H5N1

Ten steps to Ebola on the Mexican border

Earlier today I saw this tweet in the #Ebola feed:

This is not the first time I've heard the rumour; it's been on and off Twitter for several weeks. It tends to be picked up by people who express support for President Trump and building his wall, and is of course cited as a good reason to finish building the wall. When I asked Mr. Kolfage if his source with the Department of Homeland Security is trustworthy, he replied, "Very, very trusted."

That's insufficient evidence. For Ebola to turn up in northern Mexico as described, a chain of highly unlikely events would have to occur:

1. At least nine persons in North Kivu or Ituri are exposed to Ebola. In the following 21 days, they leave the region and journey to Mexico, perhaps via Kinshasa or Kampala, with connecting flights via one or more European airports.
2. The nine persons travel through several checkpoints, both inside the DR Congo and at numerous air terminals, where travellers' temperatures are taken. (Over 60 million crossings into Uganda, Rwanda, or South Sudan have been so checked; I believe seven of them were considered potential cases but I don't know their test results.)
3. For unknown reasons, these affluent, passport-bearing Congolese then try to enter the US as migrants through the Mexican border at El Paso and Laredo, rather than, say, flying directly to an American destination like Dallas (where the Liberian Thomas Eric Duncan arrived, with both visa and Ebola, in 2014).
4. By now, however, they are definitely running a fever and perhaps showing other symptoms. DHS or ICE personnel at the border order tests and in the meantime detain the nine persons—perhaps in facilities shared with other detainees.
5. Medical tests confirm Ebola, and the nine persons are placed in isolation in a facility able to deal with such cases, like the University of Nebraska Medical Center. It's not at all clear that any hospital in Laredo is equipped or trained for such a case, let alone nine of them.
6. Since it's a notifiable disease, the laboratory would presumably advise the CDC and the Texas Health Department, not to mention the health officials in Tamaulipas state and Mexico City. Such notification would trigger waves of contact tracing as the Congolese travellers' movements since arriving in Mexico would be exhaustively studied.
7. The US border officials (and other migrants) who had contact with these persons would themselves be monitored for 21 days in quarantine along with their families.
8. This response would involve a great deal of publicity. The CDC would expect to be closely consulted, and would of course notify other agencies like the Public Health Agency of Canada, ECDC, and WHO. The US media would go to battle stations, just as they did about Duncan in 2014. Twitter would have far, far more about it than we now see.
9. The Laredo and El Paso public schools would notify their communities that some pupils, the children of potentially infected border personnel, were being monitored in quarantine. The schools would likely be closed for 21 or 42 days.
10. The original case or cases, meanwhile, would die or recover. Even assuming their cases had been identified early and treatment had been good, three of them would likely have died.

Admittedly, this is a very far-fetched scenario. But it's even more unlikely to suppose that nine confirmed Ebola cases, whether in the US or Mexico, could be kept secret and then revealed only by a "very, very trusted" person in the DHS. Such secrecy would entail cooperation from people who are professionally and legally bound to go public with it, all the way from Laredo lab technicians to the head of the CDC.

It's even harder to imagine President Trump keeping such a secret, when he has been warning of threats from south for years. (He also wanted American doctors fighting Ebola in West Africa to be barred from returning home.)

So until we get confirmation from a very, very reliable source like the CDC, we can treat this story with the old Scottish verdict: "not proven." Or simply dismiss it with the old American term: "fake news."

DRC Ebola: 20 new cases, 11 deaths (7 in community)

The Ministry of Health has published EBOLA RDC - Evolution de la riposte contre l'épidémie d'Ebola dans les provinces du Nord Kivu et de l'Ituri au Vendredi 31 mai 2019. May 30 was another grim day, including the death of a vaccinated healthcare worker. At this rate the case count could pass 2,000 by Sunday or Monday. Excerpt from the Google translation:

EVOLUTION OF THE EBOLA EPIDEMIC  IN THE PROVINCES OF NORTH KIVU AND ITURI 

Friday, May 31, 2019  

The epidemiological situation of the Ebola Virus Disease  dated May 30, 2019: 

• Since the beginning of the epidemic, the cumulative number of cases is 1,974, of which 1,880 are confirmed and 94 are probable. In total, there were 1,323 deaths (1,229 confirmed and 94 probable) and 525 people cured. 

