4 September 2018

Congo-Kinshasa: Ebola Virus Disease - External Situation Report 5

Photo: Kellie Ryan/IRC
Dr. Sylvie Musema Ngimba washes her hands with chlorine and water at Case Du Salut Medical Center where she is head medical doctor for infection prevention and control at the International Rescue Committee. She has worked to contain five Ebola outbreaks.
document

Date of issue: 4 September 2018
Data as reported by: 2 September 2018

Cases
122
Deaths
82

The 1 September 2018 marks one month since the declaration of the Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces, Democratic Republic of the Congo. The Ministry of Health, WHO and partners have made progress in response to the outbreak during this time. Recent trends (Figure 1) suggest that control measures are working; however, these trends must be interpreted with caution.

Since our last situation report on 28 August 2018 (External situation report 4), an additional 11 new EVD cases (8 confirmed and 3 probable) and seven new deaths have been reported. Nine other suspected cases are currently under investigation to confirm or exclude EVD.

As of 2 September 2018, a total of 122 confirmed and probable EVD cases, including 82 deaths, have been reported. Of the 122 cases, 91 are confirmed and 31 are probable. Of the 82 deaths, 51 occurred in confirmed cases. Of the 113 confirmed and probable cases with known age and sex, females account for 55% (n=62), and the largest proportion (26%, n=29) of cases were aged 35-44 years (Figure 2). A total of 16 health workers (15 confirmed and 1 probable) have been affected, of which one has died. All health workers’ exposures occurred in health facilities outside the dedicated Ebola Treatment Centres (ETCs). As of 1 September 2018, 15 patients were being managed at Mangina ETC (6 confirmed cases and 4 suspected) and in Beni (5 confirmed cases).

The epicentre of the outbreak remains Mabalako Health Zone in North Kivu Province, reporting 70% (86/122) of all cases and 76% (62/82) deaths, including 65 confirmed and 21 probable cases (Figure 3). Additionally, four other health zones in North Kivu Province and one in Ituri Province have reported confirmed and probable cases (Table 1 and Figure 2). Of concern is an apparent increase in transmission in Beni Health Zone, where the number of confirmed and probable cases has increased from eight on 23 August 2018 to 19 cases on 2 September 2018.

Since the beginning of the outbreak, a cumulative total of 4296 contacts have been listed, of which 2512 (58.5%) remain under surveillance as of 2 September 2018. During the past seven days, daily follow-up was completed for 92-97% of these contacts.

The Ministry of Health, WHO and partners are monitoring and investigating alerts 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 as well as in Uganda, Rwanda and the Central African Republic, and, to date, EVD has been ruled out in all these alerts.

Context

North Kivu and Ituri are among the most populated provinces in the Democratic Republic of the Congo, with estimated populations of 6.7 million and 4.3 million, respectively. North Kivu shares borders with Uganda and Rwanda. The provinces have been experiencing intense insecurity and a worsening humanitarian crisis, with over one million internally displaced people and a continuous efflux of refugees to neighbouring countries, including Uganda, Burundi and Tanzania. The Democratic Republic of the Congo is also experiencing multiple disease outbreaks, including three separate outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2) in the provinces of Ituri, Mongola, Maniema and Haut Lomami, Tanganyika and Haut Katanga, and outbreaks of cholera, measles and monkeypox spread across the country.

Current risk assessment

This new outbreak of EVD is affecting north eastern provinces of the Democratic Republic of the Congo, which border Uganda. The ongoing EVD outbreak is not linked to the previous one that occurred in Equateur Province and ended on 24 July 2018. Potential risk factors for transmission of EVD at national and regional levels include the transport links between the affected areas, the rest of the country, and neighbouring countries; the internal displacement of populations; and displacement of Congolese refugees to neighbouring countries and a long-term humanitarian crisis. Additionally, the security situation in North Kivu may hinder the implementation of response activities. Based on this context, the public health risk is considered high at the national and regional levels and low globally. WHO recommends against the application of any travel or trade restrictions in relation to this outbreak.

Strategic approach to the prevention, detection and control of EVD

WHO recommends the implementation of proven strategies for the prevention and control EVD outbreaks. These include (i) strengthening the multi-sectoral coordination of the response; (ii) enhanced surveillance, including active case finding, case investigation, contact tracing and surveillance at Points of Entry (PoE); (iii) strengthening diagnostic capabilities; (iv) case management; (v) infection prevention and control in health facilities and communities, including safe and dignified burials; (vi) risk communication, social mobilization and community engagement; (vii) psychosocial care; (viii) vaccination of risk groups and research; and (ix) operational support and logistics.

