CIDRAP

“The cases bring the outbreak’s total to 980 cases, including 606 deaths.

The new cases have brought to an end the downward trend mentioned last week in a press conference held by World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus, PhD. In mid-March, DRC officials were seeing 25 cases per week, half the number of cases seen in mid-January. 

But in the past 5 days, the DRC has recorded 44 cases and several community deaths, which increase the probability of the virus spreading among family members and close contacts……”

WHO

Plague: Uganda
2 Cases
1 Death:  50% CFR

Ebola virus disease: Democratic Republic of the Congo
921 Cases
582 Deaths:  63% CFR

Hepatitis E: Namibia
4 669 Cases
41 Deaths: 0.9% CFR

Lassa fever: Nigeria
420 Cases
93  Deaths: CFR 22.1%

NIH

“…….survivors reported certain symptoms at significantly higher rates than controls, and in both groups, adults reported more symptoms than children and adolescents. Survivors reported higher rates of: urinary frequency (14.7 percent vs. 3.4 percent), headache (47.6 percent vs. 35.6 percent), fatigue (18.4 percent vs. 6.3 percent), muscle pain (23.1 percent vs. 10.1 percent), memory loss (29.2 percent vs. 4.8 percent), and joint pain (47.5 percent vs. 17.5 percent).

Evaluations by healthcare professionals showed significantly more survivors than controls had abnormal findings on abdominal (10.4 percent vs. 6.4 percent), chest (4.2 percent vs. 2 percent), and neurologic (4.5 percent vs. 1.5 percent) examinations. With regards to abnormal musculoskeletal findings on examination, only muscle tenderness was observed significantly more frequently in survivors than controls (4.5 percent vs. 0.9 percent, respectively). Other musculoskeletal findings, such as joint swelling and decreased range of motion were not observed at a significantly higher frequency in survivors compared with controls. The prevalence of health issues declined in both groups over the one-year follow-up period…….”

MSF

“……The Ebola response must take a new turn. Choices must be given back to patients and their families on how to manage the disease. Vaccination for Ebola must reach more people, and more vaccines are needed for this. Other dire health needs of communities should be addressed. And coercion must not be used as a tactic to track and treat patients, enforce safe burials or decontaminate homes...…”

• Depuis le début de l’épidémie, le cumul des cas est de 913, dont 848 confirmés et 65 probables. Au total, il y a eu 574 décès (509 confirmés et 65 probables) et 306 personnes guéries.

NEJM

“…….Results

A total of 966 EBOV antibody–positive survivors and 2350 antibody-negative close contacts (controls) were enrolled, and 90% of these participants were followed for 12 months. At enrollment (median time to baseline visit, 358 days after symptom onset), six symptoms were reported significantly more often among survivors than among controls: urinary frequency (14.7% vs. 3.4%), headache (47.6% vs. 35.6%), fatigue (18.4% vs. 6.3%), muscle pain (23.1% vs. 10.1%), memory loss (29.2% vs. 4.8%), and joint pain (47.5% vs. 17.5%). On examination, more survivors than controls had abnormal abdominal, chest, neurologic, and musculoskeletal findings and uveitis. Other than uveitis (prevalence at enrollment, 26.4% vs. 12.1%; at year 1, 33.3% vs. 15.4%), the prevalence of these conditions declined during follow-up in both groups. The incidence of most symptoms, neurologic findings, and uveitis was greater among survivors than among controls. EBOV RNA was detected in semen samples from 30% of the survivors tested, with a maximum time from illness to detection of 40 months…….”

March 7, 2019
N Engl J Med 2019; 380:924-934
DOI: 10.1056/NEJMoa1805435

WHO

Ebola virus disease – Democratic Republic of the Congo

Despite slightly fewer cases reported during the past week (Figure 1), current epidemiological indicators highlight that the Ebola virus disease (EVD) outbreak is continuing with moderate intensity. Katwa and Butembo remain the major health zones of concern, while simultaneously, small clusters continue to occur in various geographically dispersed regions. During the last 21 days (23 January – 12 February 2019), 97 new cases have been reported from 13 health zones (Figure 2), including: Katwa (59), Butembo (12), Beni (7), Kyondo (4), Oicha (4), Vuhovi (3), Biena (2), Kalunguta (2), Komanda (1), Manguredjipa (1), Mabalako (1), Masereka (1), and Mutwanga (1).¹ The recent case reported in the Komanda health zone was a resident of Katwa who was exposed to the virus, and subsequently travelled to both Bunia and Komanda. This case comes one month after the last reported case in Ituri Province; underscoring the high risks of reintroduction to previously affected areas, as well as the potential for spread to new ones.