• 328 suspected cases under investigation; 

• 20 new confirmed cases, including 7 in Mabalako, 4 in Katwa, 3 in Butembo, 2 in Beni, 2 in Musienene, 1 in Mandima and 1 in Kalunguta; 

• 11 new confirmed case deaths, including  

º 7 community deaths, including 4 in Mabalako, 1 in Butembo, 1 in Musienene and 1 in Mandima; 

º 4 deaths at CTE, including 3 in Butembo and 1 in Beni; 

• 4 new healings from the CTE, 2 in Butembo and 2 in Katwa.

 

/! \  The data presented in this table are subject to change later, after extensive investigations and after redistribution of cases and deaths in their health areas. 

FIGURES OF THE RESPONSE  

127,697 vaccinated  persons   

• 679 people vaccinated on the 30/05/2019. 

• Of those vaccinated, 35,167 are high-risk contacts (CHR), 62,648 are contacts of contacts (CC), and 29,882 are front-line providers (PPL).  

• Persons vaccinated by health zone: 32,889 in Katwa, 25,440 in Beni, 16,676 in Butembo, 10,714 in Mabalako, 6,157 in Mandima, 4,547 in Kalunguta, 3,190 in Goma, 3,048 in Komanda, 2,569 in Oicha, 2,568 in Musienene, 2,195 in Masereka , 2,045 to Vuhovi, 1,998 to Lubero, 1,980 to Kayna, 1,817 to Kyondo, 1,487 to Bunia, 1,040 to Biena, 1,012 to Mutwanga, 690 to Rutshuru, 557 to Rwampara (Ituri), 527 to Nyankunde, 496 to Mangurujipa, 494 to Alimbongo, 420 to Mambasa, 355 to Tchomia, 342 to Kirotshe, 333 to Lolwa, 250 to Mweso, 245 to Kibirizi, 161 to Nyiragongo, 97 to Watsa (Haut-Uélé) and 13 to Kisangani.    

• The only vaccine to be used in this outbreak is the rVSV-ZEBOV vaccine, manufactured by the pharmaceutical group Merck, following approval by the Ethics Committee in its decision of 19 May 2018. 

Health screening checkpoints

62,249,888 people under control 

• 80 entry points (PoE) and operational health checkpoints (PoC).

Infected healthcare workers

109 contaminated health workers 

• One vaccinated Mabalako health worker is one of the new confirmed cases (community deaths). The health worker self-medicated and refused to be transferred to the CTE.  

•The cumulative number of confirmed / probable cases among health workers is 109 (5.5% of all confirmed / probable cases), including 37 deaths.

Butembo: Traditional chiefs ask for public support to eradicate Ebola outbreak in 30 days

This is about all the Ebola news I can find so far today, given the continued lack of access to the Ebola dashboard, the two-week silence of Radio Moto Butembo-Beni, and the general apathy of the DRC media to the whole subject. Via 7sur7.cd: Butembo: Traditional chiefs ask for public support to eradicate Ebola outbreak in 30 days. The Google translation:

Different social groups take the social symposium on Ebola virus disease organized since Thursday, May 30 by the religious denominations of the commercial town of Butembo. 

Even the delegation of the traditional chiefs of the great and small north of the province of North Kivu is present in the room Isse Soma which serves as a framework for this colloquium. 

According to Mwami Stuka of the Batangi group, the traditional chiefs are determined to support the Ebola response teams with rites and sacrifices and to finish in the next 30 days.  

Nevertheless, he says eradication of the epidemic will be possible in the region when the community is willing to collaborate with response teams in the fight against Ebola Virus Disease. 

Remember that this conference is on its second day this Friday, May 31, 2019.  

It is organized by the Catholic churches, the ECC (Church of Christ in Congo) and that of Réveil. 

