via motorbike. He was transferred to an Ebola Treatment Centre, but later died. Response to the case in Goma took place within 72 hours. Contact tracing was performed, with 75 contacts vaccinated, as well as co-travellers, and family members are being monitored. Surveillance is being reinforced and readiness strengthened. 15,000 people cross the border from Goma to Rwanda every day, as Goma is an important centre of economic activities with Rwanda. Closing this border would strongly affect the population of Goma and have adverse implications for the response. There is a continuing need for increased awareness among the population on the outbreak situation and stronger engagement on health-seeking behaviours.
The UN Ebola Emergency Response Coordinator gave an update on the situation and efforts to maintain an enabling environment to support outbreak response. He emphasized the need for community engagement and access in all areas, increased multisectoral collaboration, and more financial and human resources. Insecurity is the greatest concern, especially after two community health workers were killed last week. Efforts to increase security are underway. There is a need to focus both on intervention gaps and the quality of interventions.
The WHO Secretariat provided details on the latest rapid risk assessment. The Secretariat highlighted the effectiveness of the response; there have been improvements in surveillance and the intensity of virus transmission has been reduced, but there has been a geographical extension. There has been no local transmission in these areas, but the continued seeding of virus into new areas represents a constant risk of further amplification. 3
Risk remains very high at national and regional levels but still low at global level. There is cause for concern linked to the recent case in Goma, as the city is a provincial capital with an airport with international flights.
The intensity of the epidemiological situation is fluctuating, with about 80 new cases reported weekly. There is continued shifting of hotspots and associated risks. There is continued seeding to new or previously cleared areas but thus far without sustained local transmission. The recent travel to and from Uganda of a local trader who later died of Ebola demonstrates that the risk remains high for bordering countries. The virus has extended geographically but transmission is not as intense. However, the situation in Beni remains difficult and worrisome, especially as the proportion of community deaths has been rising. Ongoing challenges include insecurity, community acceptance, delays in case detection and isolation, challenges in contact tracing, a highly mobile population, and multiple routes of transmission. Nosocomial transmission, burial practices, and the use of traditional healers continue to amplify transmission in affected communities. The level of preparedness in Goma and priority actions for Rwanda were presented, demonstrating significant improvements across a number of key preparedness pillars (surveillance, Ebola Treatment Centres, etc.). Gaps and challenges remain, specifically at the district level.
The ring vaccination strategy is proving efficient and successful. Issues related to vaccine supply were reviewed. Vaccine supply and availability data were presented and show that vaccine supplies are currently insufficient, thereby necessitating the introduction of an adjusted dose. The Secretariat welcomed the increased production planned by Merck, which will effectively double the supply of rVSV-EBOV in 2020. Further, the EVD Working Group of SAGE will monitor vaccine supplies and suggest any further dose adjustment that might be required to assure adequate doses until further production is available.
Context and Discussion
The Committee commended the response to date, under the leadership of the DRC Ministry of Health, and supported by WHO, UN agencies, NGOs and other partners. The response has contributed to limiting the spread and impact of this virus in a difficult context in many areas in DRC. The courage and commitment of all frontline workers were specifically praised by the Committee.
However, the Committee is concerned that a year into the outbreak, there are worrying signs of possible extension of the epidemic. Despite significant improvement in many places, there is concern about potential spread from Goma, even though there have been no new cases in that city. The Committee is also concerned by the reinfection and ongoing transmission in Beni, which has been previously associated with seeding of virus into multiple other locations. Further, the murder of two HCWs demonstrates continued risk for responders owing to the security situation.
In addition, despite previous recommendations for increased resources, the global community has not contributed sustainable and adequate technical assistance, human or financial resources for outbreak response.
Conclusions and Advice
It was the view of the Committee that a coordinated international response under the International Health Regulations (2005) is required. Thus, the conditions for a Public Health Emergency of International Concern (PHEIC) under the IHR (2005) have been met.
The Committee discussed the impact of a PHEIC declaration on the response, possible unintended consequences, and how these might be managed. The global community should anticipate possible negative consequences and proactively prevent them from occurring, taking into account experience with Ebola in West Africa in 2014.