As of 12 February, 823 EVD cases² (762 confirmed and 61 probable) have been reported, including 517 deaths (overall case fatality ratio: 63%). Cumulatively, cases have been reported from 118 of 287 health areas across 18 health zones, of which 37 health areas have reported a case in the last 21 days. Thus far, 283 people have been discharged from Ebola Treatment Centers (ETCs) and enrolled in a dedicated monitoring and support programme. One new health worker infection was reported in Katwa. To date, a total of 68 health workers have been infected.

Main challenges this past week primarily pertain to community mistrust, particularly in Katwa, and the difficulty in encouraging community members to be more proactive in reporting suspected cases, presenting early to ETCs for treatment, and participating in community-based prevention and response efforts. However, in the face of these protracted challenges, response strategies have demonstrated to be effective in curtailing the spread of EVD. Fostering greater community trust by strengthening engagement with its members remains a top priority for response teams.

On 13 February, the Ministry of Health (MoH) launched the Strategic Response Plan 3 (SRP 3). The plan lays out the response strategy, objectives and budget requirements for the MoH, WHO, and all implementing partners for the next six months (February through July 2019). SRP 3 takes into account recommendations from operational reviews, and builds on a series of new strategic directions that capitalize on lessons learned under the scope of SRP 2. Activities laid out aim to stop the transmission of EVD in North Kivu and Ituri provinces, and prevent its spread to other provinces and neighbouring countries.

WHO remains confident that this outbreak can be successfully brought to an end through strategies outlined in SRP 3. To achieve the goals set out by the plan, MoH, WHO, and partners are appealing for US$ 148 million. WHO and partners count on the continued support of the international community to provide the required funding in order to stop this outbreak.

Figure 1: Confirmed and probable Ebola virus disease cases by week of illness onset, data as of 12 February 2019 (n=822)

Figure 2: Confirmed and probable Ebola virus disease cases reported between 22 January and 11 February by place of residence, North Kivu and Ituri provinces, Democratic Republic of the Congo (n=101)*

*Map based on the latest available detailed line lists (data as of 11 February 2019), and excludes cases reported after this date, as well as cases with delayed/missing village or health area details. Categorization of cases by health zone may differ from the reported place of residence.

Public health response

For further information about the public health response actions by the MoH, WHO, and partners, please refer to the latest situation reports published by the WHO Regional Office for Africa:

WHO risk assessment

WHO continuously monitors changes to the epidemiological situation and context of the outbreak to ensure that support to the response is adapted to the evolving circumstances. The last review conducted on 7 February 2019, outlines the high risk the EVD outbreak poses at the national and regional levels, though global risk levels remain low. This EVD outbreak is affecting primarily the north-eastern provinces of the Democratic Republic of the Congo bordering Uganda, Rwanda, and South Sudan. There is a potential risk for transmission of EVD at the national and regional levels due to extensive travel between the affected areas, the rest of the country, and neighbouring countries for economic and personal reasons, as well as due to insecurity. The country is concurrently experiencing other epidemics (e.g. cholera, vaccine-derived poliomyelitis, malaria), and a long-term humanitarian crisis. Additionally, the fragile security situation in North Kivu and Ituri, further limits the implementation of response activities.

As the risk of national and regional spread is very high, it is important for neighbouring provinces and countries to enhance surveillance and preparedness activities. The International Health Regulations (IHR 2005) Emergency Committee has advised that failing to intensify these preparedness and surveillance activities would lead to worsening conditions and further spread. WHO will continue to work with neighbouring countries and partners to ensure that health authorities are alerted and are operationally prepared to respond.

WHO advice

International traffic: WHO advises against any restriction of travel to, and trade with, the Democratic Republic of the Congo based on the currently available information. There is currently no licensed vaccine to protect people from the Ebola virus. Therefore, any requirements for certificates of Ebola vaccination are not a reasonable basis for restricting movement across borders or the issuance of visas for passengers leaving the Democratic Republic of the Congo. 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. Travellers should seek medical advice before travel and should practice good hygiene.