Nepal: After the first H5N1 bird flu death

Via The Himalayan Times, a well-informed and thoughtful article by Dr. Sher Bahadur Pun: First bird flu death: What next?

On May 3, the Ministry of Health and Population called an unexpected press meet to announce that a 21-year-old male had died of influenza A “H5N1”, popularly known as “bird flu”. This is the first reported case of a human casualty from a bird flu infection in Nepal. 

It would be worth mentioning here that this author had previously examined two other suspected bird flu cases, but they could not be verified by laboratory testing due to its unavailability. The author again met a female patient, with a 7-day history of high-grade fever, cough, shortness of breath, and showing signs of pneumonia in the chest x-ray. According to her, she had disposed of chickens herself after their sudden unexplained deaths. 

These are some recent developments of possible bird flu infections that reinforce one to think “what next?” 

Hong Kong was the first country to report H5N1 bird flu infection in humans in 1997. Since then, it has been known to spread to more than 60 countries. Avian influenza H5N1 virus was first reported in chickens in mid-January 2009 in Nepal, the third nation in South Asia to do so after Pakistan and Bangladesh. 

This incident immediately triggers several questions: What was the source of infection? Does the virus have the ability to spread from birds to humans or even human-to-human? Is chicken meat or egg safe for consumption? 

Interestingly, one of the visitors at our hospital showed fears of bird flu infection after handling live chickens. Some people even began avoiding consumption of chicken or eggs. Indeed, this incident occurred nearly a month ago, and the concerned body has not felt the need to address such panic. It is essential to prepare for a public situation that can trigger such anxiety and panic attacks.  

The screening for H5N1 virus on a regular basis is necessary for farmers, chicken handlers, transporters, chicken sellers, frequent visitors to live bird markets, butchers and veterinarians, especially during bird flu outbreaks. Importantly, healthcare providers are always at increased risk of contracting bird flu infection. 

According to the Epidemiology and Disease Control Division (EDCD), out of 179, 172 (96%) samples have been taken from healthcare providers and sent to Japan to screen for the virus. It shows that healthcare providers are at the highest risk of bird flu infection. Nepal is not capable of confirming the H5N1 virus, which may delay in identifying it.  

A couple of weeks ago, there was a sudden death of a large number of crows due to the H5N1 virus in Kathmandu, something not known previously. At present, it is unclear how this highly pathogenic avian influenza H5N1 virus was introduced in the crow population of Kathmandu. Policy makers usually believe that bird flu infection spreads through transportation of an infected chicken or bird from one place to another. However, many research studies have shown that wild migratory birds are a major source of spreading avian influenza from one place to another or even between regions. There is not much information on wild migratory birds that are potentially spreading bird flu infection in this country.  

In the case of Nepal, the present case is the first H5N1 virus infection in humans, but certainly may not be the last one, meaning a future infection or an outbreak of this deadly virus in humans is possible anytime, anywhere. Those who are in the risk groups must take precautionary measures. Until now, it is believed that the H5N1 virus does not spread from human to human, although the question itself remains debatable. 

It is interesting to mention here that data from the WHO (from 2007 to 2012) showed that most of the H5N1 victims were children less than 5 years old, meaning, there is still a huge knowledge gap about its exact nature of transmission. Influenza A(H1N1)pdm09 virus, popularly known as “swine flu”, now spreads from human to human.

Canada: Changes in life expectancy by selected causes of death, 2017

Via Statistics Canada: Changes in life expectancy by selected causes of death, 2017. Excerpt:

Life expectancy stops increasing in Canada 

Life expectancy at birth did not increase from 2016 to 2017 for either males or females, a first in over four decades. This was largely attributable to the opioid crisis. 

Life expectancy at birth increased on average by 0.2 years per year in Canada from the mid-1990s to 2012. Gains then slowed to a 0.1 year annual increase until 2016. 

On average, women in Canada can expect to live for 84.0 years and men for 79.9 years, if they were to experience the mortality patterns observed in 2017 throughout their lives.

