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Published Date: 2018-11-24 20:37:44
Subject: PRO/AH/EDR> Ebola update (139): Congo DR (NK, IT) cases, WHO, news, control
Archive Number: 20181124.6163036
EBOLA UPDATE (139): DEMOCRATIC REPUBLIC OF CONGO (NORTH KIVU, ITURI) CASES, WHO, NEWS, CONTROL
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A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

In this update:

[1] Case update
- Epidemiological situation report, 24 Nov 2018, DRC Ministry of Health
- Epidemiological situation report, 23 Nov 2018, DRC Ministry of Health
[2] WHO - Ebola virus disease - Democratic Republic of the Congo disease outbreak news: update
[3] News
- Newborn babies
- Violence
[4] Prevention and control
- Clinical trial approved
- Vaccination of healthcare workers

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[1] Case update
- Sat 24 Nov 2018. Epidemiological situation report, DRC Ministry of Health [in French, machine trans., edited]
https://us13.campaign-archive.com/?u=89e5755d2cca4840b1af93176&id=affd57dff1

The epidemiological situation of the Ebola virus disease in the provinces of North Kivu and Ituri dated 23 Nov 2018:
- Since the beginning of the epidemic, the cumulative number of cases is 403, with 356 confirmed and 47 probable. In total, there were 231 deaths (184 confirmed and 47 probable) and 120 people healed.
- 56 suspected cases are under investigation.
- 4 new confirmed cases: 2 in Katwa, 1 in Kalunguta and 1 in Beni. (The case confirmed in Musienene reported in the bulletin of 23 Nov 2018 was reclassified to Butembo after investigations.)
- 3 new confirmed case deaths, including 2 in Katwa and 1 in Butembo.
- 2 new people healed in Butembo.

News of the response
- On Fri 23 Nov 2018, the sensitizers of Beni, accompanied by 2 local actors, organized a motorized caravan to remind the population of the 5 citizen commitments to protect themselves against Ebola and put an end to the epidemic. The caravan left the administrative office of Butanuka district, before continuing to the small markets of Mabakanga and Kalinda, before stopping at the Ngongolio roundabout. Contests were held at each stop with distribution of rewards for those who answered the questions correctly. Many children and adults participated, and it was the children who won the most gifts.

Vaccination
---------
Since the beginning of vaccination on 8 Aug 2018, 34 839 people have been vaccinated, including 16 832 in Beni [North Kivu] . . .

[Any type of game is a good approach to attract people's attention, especially when awards are offered. - Mod.LK]

- Fri 23 Nov 2018. Epidemiological situation report, DRC Ministry of Health [in French, machine trans., edited]
https://us13.campaign-archive.com/?u=89e5755d2cca4840b1af93176&id=104902cbb9

-The epidemiological situation of the Ebola virus disease in the provinces of North Kivu and Ituri dated 22 Nov 2018:
Since the beginning of the epidemic, the cumulative number of cases is 399, with 352 confirmed and 47 probable. In total, there were 228 deaths (181 confirmed and 47 probable) and 118 people healed.
- 91 suspected cases under investigation.
- 6 new confirmed cases, including 2 in Beni, 2 in Katwa, 1 in Oicha, and 1 in Musienene.
- 6 new confirmed case deaths, including 3 in Beni (including 1 postponed from 22 Nov 2018), 1 in Oicha, 1 in Butembo, and 1 in Musienene.
- 1 new person healed in Beni.

News of the response
- This Fri 23 Nov 2018, the coordination of the response made a short trip to Lubero to participate in a working meeting with the rapid intervention team and arrived in the locality on Wed 21 Nov 2018. Following the increase of cases in the health zone of Butembo and its surroundings, the coordination decided to send additional intervention teams to the areas of Katwa, Kalunguta, and Lubero. The role of the teams in Lubero is to strengthen the epidemiological surveillance in a preventive way and to train local healthcare providers to identify and treat possible cases of Ebola and high-risk contacts from Butembo. Healthcare providers, who accept it, will also be vaccinated.

Vaccination
----------
- Since the start of vaccination on 8 Aug 2018, 34 091 people have been vaccinated, including 16 635 in Beni [North Kivu], 4544 in Mabalako [North Kivu], 4309 in Katwa [North Kivu], 2090 in Butembo [North Kivu], 1751 in Kalunguta [North Kivu], 1663 in Mandima [Ituri], 732 in Masereka [North Kivu], 434 in Bunia [Ituri], 359 in Vuhovi [North Kivu], 355 in Tchomia [Ituri], 292 in Mutwanga [North Kivu], 241 in Kyondo [North Kivu], 240 in Komanda [Ituri], 234 in Musienene [North Kivu], 178 in Oicha [North Kivu], and 34 in Alimbongo [North Kivu].