The declaration of the PHEIC is not a reflection on the performance of the response team but rather a measure that recognizes the possible increased national and regional risks and the need for intensified and coordinated action to manage them.
The Committee provided the following advice to the Director-General for his issuance as formal Temporary Recommendations under the IHR (2005).
For affected countries:
- Continue to strengthen community awareness, engagement, and participation, including at points of entry, with at-risk populations, in particular to identify and address cultural norms and beliefs that serve as barriers to their full participation in the response.
- Continue cross-border screening and screening at main internal roads to ensure that no contacts are missed and enhance the quality of screening through improved sharing of information with surveillance teams.
- Continue to work and enhance coordination with the UN and partners to reduce security threats, mitigate security risks, and create an enabling environment for public health operations as an essential platform for accelerating disease-control efforts.
- Strengthen surveillance with a view towards reducing the proportion of community deaths and the time between detection and isolation, and implementing real-time genetic sequencing to better understand the dynamics of disease transmission.
- Optimal vaccine strategies that have maximum impact on curtailing the outbreak, as recommended by WHO’s Strategic Advisory Group of Experts (SAGE), should be implemented rapidly.
- Strengthen measures to prevent nosocomial infections, including systematic mapping pf health facilities, targeting of IPC interventions and sustain support to those facilities through monitoring and sustained supervision.
For neighbouring countries:
- At-risk countries should work urgently with partners to improve their preparedness for detecting and managing imported cases, including the mapping of health facilities and active surveillance with zero reporting.
- Countries should continue to map population movements and sociological patterns that can predict risk of disease spread.
- Risk communications and community engagement, especially at points of entry, should be increased.
- At-risk countries should put in place approvals for investigational medicines and vaccines as an immediate priority for preparedness.
For all States:
- No country should close its borders or place any restrictions on travel and trade. Such measures are usually implemented out of fear and have no basis in science. They push the movement of people and goods to informal border crossings that are not monitored, thus increasing the chances of the spread of disease. Most critically, these restrictions can also compromise local economies and negatively affect response operations from a security and logistics perspective.
- National authorities should work with airlines and other transport and tourism industries to ensure that they do not exceed WHO’s advice on international traffic.
- The Committee does not consider entry screening at airports or other ports of entry outside the region to be necessary.
The Committee recognizes the shortage of supply of rVSV ZEBOV GP vaccine, despite the commendable efforts of the manufacturer of doubling the supply by 2020, and recommends that WHO works with member states and manufacturers to immediately take all measures to increases supplies, including consideration of working with Contract Manufacturing Organizations (CMOs) and transfer of technology.
The Committee emphasized the importance of continued support by WHO and other national and international partners towards the effective implementation and monitoring of these recommendations.
Based on this advice, the reports made by the affected State Party, and the currently available information, the Director-General accepted the Committee’s assessment and on 17 July 2019 declared the Ebola outbreak in the Democratic Republic of the Congo a Public Health Emergency of International Concern (PHEIC).
The Director-General endorsed the Committee’s advice and issued them as Temporary Recommendations under IHR (2005) to reduce the international spread of Ebola, effective 17 July 2019. The Director-General thanked the Committee Members and Advisors for their advice and requested their reassessment of this situation within three months.
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CDC supports WHO declaration of “Public Health Emergency of International Concern” for Ebola outbreak in eastern region of The Democratic Republic of the Congo
Wednesday, July 17, 2019
As cases of Ebola continue to increase in the eastern region of The Democratic Republic of the Congo (DRC), and travel-associated cases have been reported in neighboring Uganda, CDC fully supports the decision by the International Health Regulations Emergency Committee of the World Health Organization (WHO) to declare the outbreak a “public health emergency of international concern” (PHEIC). A PHEIC is declared if an extraordinary event poses a public health threat to other nations through the spread of disease and requires a more robust coordinated international response…
“Ending the Ebola outbreak is one of the Trump Administration’s top global health priorities,” said HHS Secretary Alex Azar. “We appreciate the strong response of Dr. Tedros and WHO leadership to this outbreak, yet it is clear that much more remains to be done. The United States government has already played a vital role in supporting the response in the DRC and neighboring nations, and will continue this support until we have put an end to the outbreak.”…
“Make no mistake, the challenges to stopping the Ebola outbreak are growing steeper and the public health response will unquestionably be longer,” said CDC Director Robert R. Redfield, M.D. “CDC stands ready to support our U.S. government and international partners in limiting the spread of Ebola, improving the human condition, and bringing this outbreak to an end.”