Increases in life expectancy in four provinces are largely offset by a marked decline in British Columbia 

Life expectancy at birth increased in four provinces (Newfoundland and Labrador, Prince Edward Island, Quebec, Saskatchewan) and in Nunavut, while there was no change in life expectancy in Ontario from 2016 to 2017.  

Life expectancy for men increased by 0.3 years to 80.6 in Quebec from 2016 to 2017. As a result, life expectancy for men living in Quebec surpassed that of Ontario men for the first time on record. Life expectancy at birth for men in Prince Edward Island hit a record high of 80 years.  

In contrast, life expectancy at birth in British Columbia fell for the second year in a row, decreasing by 0.3 years for men and by 0.1 years for women from 2016 to 2017. 

Changes in life expectancy at birth in Canada are due to a number of factors. Life expectancy increases when there are fewer deaths in general, or when deaths tend to occur at older ages, or a combination of both. Life expectancy declines when there are more deaths, when deaths occur at younger ages, or a combination of both.  

By examining changes in deaths by age and cause, in 2017, it was possible to identify the main factor that was responsible for the recent change in life expectancy in Canada, and in particular in British Columbia: accidental drug overdoses among young adult men. 

More deaths among younger adult men offset life expectancy gains in older men 

Canadians aged 55 to 89 years died at a slower rate in 2017 than in 2016, indicating that older adults are living longer. In 2017, 65 year old men could expect to live for an additional 19.3 years (to age 84.3), while 65 year old women could expect to live for an additional 22.1 years (to age 87.1). Both figures were up 0.1 years from 2016.  

In contrast, young adults in Canada were dying at a higher rate in 2017 than in 2016. This was especially noticeable among Canadian men aged 20 to 44 years. 

Although older men are living longer, the increase in deaths among young men almost completely offset these gains. A similar pattern occurred among women, although to a lesser extent.

Improved outcomes for cancer and circulatory diseases increase life expectancy 

Among various causes of death, fewer or later deaths due to cancer and circulatory diseases had the most positive effect on life expectancy in Canada. In 2017, fewer or later deaths due to cancer led to a 0.07 year gain in life expectancy for men, and a 0.05 year gain in life expectancy for women. Additionally, fewer or later deaths due to circulatory diseases (such as ischaemic heart disease) led to a 0.06 year gain in life expectancy for both men and women. 

Accidental drug poisoning deaths offset gains in life expectancy in other areas 

While developments in treatments for cancer, circulatory disease and other causes of death led to improvements in life expectancy, these gains were offset by losses in life expectancy from other causes. In particular, the drug overdose crisis occurring in Canada was a major contributing factor in the changes seen in life expectancy from 2016 to 2017, especially for men.  

Death rates due to overdose were 1.6 times higher for women and 2.1 times higher for men in 2017 than they were in 2015. Accidental drug poisoning deaths tend to occur among young adults, and therefore have a greater impact on life expectancy. In 2017, out of 4,108 drug overdose deaths in Canada, 571 occurred among people aged 30 to 34 years old and 525 occurred among people 35 to 39 years old.

Aid community raises highest alert on Ebola

Via The New Humanitarian: Aid community raises highest alert on Ebola. Excerpt:

UN and leading aid groups on Wednesday took the step of formally declaring that the Ebola outbreak in the Democratic Republic of Congo needs a major scale-up from the humanitarian community.  

A spokesperson for the UN’s emergency aid coordination body, OCHA, confirmed the decision of the Inter-Agency Standing Committee, which it chairs. The move can unlock stronger leadership and more funding, but “it’s not a panacea”, according to a top Red Cross official. 

The IASC includes the major UN agencies and international NGOs, and it agreed on Wednesday to activate a range of special measures to respond to the Ebola epidemic in Congo – a move analogous to the former “L3” designation the IASC gave to only the most critical crises. 

The OCHA spokesperson said the “scale-up” activation will “help optimise coordination and response capacity in affected and at-risk areas, strengthen engagement with communities, and bolster preparedness actions.” A World Health Organization spokesperson also confirmed the decision, saying it was “good news”.  