--
Communicated by:
ProMED-mail Rapporteurs Mary Marshall and Kunihiko Iizuka

[Tweets as submitted by Rap MJM:
- From Helen Branswell‏ (@HelenBranswell) (https://twitter.com/HelenBranswell)
#Ebola thread: +6 cases, +6 deaths today bring the outbreak totals to 399 cases and 288 deaths. The @MinSanteRDC seems not to flag community deaths anymore but I suspect the deaths reported here from Oicha and Musienene may be people who died at home. If so [these equal] transmission events.
- From Helen Branswell: The @MinSanteRDC daily #Ebola update says plans are afoot to step up surveillance and response in areas around Butembo, a large city (about 1 million) south of the outbreak epicenter, Beni. There has been deep concern about Butembo.
- Peter Salama tweeted, as retweeted by Greg Folkers and submitted to ProMED-mail by Rap MJM:
Greg Folkers https://twitter.com/greg_folkers?lang=en Fri 23 Nov 2018
Peter Salama‏ (@PeteSalama): Recent analysis shows in general, people with #Ebola symptoms in #DRC are seeking treatment earlier. Good because - getting treatment early increases chances of surviving Ebola - quicker hospitalization reduces transmission - shows communication work is having a positive impact.
- Mod.LK]

******
[2] WHO - Ebola virus disease - Democratic Republic of the Congo disease outbreak news: update
Date: Thu 22 Nov 2018
Source: WHO disease outbreak news, 22 Nov 2018, Ebola virus, DR Congo [edited]
http://www.who.int/csr/don/22-november-2018-ebola-drc/en/

Containing the ongoing Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo (DRC) is a complex and challenging task, but WHO remains confident that the outbreak can be successfully contained in collaboration with the Ministry of Health (MoH) and partners.

On 16 Nov 2018, an armed group attacked the United Nations Organization Stabilization Mission in the DRC (MONUSCO) base in the Boikene district, in the city of Beni, close to the UN Ebola response residences. Response operations in Beni were briefly paused, but all activities, including vaccination, resumed by [Sun 18 Nov 2018]. WHO condemns the attacks on peacekeepers who are integral to the ongoing efforts to manage the EVD outbreak. WHO will continue to evaluate the situation and risks involved and remain vigilant about measures to protect responders and civilians.

Health centres have been identified as a source of disease transmission. Medications administered via injections were a notable cause of infection.

Current efforts are focused on improving infection prevention and control (IPC) measures, including providing water and products for cleaning, training health providers at informal health centres, and encouraging the provision of medications that do not require injections.

During the reporting period (14-20 Nov 2018), 36 new confirmed EVD cases were reported from Beni, Mutwanga, Kalunguta, Butembo, Katwa, and Oicha, while 7 probable cases were reported from Kalunguta. Seven of the new cases were newborn babies and infants aged less than 2 years; 6 were children aged between 2 and 17 years; and one case was a pregnant woman. Five health workers from Beni and Katwa were among the newly infected; 39 health workers have been infected to date. Ten additional survivors were discharged from Ebola treatment centres (ETCs) in Beni (6) and Butembo (4) and reintegrated into their communities; 113 patients have recovered to date.

As of 20 Nov 2018, 386 EVD cases (339 confirmed and 47 probable), including 219 deaths (172 confirmed and 47 probable), have been reported in 11 health zones in North Kivu province and 3 health zones in Ituri province (Figure 1). The overall trends in weekly case incidence reflect continued community transmission in several cities and villages in North Kivu (Figure 2). Given the expected delays in case detection and ongoing data reconciliation activities, trends, especially in the most recent weeks, must be interpreted cautiously.

The risk of the outbreak spreading to other provinces in the DRC, as well as to neighbouring countries, remains very high. Over the course of the past week, alerts have been reported from Uganda and Zambia; EVD has been ruled out for all alerts to date.

Figure 1: Confirmed and probable Ebola virus disease cases by health zone in North Kivu and Ituri provinces, DRC, data as of 20 Nov 2018 (n=386)

Figure 2: Confirmed and probable Ebola virus disease cases by week of illness onset, data as of 20 Nov 2018 (n=382)* [see updated case numbers in MoH report [1]. - Mod.LK]

* Onset date unknown for 4 cases. 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.