2. Actions to date

Coordination of the response

The Prime Minister and the Minister of Health of the Democratic Republic of the Congo visited various points of entry (PoEs) in Goma where health measures to screen travellers are being implemented.

On 17 August 2018, the National Minister of Public Health visited patients admitted to treatment centres in Beni and Mangina, accompanied by a delegation from US Government agencies (CDC Atlanta, USAID, US Embassy in the Democratic Republic of the Congo).

The Provincial Coordination authorities in Mangina have been deployed to Makeke in Mandima Health Zone to resolve the community resistance to contact follow up.

The Ministry of Health, with technical and operations support of WHO and partners, has activated a multi-partner, multi-agency Incident Management System and Emergency Operations Centre to coordinate the response. The main coordination centre is based in Beni while field technical coordination is at Mangina.

The Ministry of Health, WHO and partners have deployed Rapid Response Teams to the affected health zones to implement response activities. As of 3 September 2018, WHO has deployed a total of 193 experts in the various response pillars, of which 156 are based in Beni and Mangina. WHO has activated country, regional and global coordination mechanisms to assess risk and respond to the outbreak accordingly.

Global Outbreak Alert and Response Network (GOARN) partner institutions continue to support the response, as well as urgent readiness and preparedness activities in non-affected provinces of the Democratic Republic of the Congo, and in bordering countries, particularly Rwanda and Uganda.

An incident management team has been established in the Democratic Republic of the Congo and support teams have been reactivated at the WHO Regional Office for Africa and at Headquarters.

The Sub-National Health Cluster Coordinator deployed through the Standby Partner (SBP), NORCAP, in Kananga, has been re-assigned to North Kivu to support EVD response. Efforts are on to backfill all non-Ebola positions through Standby Partner (SBP) deployments. Meanwhile, all SBPs are also keen to support and deploy health professionals for EVD preparedness and response, as may be required.

Surveillance

Surveillance teams continue to enhance active case search, case investigation and contact tracing activities across the affected and neighbouring areas. In-depth reviews are being undertaken of all confirmed and probable cases to elucidate the chains of transmission, and identify risks and potential gaps in response gaps for improving interventions (such as delays in ETC referral of newly identified suspected cases, unsafe burials, etc.).

Systematic monitoring and rapid investigation of all alerts continues in all provinces of the Democratic Republic of the Congo, and in neighbouring countries. This past week between 16–26 alerts per day were investigated in the outbreak affected areas. In addition Burundi, the Central African Republic, Rwanda and Uganda detected, investigated and ruled out EVD in alert and suspected viral haemorrhagic fever cases; a strong sign that surveillance systems are working.

There is continued strengthening of surveillance through training health personnel on EVD and the early warning system, as well as community contact relay training and supervision in Oicha.

As at 2 September, 37 points of entry in Democratic Republic of the Congo are functional for health screening. Since the beginning of the screening, over 2 million travellers have been screened, and 35 alerts were reported, of which seven were validated. Activities to strengthen PoE capacity in neighbouring countries as part of preparedness are on-going in collaboration with partners.

Laboratory

Laboratory testing capacity for Ebola has been established in hospital facilities in Beni, Goma and Mangina to facilitate rapid diagnosis of suspected cases.

From the start of the outbreak to 31 August 2018, a total of 510 samples were tested in three laboratories.

The US CDC and other partners are providing technical assistance and training for laboratory testing for Ebola in neighbouring countries.

Case management

The Ethics Committee in the Democratic Republic of the Congo has approved five experimental therapeutics (ZMapp, Remdesivir, mAb 114, Favipiravir, and REGN3470-3471-3479) to be used under the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI) framework for EBV.

As of 2 September, 23 patients have received mAb 114 (13), Remdesivir (6) or ZMapp (4). Nine of these patients have been discharged.

Bed capacity in the ETC run by MSF in Mangina has increased to 74, while bed capacity in the ETC run by ALIMA in Beni has increased to 13 with the ability to surge to 25.

A 50-bed ETC is being constructed in Ituri Province to be run by International Medical Corps, which is expected to be operational within one week.

A medical evacuation (Medevac) support team from Norway arrived in Goma to provide specialized training on Medevac procedures and handling of equipment using the already existing facilities (EpiShuttles and isolation bubbles) donated by Norway.

Infection prevention and control and water, sanitation and hygiene (IPC and WASH)

The infection prevention and control (IPC) teams have started decontamination of the Nyankunde Hospital Centre and the Victory Clinic in Beni Health Zone.

Red Cross IPC technical team started implementation of support (IPC and triage) to 6 health facilities in Tamende health areas.