Ten months since the second-largest Ebola outbreak in history was declared, response operations face an uphill battle. The number of cases is approaching 2,000 – with a two thirds death rate – and insecurity is hampering vaccinations and tracing contacts of those infected.  

The virus has so far stayed within Congo’s northeastern provinces of North Kivu and Ituri, but officials have warned that spread to bigger cities and across borders is entirely likely.  

Chronic neglect, political resentments, and underlying ill health have fuelled suspicion towards the response, which has led to direct attacks on health centres, as well as both international and local health workers. After a spike in cases, WHO experts recommended a change in strategy on 7 May that included vaccinating a wider group of at-risk people.

Measures that may be taken under the short-term “Humanitarian System-wide Scale-Up Activation” package include new plans and priorities, funding appeals, and coordination arrangements for an initial three-month period. Under the guidelines, new funding could also be released quickly from the UN-managed Central Emergency Response Fund. 

Emanuele Capobianco, director of health at the International Federation of the Red Cross and Red Crescent Societies (IFRC), said the decision was a “welcome signal politically” and could improve coordination and funding and support shifts in the way the response is carried out. “We need all the attention we can get,” he said in a telephone interview.

Canada: New Brunswick moves to ban non-medical exemptions to school immunizations in wake of measles outbreak

Via The Globe and Mail, a report by The Canadian Press: New Brunswick moves to ban non-medical exemptions to school immunizations in wake of measles outbreak. Excerpt:

Facing a measles outbreak, New Brunswick is moving to ban non-medical exemptions to its school-based immunization program, meaning parents who won’t vaccinate their children for personal-belief or religious reasons would be forced to keep them home.  

If enacted, the ban on non-medical exemptions would give the province the strictest vaccination policies in Canada. Only New Brunswick and Ontario have mandatory school immunization programs and both allow parents to opt out for personal reasons in addition to medical ones. British Columbia plans on introducing a similar program in September. 

New Brunswick Education Minister Dominic Cardy said the province needs to find new ways to improve vaccination rates, given that preventable illnesses such as measles are on the rise. New Brunswick is facing an outbreak of measles that has so far infected 11 people. Most of them were exposed to the virus at a high school near Saint John. Mr. Cardy said just as officials don’t allow weapons in schools, neither should they allow unvaccinated children.  

“When we’re talking about public schools, public safety comes first,” he said in an interview. “[Parents] cannot and do not have the right to send their children to school to endanger others.” 

Mr. Cardy said the focus is on getting the measles outbreak under control, so there is no timeline for when the non-medical exemptions could be phased out. 

With the number of measles cases on the rise worldwide and public-health experts sounding the alarm about parents who refuse or are reluctant to have their children vaccinated, officials are scrambling to find ways to increase confidence in vaccines and boost immunization rates. 

A growing number of jurisdictions are turning to vaccine exemptions as the answer. Medical exemptions are given to children with allergies or health conditions that don’t allow them to be vaccinated. But non-medical exemptions are granted to those who object to vaccination because of their religious beliefs or personal convictions. In some cases, such as in Ontario, non-medical exemptions were created after lobbying by antivaccination advocates.

DRC Ebola: 9 new cases, 10 deaths (5 in community)

The Ministry of Health has published EBOLA DRC - Evolution of the response to the Ebola outbreak in the provinces of North Kivu and Ituri on Thursday, May 30, 2019. Excerpt from the Google translation:

EVOLUTION OF THE EBOLA EPIDEMIC  IN THE PROVINCES OF NORTH KIVU AND ITURI 

Thursday 30 May 2019  

The epidemiological situation of the Ebola Virus Disease  dated May 29, 2019: 

• Since the beginning of the epidemic, the cumulative number of cases is 1,954, 1,860 confirmed and 94 probable. In total, there were 1,312 deaths (1,218 confirmed and 94 probable) and 521 people healed. 