Public health response
-----------
The MoH continues to strengthen response measures, with support from WHO and partners. Priorities include coordinating the response, surveillance, contact tracing, laboratory capacity, IPC, clinical management of patients, vaccination, risk communication and community engagement, psychosocial support, safe and dignified burials (SDB), cross-border surveillance, and preparedness activities in neighbouring provinces and countries. To support the MoH, WHO is working intensively with a wide range of multisectoral and multidisciplinary regional and global partners and stakeholders for EVD response, research and urgent preparedness, including in neighbouring countries.

For detailed information about the public health response actions by WHO and partners, see the latest situation reports published by the WHO regional office for Africa: Ebola situation reports: DRC.

WHO risk assessment
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This outbreak of EVD is affecting northeastern provinces of the country, 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; the internal displacement of populations; and the displacement of Congolese refugees to neighbouring countries. The country is concurrently experiencing other epidemics (e.g., cholera, vaccine-derived poliomyelitis, malaria) and a long-term humanitarian crisis. Additionally, the security situation in North Kivu and Ituri at times limits the implementation of response activities. WHO's risk assessment for the outbreak is currently very high at the national and regional levels; the global risk level remains low. WHO continues to advise against any restriction of travel to, and trade with, the DRC based on currently available information.

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 and trade to the DRC based on the currently available information . . .
For more information, see the following:
- WHO statement on the latest attacks in the DRC;
- 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 DRC;
- WHO interim recommendation for Ebola vaccines;
- WHO recommendations for international travellers related to the Ebola virus disease outbreak in the DRC;
- Ebola virus disease in the DRC: Operational readiness and preparedness in neighbouring countries; and
- Ebola virus disease fact sheet.

The number of cases is subject to change due to ongoing reclassification, retrospective investigation, and the availability of laboratory results.

--
Communicated by:
ProMED-mail from HealthMap Alerts
<promed@promedmail.org>

*****
[3] News
- 23 Nov 2018. Ebola in Congo now infecting newborn babies, UN says
[AP News, edited]
https://apnews.com/7218446381a247118466fa7d03f15fe1

The World Health Organization says a worrying number of the newest Ebola cases amid Congo's ongoing outbreak are in patients not usually known to catch the disease: babies.

In an update published this week [week of 19 Nov 2018], the UN health agency reported 36 new confirmed cases of Ebola, including 7 in newborn babies and infants younger than 2 years old. Six cases were reported in children aged between 2 and 17, and one case was in a pregnant woman.

While Ebola typically infects adults, as they are most likely to be exposed to the lethal virus, children have been known in some instances to catch the disease when they act as caregivers.

Few cases of Ebola in babies have been reported, but experts suspect transmission might happen via breast milk or close contact with infected parents. Ebola is typically spread by infected bodily fluids. WHO noted that health centers have been identified as a source of Ebola transmission, with injections of medications "a notable cause."

The outbreak has been plagued by security problems, with health workers attacked by rebels in districts where the virus has been spreading. Earlier this month, Ebola containment operations were paused after seven UN peacekeepers and 12 Congolese soldiers were killed, but all activities have resumed.

The increasing number of cases in children and health workers -- 39 health workers have been infected to date -- suggests outbreak responders are having major problems stopping the virus in health clinics and convincing people to seek help when they develop symptoms. This is the 1st time this part of Congo has faced an Ebola outbreak.

WHO said the risk of the outbreak spreading to neighboring countries remains "very high," but it does not recommend travel restrictions. Uganda this month [November 2018] started vaccinating health workers against Ebola in a heavily traveled border district near the outbreak.

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[It is not clear how the virus is spreading from infected patient to healthcare worker in the clinics, but it is important to determine what the route of transmission is in order to take the proper measures to stop it. Similarly, it is important to know how newborn babies are becoming infected in order to protect them. As stated, breast milk is a possibility, but equally likely is close contact following birth with an infected mother. - Mod.LK]

- Thu 22 Nov 2018. Ebola in DRC: violence result of battles to control the region and mistrust of health directives
Express [abridged, edited]
https://www.express.co.uk/news/world/1049137/ebola-outbreak-congo-2018-ebola-symptoms-map-who-latest

The Ebola outbreak in the DRC keeps concerning health authorities worldwide as the country's health ministry confirmed 20 more people have been infected by the hemorrhagic fever in the last 48 hours.