As part of the Administration’s whole-of-government effort, CDC experts are working with the United States Agency for International Development (USAID) Disaster Assistance Response Team (DART) on the ground in the DRC and the American Embassy in Kinshasa to support the Congolese and international response. The United States government, including CDC, is working with DRC, Uganda, WHO, and other partners to support the current Ebola outbreak response by providing technical assistance and expertise in disease tracking, case investigation, contact tracing, case management, infection prevention and control, safe burials, community engagement and social mobilization, risk communication and health education, behavioral science, laboratory testing, border health, data management, vaccination campaigns, and logistics.
To rapidly identify cases and prevent further spread of Ebola, CDC is working with the U.S. Embassy in DRC to preposition CDC staff in Goma to rapidly respond to hotspots where the security situation is permissible. As of July 16, 2019, CDC staff have conducted 311 deployments to the DRC, neighboring countries, and WHO headquarters. CDC has 246 permanent staff in the three high-risk countries bordering the outbreak (South Sudan, Rwanda, Uganda), including 43 in DRC. DRC has more than 150 graduates of CDC’s Field Epidemiology and Laboratory Training Program who are playing a central role in this public health response.
CDC activated its Emergency Operations Center (EOC) on Thursday, June 13, 2019, to support the inter-agency response to the outbreak in eastern Democratic Republic of the Congo. CDC’s activation of the EOC allows the agency to provide increased operational support for the response to meet the outbreak’s evolving challenges.
There are no cases of Ebola in the United States. At this time, we believe the risk to the United States from the current Ebola outbreak in DRC remains low based on the travel volume and travel patterns from the outbreak area to the United States…
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Disease Outbreak News (DONs}
Ebola virus disease – Democratic Republic of the Congo
18 July 2019
…The outbreak of Ebola virus disease (EVD) in North Kivu and Ituri provinces continued this past week with similar transmission intensity to recent weeks. While the stability of the transmission intensity of the outbreak is an indication of the strong response efforts to limit local transmission in affected health zones, the spread of EVD into new geographical areas and continued insecurity in the affected regions continue to complicate the control of the outbreak.
A salient example of this is the confirmed case of EVD that was reported in Goma, a city of approximately two million inhabitants close to the Rwandan border, on 14 July 2019. The case was a man who travelled to the city from Beni by bus, visiting a local health centre on arrival where the alert was raised. He transferred the same day to the Ebola Treatment Centre (ETC) in Goma, and died while being transferred to the ETC in Butembo. The case’s full travel history is known, and all contacts are being identified and followed-up. Vaccination of his contacts, and contacts of contacts, in Goma commenced on 15 July 2019. The confirmation of a case of EVD in the city of Goma had been long anticipated. Preparation activities, including the vaccination of health workers, intensive training in infection prevention and control, and heightened surveillance have been ongoing for more than six months. Neighbouring Rwanda is also conducting preparedness activities. Rumours of his contacts travelling to Bukavu, South Kivu, have been investigated and ruled out by response teams…
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High-level meeting on the Ebola outbreak in the Democratic Republic of the Congo affirms support for Government-led response and UN system-wide approach
15 July 2019 News release Geneva
Almost a year after the outbreak of Ebola was declared in eastern Democratic Republic of the Congo (DRC) and with the number of new cases at worrying levels, the United Nations hosted a high-level meeting today in Geneva to take stock of the coordinated response and galvanize further support for the government-led effort to defeat the deadly disease…
Statement
Remarks from UNICEF Deputy Executive Director Omar Abdi at the High-Level Event on the Response and Preparedness for the Ebola Outbreak in the Democratic Republic of the Congo
GENEVA, 15 July 2019 – On behalf of everyone at UNICEF, thanks to OCHA and WHO for hosting this important discussion.