For more information, see:

• South Sudan vaccinates health workers against Ebola
• Ebola – Following a Full Simulation Exercise, a Joint Monitoring Mission is deployed in Rwanda
• Summary report for the SAGE meeting of October 2018
• Statement on the October 2018 meeting of the IHR Emergency Committee on the Ebola virus disease outbreak in the Democratic Republic of the Congo
• WHO Interim recommendation Ebola vaccines
• WHO recommendations for international travellers related to the Ebola Virus Disease outbreak in the Democratic Republic of the Congo
• Ebola virus disease in the Democratic Republic of the Congo – Operational readiness and preparedness in neighbouring countries
• Ebola virus disease fact sheet

---

¹ Excludes newly probable cases from Katwa (7) and Komanda (5), who died in November and December 2018 and were reported during the period of 21 January to 10 February following a retrospective re-classification of cases.

² Data in recent weeks are subject to delays in case confirmation and reporting, as well as ongoing data cleaning – trends during this period should be interpreted cautiously.

DRC

Lancet

“…..Faced with an evolving complex humanitarian crisis, and recent elections complete, WHO Director-General Tedros Adhanom Ghebreyesus should reconvene the Emergency Committee (EC) and consider declaring a Public Health Emergency of International Concern (PHEIC)……..”

WHO

Yambio, 28 January 2019 – The Ministry of Health of South Sudan, with support from the World Health Organization (WHO), Gavi, the Vaccine Alliance, UNICEF and the US Centers for Disease Control and Prevention (CDC) and other partners, today started vaccinating health workers and other front-line responders against Ebola as part of preparedness measures to fight the spread of the disease.

Vaccination began in Yambio, Gbudue State, but health workers in Tombura, Yei and Nimule as well as the capital city, Juba, will also be offered the vaccine. These are high-risk areas bordering the Democratic Republic of the Congo (DRC), now experiencing its tenth outbreak of Ebola. The outbreak began 1 August 2018. Neighbouring countries have not reported any cases of Ebola, but preparedness is crucial.

As part of these preparedness activities, South Sudan received 2 160 doses of the Ebola vaccine (rVSV-ZEBOV) from Merck, the vaccine developer. The vaccine offers protection against the Zaire strain of the virus, which is the one affecting DRC at present.

“It is absolutely vital that we are prepared for any potential case of Ebola spreading beyond the Democratic Republic of the Congo,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “WHO is investing a huge amount of resources into preventing Ebola from spreading outside DRC and helping governments ramp up their readiness to respond should any country have a positive case of Ebola.”

Vaccination is one of a raft of preparedness measures South Sudan is putting into place. WHO has deployed more than 30 staff members to support these activities.

In particular, WHO has helped train 60 health workers in good clinical practice principles and protocol procedures to administer the yet-to-be-licensed Ebola vaccine. To detect any travellers entering the country who may be infected with the virus, the Ministry of Health, with the support of its partners, has established 17 screening points. Nearly 1 million people have been screened to date.

WHO is also supporting engagement with communities, active surveillance for the disease at the community and health facility levels, strengthening capacity for infection prevention and control and case management, and supporting dissemination of Ebola information through the media. Local laboratory capacity to test samples taken from people suspected of having Ebola is also being strengthened. Protective gear for responders has been stockpiled in a dedicated warehouse.

Gavi, the Vaccine Alliance, in addition to its work making the Ebola vaccine stockpile available, is providing US$2 million to support the WHO’s vaccination efforts in countries neighbouring the DRC, including South Sudan.

“Although research is ongoing, the evidence so far suggests the Ebola vaccine is a highly effective tool to help stop epidemics and can be used to prevent this national outbreak from becoming a regional one,” said Dr Seth Berkley, CEO of Gavi. “Vaccinating front-line workers and health workers in South Sudan border regions will be crucial: an outbreak in South Sudan would be deeply concerning.”

Uganda began vaccinating its front-line workers in November 2018. So far, more than 2 600 health workers in eight high-risk districts have been immunized. In DRC, more than 66 000 people have been vaccinated – more than 21,000 of them are health and other front-line workers. Rwanda also plans to vaccinate its front-line responders.

The yet-to-be-licensed rVSV-ZEBOV vaccine has been shown to be highly protective against the Zaire strain of the Ebola virus in a major trial. Though not yet commercially licensed, the vaccine is being provided under what is known as “compassionate use” in the ongoing Ebola outbreak in North Kivu province of DRC as part of recommendations from the Strategic Advisory Group of Experts on Immunization. This vaccine was also used in the Ebola outbreak in Equateur province of DRC in May–July 2018.

DRC