[Byline: Alice Scarsi]

Communicated by:
ProMED-mail Rapporteur Mary Marshall

******

[4] Prevention and control
- Sat 24 Nov 2018. Randomized clinical trial protocol for experimental therapeutic Ebola treatments approved by ethics committee
Ministry of Health [edited]
https://us13.campaign-archive.com/?u=89e5755d2cca4840b1af93176&id=e724fba405

The ethics committee approves the randomized clinical trial protocol for experimental therapeutic Ebola treatments
---------------------------

The ethics committee of the School of Public Health of the University of Kinshasa has issued, in its decision ESP / CE / 129/2018, a favorable opinion on the protocol of the randomized clinical trial of the feasibility, safety, and efficacy of experimental treatments for patients with Ebola virus disease (EVD).

Since the beginning of the Ebola outbreak in North Kivu, 4 therapeutic molecules have been used to treat patients in all established Ebola treatment centers (ETCs), namely mAb 114, ZMapp, Remdesivir, and Regeneron.

To date, these 4 therapeutic treatments have been administered to the majority of Ebola patients in the current compassionate epidemic, or, more formally, under the emergency controlled use protocol for unlicensed interventions (MEURI). However, the use of therapeutic treatments under this protocol does not provide for the generalization of scientific evidence collected on the efficacy and safety of each of these treatments. In addition, compassionate use is only permitted when there is no clinical trial in progress.

The joint scientific committee has now agreed on a clinical trial protocol. Valuable information on the effectiveness of the treatments obtained in the clinical trial will help develop these treatments on a larger scale to save more lives.

The clinical trial began this week with 3 of the 4 therapeutic molecules, namely Zmapp, mAb 114, and Remdesivir, only in the CTE of Beni. In the future, the test could be extended to other sites and include the 4th molecule. For the moment, the other CTEs in place will continue to administer therapeutic treatments on a compassionate basis according to the MEURI protocol.

From a practical point of view, the patient (or the patient's family) will have to give their firm and informed consent to participate in the clinical trial and to benefit from a therapeutic treatment, just as it was the case with compassionate use. The major difference is that the choice of treatment administered to the patient will be randomized; that is to say, it will no longer be based on a decision of the CTE doctors, but will be done by lottery to avoid any risk of subjectivity.

Patients may refuse to participate in the clinical trial. They will still receive a level of care equal to the participating patients and will continue to benefit from symptomatic treatments (such as rehydration, blood transfusions, blood pressure monitoring) whose benefits remain significant. Patients participating in the clinical trial will continue to be treated in the CTE; symptomatic treatments will always be administered in addition to therapeutic treatments, and patients will be followed by clinicians until fully recovered.

The number of patients who will participate in the clinical trial during the current outbreak will depend on the evolution of the epidemic and the willingness of patients to participate. Data collected during the North Kivu epidemic alone is unlikely to be sufficient for a complete study and to draw definitive conclusions about the safety and efficacy of these molecules. Thus, the current clinical trial protocol may extend over a 5-year period to cover several EVD outbreaks in several affected countries.

Professor Jean-Jacques Muyembe, director general of the National Institute of Biomedical Research (INRB), and Dr. Richard T. Davey Jr., deputy director of the Division of Clinical Research of the National Institute of Allergy and Infectious Diseases (NIAID), are the 2 principal investigators (PI) of this clinical trial.

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

- Sat 24 Nov 2018. Effect of vaccinating health care workers to control Ebola virus disease: a modelling analysis of outbreak data
[Robert A et al. Biorxiv 2018. doi: https://doi.org/10.1101/113506
https://www.biorxiv.org/content/early/2018/11/23/113506?%3Fcollection=

New Results

Abstract
-----
Background: Healthcare workers (HCW) are at risk of infection during Ebola virus disease outbreaks and therefore may be targeted for vaccination before or during outbreaks. The effect of these strategies depends on the role of HCW in transmission, which is understudied.

Methods: To evaluate the effect of HCW-targeted or community vaccination strategies, we used a transmission model to explore the relative contribution of HCW and the community to transmission. We calibrated the model to data from multiple Ebola outbreaks. We quantified the impact of ahead-of-time HCW-targeted strategies, and reactive HCW and community vaccination.

Results: We found that, for some outbreaks (we call "type 1"), HCW amplified transmission both to other HCW and the community, and in these outbreaks prophylactic vaccination of HCW decreased outbreak size. Reactive vaccination strategies had little effect because type 1 outbreaks ended quickly. However, in outbreaks with longer time courses ("type 2 outbreaks"), reactive community vaccination decreased the number of cases, with or without prophylactic HCW-targeted vaccination. For both outbreak types, we found that ahead-of-time HCW-targeted strategies had an impact at coverage of 30 percent.