Yesterday’s confirmed case in Goma makes clear: we are at a pivotal juncture in the response.
As we discuss the situation and plan next steps, let’s remember to consider the “human” impact of the Ebola outbreak and the devastating toll it has on the lives of children…
Preventing infection among children must therefore be at the heart of the Ebola response.
Ebola also affects children in different ways than adults.
For first responders at the community level — including many of the groups and organizations represented here today — this means adapting our responses to the unique physical, psychological and social needs of children and young people.
For example, children who lose a parent due to Ebola or whose parents are infected by the disease are at risk of being stigmatized, isolated or abandoned, in addition to the heartbreak of losing a loved one. They are doubly affected by Ebola.
And so, together with the Government, WHO, OCHA, Medair, IFRC and many other national and international partners, UNICEF staff members are working around the clock to meet the immediate and longer-term needs of the children and families affected.
UNICEF and our implementing partners have 1,200 staff on the ground, along with nearly 2,000 social mobilizers and psychosocial workers contributing to key areas of the response. This includes infection prevention and control, psychosocial and nutrition support, pediatric care, and support for supplies and logistics.
Also, given our longstanding presence and experience within communities, UNICEF is leading on “community engagement.”
This is an essential component of any outbreak response. The trajectory of this Ebola outbreak hinges on deeply personal decisions taken by individual households and communities with no previous experience of this terrifying disease. To defeat Ebola, they require knowledge, skills and resources.
From the start of the outbreak in North Kivu, it was evident that we would face tremendous challenges in this work with communities. We had to walk a very fine line in order to remain neutral in a very politicized environment, particularly during the high-stakes electoral period. This seriously undermined our ability to engage communities, and there was more than one setback in the response.
We have learned hard lessons about the ways in which people’s perceptions about the disease can be manipulated; and how violence, or fear of violence, can derail the work to prevent and treat Ebola – even in communities that want to work with us.
Once the elections were behind us, we were able to again start working on building a critical mass of community engagement that is now showing results, although this work will always remain vulnerable to the conflict dynamics of the region.
We are working with longstanding national institutions including Initiative for a Cohesive Leadership, and Search for Common Ground, who are working behind doors, bringing together the social and political influencers, community leaders and members of armed groups, that can allow Ebola response teams to work in a safe and trusting environment.
We are scaling up our work with pre-existing, village-level Community Action Committees to identify the concerns and needs of the population, so that we can collectively adapt the response, and address humanitarian needs.
We have listened, and we have learned. We are responding with a lighter footprint. We have adjusted burial practices so that they are both culturally acceptable and medically safe. We are decontaminating sensitive sites at night, to protect affected households from stigma and discrimination. And we will keep listening and learning.
We have seen consistent reactions from the community that underline the need to improve the way the entire Ebola response is being implemented by all actors. They have made very clear that every aspect of the response, from preparedness through to medical treatment and beyond, must ensure a constructive approach to engaging with the community and doing no harm. There are efforts underway to improve how we coordinate with all actors involved in the response to achieve this, which is a key priority to deliver on going forward.
For UNICEF, this means getting communities to understand, accept and ultimately lead a response, that to them, must seem alien and overwhelming. We are there to support them.
To build this acceptance, awareness and action, we work with a broad range of influential political, community and religious leaders, Ebola survivors, and mass media, to bring crucial knowledge on symptoms, prevention and treatment to at-risk households and communities.
UNICEF-supported psychosocial workers are often the first people that a family newly affected by Ebola meets. The role they play in supporting families to make safe decisions related to treatment or burial, is crucial to preventing the spread of infection.
We know that each time that the outbreak moves to a new health zone, the work needs to be started anew. This is why community engagement is now part of preparedness activities in all at-risk areas in DRC and neighboring countries.
Through the new Strategic Response Plan, we’re also working to rehabilitate critical basic services and structures, while strengthening social safety nets and social cohesion. This longer-term, more comprehensive approach is essential in a context like northeast DRC, which was in crisis long before the Ebola outbreak.
Ebola cannot be defeated in isolation. We need to address the full range of long-standing needs among communities that have suffered through decades of conflict and other pressing needs. This approach will contribute towards rebuilding trust.