Water storage devices have been installed and are being monitored in Beni and Mangina, with the support of PPSSP, CBCA, and SOS Waters and Forests, along with installation and monitoring of chlorination points and hand washing facilities in Beni, Mabalako, Mandima and Mutwanga, with the support of Oxfam, UNICEF, Care International and PPSSP. PPSSP have provided 7425 litres and 4343 litres of water for handwashing in Beni and Goma, respectively.

Red Cross Safe and Dignified burial (SDB) teams are operational in Beni (3), Mangina (4) and Butembo (2). Initial training for SDB teams in Bunia (1) and Mambasa (1) has been conducted. As of 4 September 2018, these teams have responded to a total of 111 SDBs alerts and successfully completed 103 SDB. There is continuing work on strengthening the community engagement approach within the SDB, along with increased efforts to increase community acceptance and support. The SDB sub-commission is meeting daily to strengthen coordination.

WHO, CDC, and other partners are working with the Ministry of Health staff to conduct healthcare facility assessments and training on IPC in neighbouring countries.

Routine water, sanitation and hygiene (WASH) teams are continuing activities in all areas: supplying water for hand hygiene, providing chlorination points, and installing and monitoring the operation of hand hygiene devices.

The International Rescue Committee (IRC) is working on triage, IPC and WASH at 37 health facilities in Mabalako (6), Beni (27), and Oicha (4) health zones, where they have trained 15 staff from 11 partner NGOs on improving IPC.

IRC has initiated IPC and WASH assessments, delivered training, distributed thermometers, chlorine, buckets, sprayers, and personal protective equipment (PPE) at assigned health facilities.

IRC has been assigned to improve IPC and WASH at the Beni General Hospital. This will include building an isolation unit and a proper waste management zone.

Routine activities of the WASH cluster include water supply, installation and monitoring of the operation of hand washing devices (75 in Beni, Mabalako and Oicha) and chlorination points (39 in Mabalako), disinfection of a health facility in Beni and 10 households in Beni and Mabalako, along with briefing of 88 providers on personal protection and distribution of hygiene kits in 81 schools in Beni and Mabalako.

WHO, CDC, and other partners are working with the Ministry of Health staff to conduct healthcare facility assessments and training in infection prevention and control in neighbouring countries.

UNICEF is scaling up in education, health and water, sanitation, and hygiene programmes to assist schools in North Kivu and Ituri provinces to provide a protective learning environment for children and teachers with the reopening of schools on 3 September 2018. UNICEF is developing a WASH REST (Rapid Ebola School Team) strategy with key partners such as Oxfam to prepare for the new school year.

UNICEF provided eight WASH kits to discharged patients from the ETCs, of which five patients received feminine hygiene kits in Mabalako Health Area.

100 WASH kits (1 bucket, 1 water container of 20 litres, 9 bars of soap of 400 grams each, 50 chlorine tablets (Aquatabs), and 1 Ebola pamphlet) are pre-positioned in Mabalako Health Area by UNICEF for Ebola survivors.

All WASH infrastructures (water supply network, latrines, showers and drainage) have been completed in the two sites hosting approximately 250 staff for the Ebola Response. Operations and maintenance of WASH infrastructure has been handed over to WHO.

UNICEF Supply Division and the local warehouse in Beni, continues to provide supplies such as WASH materials (water storage and treatment; hygiene kits; water containers and soap); Personal Protective Equipment; Non-Food Items (tents, bladders, tarpaulins) and 1500 infrared thermometers.

Implementation of ring vaccination protocol

As of 3 September 2018, 38 rings have been defined, in addition to five rings of health workers and other frontline workers. These rings include the contacts and contacts of contacts of the 47 most recently confirmed cases. To date, 6134 participants have been vaccinated, of which 1395 are healthcare workers and front line workers and 1642 are children.

The ring vaccination teams are currently active in two health areas in North Kivu and one in Ituri.

Psychosocial care

During the reporting period, 39 affected families by Ebola virus received psychosocial support and material assistance, including food assistance, in Beni and Mangina; reaching a total of 101 (88% coverage) of the targeted 115 affected families (as of 28 August 2018). Among them, 19 families received direct support, mainly through food assistance, to organize the funerals of family members who died from EVD. Those families are also receiving the continuous psychosocial support available to communities who have been profoundly disrupted by the virus, including material support to families who have had to rebuild their homes following contamination, case management and referrals for medical or psychological assistance.