Conclusions: The optimal vaccine strategy depends on the dynamics of the outbreak and the impact of other interventions on transmission. Although we will not know the characteristics of a new outbreak, ahead-of-time HCW-targeted vaccination can decrease the total outbreak size, even at low vaccine coverage.

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[The importance of vaccinating HCW cannot be overstated. They are sacrificing themselves to save patients and should be protected. They also contribute to virus transmission in clinics if they become infected. This paper supports the role vaccination of HCW can play in controlling Ebola virus outbreaks. - Mod.LK

Maps of DR Congo: http://goo.gl/DM2AT8 and http://healthmap.org/promed/p/194]

See Also

Ebola update (138): Congo DR (NK, IT) cases, response, vaccine RFI 20181123.6160726
Ebola update (137): Congo DR (NK, IT) cases, summary, response 20181120.6156862
Ebola update (136): Congo DR (NK,IT) cases, response 20181119.6154485
Ebola update (135): Congo DR (NK,IT) cases, security 20181118.6152384
Ebola update (134): Congo DR (NK, IT) cases, challenges 20181117.6150791
Ebola update (133): Congo DR (NK,IT) cases, international 20181116.6149045
Ebola update (132): Congo DR (NK,IT) cases, vaccine, plans 20181115.6146562
Ebola update (131): Congo DR (NK,IT) cases, trial, prospects 20181114.6143952
Ebola update (130): Congo DR (NK, IT) cases, control 20181112.6141091
Ebola update (129): Congo DR (NK, IT) cases, summary, testing 20181110.6137491
Ebola update (128): Congo DR (NK, IT) cases, approach 20181109.6135658
Ebola update (127): Congo DR (NK, IT) cases, summary, Uganda vaccination 20181108.6133491
Ebola update (126): Congo DR (NK, IT) cases, fear, summary 20181107.6130618
Ebola update (125): Congo DR (NK, IT) cases, vaccine, WHO, CDC, response 20181106.6129471
Ebola update (124): Congo DR (NK, IT) cases, summary, response 20181104.6125320
Ebola update (123): Congo DR (NK, IT) cases, summary, maps and graphs 20181103.6124809
Ebola update (122): Congo DR (NK, IT) cases, WHO, vaccines, experimental tx 20181101.6123477
Ebola update (121): Congo DR (NK, IT) cases, children 20181029.6117351
Ebola update (120): Congo DR (NK, IT) cases, WHO, vaccination in pregnancy 20181027.6114985
Ebola update (119): Congo DR (NK, IT) case update, summary 20181025.6110665
Ebola update (118): Congo DR (NK, IT) case update, summaries, response 20181024.6108433
Ebola update (117): Congo DR (NK, IT) case update, summaries 20181023.6106210
Ebola update (116): Congo DR (NK, IT) case update, violence 20181021.6103880
Ebola update (115): Congo DR (NK, IT) case update, summaries, South Sudan 20181020.6102472
Ebola update (114): Congo DR (NK, IT) case update, summaries, WHO, Uganda, cell phones 20181019.6099431
Ebola update (113): Congo DR (NK, IT) case update, PHEIC not declared 20181017.6096315
Ebola update (112): Congo DR (NK, IT) update, community, response, WHO, S Sudan 20181016.6094337
Ebola update (111): Congo DR (NK, IT) case update, security concerns 20181015.6091128
Ebola update (110): Congo DR (NK, IT) case update, hearse 20181013.6089833
Ebola update (109): Congo DR (NK, IT) case update, DNA vaccine 20181013.6088789
Ebola update (108): Congo DR (NK, IT) cases, WHO, new vaccine warehouse 20181011.6084235
Ebola update (107): Congo DR (NK, IT) cases, int'l donations, novel PPE suit 20181009.6079086
Ebola update (106): Congo DR (NK, IT), case update, knowledge attitudes, practices 20181007.6076081
Ebola update (105): Congo DR (NK, IT) cases, WHO, airport 20181005.6072036
Ebola update (104): Congo DR (NK, IT) cases, strife, context 20181004.6069637
Ebola update (103): Congo DR (NK, IT) cases, risk, response, research 20181003.6067199
Ebola update (102): Congo DR (NK, IT) cases, orphans 20181002.6064981
Ebola update (101): Congo DR (NK, IT) cases 20181001.6062627
Ebola update (100): Congo DR (NK, IT) case update, survivors, suspect cases 20180930.6061276
Ebola update (99): Congo DR (NK, IT) case update, risk, preparedness, unrest 20180929.6059771
Ebola update (98): Congo DR (NK, IT) case update, protection, WHO 20180927.6057088
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