In Goma this weekend, we’ve seen again that good preparedness is indispensable. In DRC, emergency response efforts must be redoubled. High-risk countries must be equipped and ready to respond quickly to contain the disease as soon as it spills over. It is not a question of ‘if’ but a question of ‘when’. We must be vigilant.
Our work is not done until the last case is successfully treated, and transmission completely stopped.
For this, we need faster isolation of patients, additional vaccines, better infection prevention and control to prevent a rapid, “super-spreader” event from occurring.
This can only be achieved by a well-financed response — one that is grounded in strong community engagement, and well co-ordinated among all partners, without exception.
UNICEF hopes that today’s session is an important moment in gathering the needed support and resources around this critical issue.
Lives are hanging in the balance. And young people like Dieudonné are counting on us to deliver. We must not let them down.
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Press release
Geneva Palais briefing note on the impact of the Ebola outbreak on children in the Democratic Republic of the Congo
This is a summary of what was said by Marixie Mercado, UNICEF spokesperson in Geneva – to whom quoted text may be attributed – at today’s press briefing at the Palais des Nations in Geneva.
GENEVA, 16 July 2019 – I returned from the Democratic Republic of the Congo (DRC) on Sunday. While I was there, I spent 10 days in North Kivu and Ituri, the two provinces affected by Ebola, and spent time in Goma, Beni, Butembo, and Bunia.
I’ll start with the reasons why the Ebola outbreak response needs to focus on children.
This outbreak is infecting more children than previous outbreaks. As of 7 July, there had been 750 infections among children. This represents 31% of total cases, compared with about 20% in previous outbreaks.
Young children – those below five years old, are especially hard hit. Of the 750 cases among children, 40 per cent were among under-fives. They, in turn, are infecting women. Among adults, women comprise 57 per cent of cases. According to the latest data I have, the case fatality ratio for under-fives is 77 per cent, compared with 67 per cent for all age groups.
Preventing infection among children must be at the heart of the overall Ebola response.
Young children are at higher risk than adults – which is why they need specialized attention. But Ebola also affects children very differently from adults, and the response needs to also factor in their very specific psychological and social needs.
Children infected with Ebola need child-specific medical care. Same drugs, but different dosages, but also need zinc to treat diarrhea, as well as treatment against intestinal parasites. Already malnourished children – which is far too common in the DRC – require treatment with food specifically formulated for children.
Children who are separated, often abruptly and brutally, from their parents due to Ebola, need dedicated care and attention while their parents undergo treatment.
Children who are orphaned due to Ebola need longer-term care and support. This includes mediation with extended families that refuse to take them in; health and nutrition support to make sure they stay healthy; and, for those who need it, school fees and other material aid to enable children to go back to school, which is so critical to their overall well-being.
Virtually all of them need help to counter the debilitating effects of the stigma and discrimination that taints children affected by Ebola, so that they are accepted, valued and loved by their families and communities.
Now I’ll move on to what we’ve done in response.
We have dedicated paediatricians working within the Ebola Treatment Centres to provide child-specific medical care. Every child under treatment has a dedicated caregiver who is also an Ebola survivor.
We provided the equipment and supplies to convert one of the treatment “cubes” at the Beni Ebola Treatment Center (ETC) into a delivery room for pregnant mothers, and are procuring similar material for the ETC in Katwa, which also handles similar cases from Butembo.
We have incorporated teams of nutritionists to work alongside the Ebola Treatment Centers to provide individualized, specialist nutritional care for children (and adults) who are suspected or confirmed to have Ebola. This is the first time an Ebola outbreak response has included this kind of care, and there is growing recognition among responders that it plays a vital role in the overall health status of patients.
We have provided every child known to us who has been separated from their parents or orphaned due to Ebola with dedicated care at specially set up childcare facilities located alongside the Ebola Treatment Centres. To soften the trauma of separation, the facilities are staffed with Ebola survivors, who are now immune to the disease, and able to hold children, and bring them to see their parents at the Ebola Treatment Centers.
We work with trusted community-based psychosocial workers to counsel children and families before, during, and after treatment, to explain the process and support them every step of the way.
vaccines and global health :: ethics and policy 