In addition, 55 contacts families received psychosocial support, reaching a total of 143 (6% coverage) out of the targeted 2400. There are some challenges around information dissemination identified among the different EVD response commissions, particularly those dealing with surveillance and psycosocial support, which explains the difficulty in reaching and assisting families of contacts. The psychosocial commission has set up referral mechanisms to effectively assist EVD-affected families and families of contacts in coordination with the prevention, communication and vaccination commissions.

The psychosocial care commission has transferred the food management of patients and their families to the medical care committee, training nutritionists in biosecurity at the Ebola treatment centres in Mangina and Beni, with the support of UNICEF.

Psychosocial support is being provided to surveillance teams by care and communication teams, during epidemiological investigations and water, sanitation and hygiene (WASH) teams in order to help in situations of community resistance.

Routine psychosocial activities include interviews and individual psychological support, psychological follow up and community reintegration of cured patients and those designated as non-cases, and their caregivers.

An Ebola survivor programme, adapted from that offered in Equateur Province, is being established and mental health and psychosocial supported activities are underway in affected health zones.

Risk communication, social mobilization and community engagement

The Ministry of Health with support from UNICEF, WHO, the Red Cross and other partners are working to scale up risk communication and community engagement work in local leaders and community networks Beni and Butembo.

In Butembo, the risk communication and community engagement teams joined a gathering of over 500 religious leaders over the weekend to brief them on Ebola prevention and control measures. A workshop was this week held with 40 traditional healers to engage them on Ebola prevention and encourage referral of their patients with Ebola-like symptoms to treatment facilities. Meetings are also held with indigenous leaders to urge for their support on Ebola prevention and control.

In Beni, in preparation for the re-opening of schools in the new term on 3 September 2018, activities were held involving teachers and parents on Ebola prevention. To better engage the youth in the Ebola response, a training of 23 youth leaders was held earlier this week, in collaboration with the Scouts Association.

Testimonies of survivors are being broadcasted on radio and by outreach teams to build trust and encourage early care. The 122 people who were tested negative or discharged from health facilities were briefed on their roles to support Ebola awareness and to demystify negative perception around Ebola treatment facilities.

A total of 387 motorcycle transporters were briefed in Beni, Mangina and Mandima health zones on the dangers of transporting patients suspected of suffering from EVD.

The Red Cross has 100 trained volunteers across Beni, Mangina and Oicha, who are supporting community engagement efforts and is refining a rumour tracking system to inform localized community engagement approaches. As of 26 August 2018, Red Cross volunteers have reached over 19 000 people in Beni, Mangina and Oicha with community engagement messages. Further the Red Cross team has trained outreach persons from the PSS commission in Beni, to facilitate better communication on SDB by psychosocial support workers in the communities. In addition, there is training of religious leaders in Beni area to enable increased understanding and acceptance of SDB.

Logistics

A total of five ambulances and the first batch of 34 motorcycles reached Beni city on 17 August 2018.

Resource mobilization

Implementation of and resource mobilization for the joint strategic response plan, approved by the Minister of Health of the Democratic Republic of the Congo, is progressing well, in collaboration with the national authorities and all partners.

Preparedness

In addition to the ongoing response activities within outbreak affected areas, the MoH, WHO and partners will be implementing a 30-day strategic plan to ensure that operational readiness measures against EVD are strengthened in all provinces of the Democratic Republic of the Congo. The first phase of implementation will prioritise six provinces at highest risk of case importations: South Kivu, Maniema, Ituri, Tanganika, Haut Uele and Bas Uele. The main objective is to ensure that these provinces implement essential operational readiness measures, including enhancing surveillance, IPC and social mobilization to mitigate, rapidly detect, investigate and effectively respond to a possible outbreak of EVD.

The WHO Regional Office for Africa has prioritized Burundi, Rwanda, South Sudan and Uganda to enhance operational readiness and preparedness. These countries were prioritised based on their capacity to manage EVD and viral haemorrhagic fever (VHF) outbreaks, and their connections and proximity to the areas currently reporting EVD cases. Extensive preparedness efforts are underway by the respective Ministries of Health, national partners and stakeholders, and global partners.

WHO and partners are deploying Preparedness Support Teams to these countries and other neighbouring countries, as was done during the previous EVD outbreak in Equateur Province.

GOARN partners have provided 56 offers of technical support for preparedness and readiness activities in non-affected provinces of Democratic Republic of the Congo and in neighbouring countries.

The regional office has updated the regional preparedness plan and reprioritized neighbouring countries based on proximity to North Kivu, the current EVD epicentre.

The new prioritizations are as follows: Priority 1: Rwanda, Uganda, South Sudan and Burundi; Priority

2: Angola, Congo, Central African Republic, Tanzania, Zambia;

The regional office has facilitated the deployment of nine experts and is in the process of deploying an additional 15 experts to 10 countries including the Democratic Republic of the Congo for EVD preparedness activities.

Operations partnership

Under the overall leadership of the Ministry of Health, WHO is supporting all major pillars of the EVD response. WHO is working intensively with wide-ranging, multisectoral and multidisciplinary regional and global partners and stakeholders for EVD response, research, and preparedness including:

UN secretariat and sister agencies, OCHA, Inter-Agency Standing Committee (IASC), multiple clusters, and peacekeeping operations;

World Bank and regional development banks;

African Union, and Africa CDC and regional agencies;

GOARN, technical networks, including Emerging and Dangerous Pathogens Laboratory Network (EDPLN), and Emerging Diseases Clinical Assessment and Response Network (EDCARN), operational partners and WHO collaborating centres;

Emergency Medical Team (EMT) initiative;

Standby Partnership.

WHO is engaging GOARN, EMT and regional partners in Africa to deploy experts and multidisciplinary teams for the response, and to support intensive preparedness and readiness activities in the neighbouring and at-risk countries of the Democratic Republic of the Congo.

As of 28 August 2018, 116 offers of support have been received for the EVD response and preparedness missions in the Democratic Republic of the Congo.

The International Federation of Red Cross and Red Crescent Societies (IFRC), UNICEF and CDC have deployed liaisons to WHO headquarters to ensure optimal coordination of activities, as these organizations have extensive presence on the ground, working closely with Ministries of Health.

Red Cross

The Red Cross of the Democratic Republic of the Congo, with the support from IFRC and ICRC, is supporting SDBs and community engagement/risk communication activities. IPC interventions to support non-ETC health facilities has also started in one Health area in Beni

Red Cross SDB teams are operational in Beni (3), Mangina (4) and Butembo (2). Initial training for SDB teams in Bunia (1) and Mambasa (1) has been conducted. As of 4 September 2018 teams have responded to total of 111 SDB alerts.

The Red Cross has trained total of 100 community volunteers to conduct risk communication/ community engagement activities in Beni, Mangina and Oicha. Training of additional volunteers in Butembo is underway. A rumour tracking/community feedback system was established as of 18 August 2018.

As of 4 September 2018, Red Cross volunteers have reached over 19 000 people in the above mentioned health areas.

An IPC technical team has started implementing support to Tamende health area in Beni

IRC

IRC has a team of 18 staff on the ground, with ongoing recruitment of an additional 30 local clinical and support staff. IRC’s first action was to support the safe resumption of services in nine of 61 high-risk primary health centres (PHCS) that IRC already supports in North Kivu.

With support from MSF, a triage area has been constructed in the health facility in Mabalako Health Zone where a healthcare worker was confirmed positive for EVD last week. A facility decontamination was also conducted.

IOM

A population Mobility Mapping exercise in Beni was completed by 31 August 2018 and the final map was shared with WHO and partners.

IOM, working with partners, conducted training and supervision of PoE surveillance activities, including health screening, risk communication, prevention methods such as hand washing, and health seeking behaviour, as well as setting up screening points at key POEs. So far, 59 PoE supervisors have been trained.

IOM supported the Congolese Ministry of Health in the deployment of 10 PNHF (Programme national d’hygiène aux frontiers; a national border health programme) supervisors from Kinshasa to key PoEs in Beni, Goma, Mangina, Butembo and Kasindi.

CDC Atlanta

o As part of the overall strategic response plan for points of entry (PoE), Goma PoEs were mapped, with support of CDC Atlanta.

IHR travel measures and cross border health

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.

As investigations continue to establish the full extent of this outbreak, it is important for neighbouring provinces and countries to enhance surveillance and preparedness activities1.

3. Conclusion

The EVD outbreak in the Democratic Republic of the Congo has been ongoing for one month since its declaration and a lot of progress has been made to limit the spread of the disease to new areas. The number of new confirmed EVD cases and new deaths recorded during the reporting week declined significantly, compared to the last weeks. The situation in Mangina, the epi-centre of the outbreak, is stabilizing, while Beni has become the new hotspot.

While these gains have been made, there are still significant threats for further spread of the disease, including potential undocumented chains of transmission, reluctance by some communities to adopt public health prevention measures, weak infection prevention and control practices in healthcare facilities, risk of the virus spreading into an insecure area, and insecurity hindering response activities. The coming few days will be critical in determining the trajectory of the outbreak. The priority remains strengthening all components of the response as well as enhancing preparedness in the non-affected provinces of the Democratic Republic of the Congo and in the neighbouring countries.

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