• 342 suspected cases under investigation; 

• 9 new confirmed cases, including 3 in Katwa, 2 in Mabalako, 2 in Beni, 1 in Vuhovi and 1 in Kalunguta; 

• 10 new confirmed deaths, including  

º 5 community deaths, including 1 in Katwa, 1 in Mabalako, 1 in Beni, 1 in Vuhovi and 1 in Kalunguta; 

º 5 deaths at CTE, including 3 in Butembo and 2 in Mabalako;  

• 9 new healings from the CTE, including 6 in Butembo and 3 in Mabalako. 

/! \  The data presented in this table are subject to change later, after extensive investigations and after redistribution of cases and deaths in their health areas.

NEWS   

Operations of the response

Social Symposium against Ebola 

• The religious leaders of Butembo launched Thursday, May 30, 2019, the Social Symposium Against Ebola. This meeting, initiated by the religious leaders, will last two days and will bring together all the resistant layers of the population. The aim of the Symposium is to give the people of Butembo the opportunity to work together to find a lasting solution to get out of the crisis and recreate a bond of trust between the population, local authorities and the agents of the response.    

Ebola Hackathon 

• After a successful first edition in Kinshasa last March, the Ebola hackathon returns for a second edition in Goma. From Thursday, May 30 to Friday, May 31, 2016, 60 young students will work to develop new solutions using new technologies to help fight Ebola while also promoting the right to health. This second hackathon is organized in collaboration with Internews, Kinshasa Digital, Path, the DRC Information Media Association and the French Institute of Goma. 

• As a reminder, the first edition of the Ebola hackathon took place from March 2 to 3, 2019 in Kinshasa. The winning team of this first edition is called Lokole , a name inspired by the traditional drum. Their project was to develop a mobile application that allows community relays and people to share information in real time with the coordination of the Ebola response. Thanks to financial support from the World Bank and technical support from the Ministry of Health, the Lokole team is following an incubation program at Ingenious City where they will develop a prototype of the project which will then be tested with ground.

FIGURES OF THE RESPONSE  

127,018 people vaccinated   

• 453 people vaccinated on 29/05/2019. 

• Of those vaccinated, 34,962 are high-risk contacts (CHR), 62,197 are contacts of contacts (CC), and 29,859 are front-line providers (PPL).  

• Persons vaccinated by health zone: 32,739 in Katwa, 25,323 in Beni, 16,539 in Butembo, 10,584 in Mabalako, 6,111 in Mandima, 4,547 in Kalunguta, 3,170 in Goma, 3,048 in Komanda, 2,569 in Oicha, 2,529 in Musienene, 2,195 in Masereka , 2.005 to Vuhovi, 1.986 to Lubero, 1.980 to Kayna, 1.817 to Kyondo, 1.487 to Bunia, 1.040 to Biena, 1.012 to Mutwanga, 690 to Rutshuru, 557 to Rwampara (Ituri), 527 to Nyankunde, 496 to Mangurujipa, 494 to Alimbongo, 420 to Mambasa, 355 to Tchomia, 342 to Kirotshe, 333 to Lolwa, 250 to Mweso, 245 to Kibirizi, 161 to Nyiragongo, 97 to Watsa (Haut-Uélé) and 13 to Kisangani.   

• The only vaccine to be used in this outbreak is the rVSV-ZEBOV vaccine, manufactured by the pharmaceutical group Merck, following approval by the Ethics Committee in its decision of 19 May 2018.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published Ebola virus disease – Democratic Republic of the Congo: Disease outbreak news, 30 May 2019. This is a long report. Excerpt:

A decline in the number of confirmed Ebola virus disease (EVD) cases has been reported this week (22 to 28 May). Over the past seven days, a total of 73 new confirmed cases were reported compared to the previous where 127 new confirmed cases were reported. This should be interpreted with caution given the complex operating environment and fragility of the security situation. Katwa, one of the epicenters of the outbreak, reported fewer cases this week and other health zones such as Mabalako, Kalunguta and Mandima have also seen a decline in case reporting. 

Active transmission was reported in 14 of the 22 health zones that have been affected to date. Other initial encouraging findings such as a lower proportion of reported nosocomial infections, a lower proportion of community deaths and a higher proportion of registered contacts at case detection have also been reported. Weekly fluctuations in these indicators have been reported in the past and uncertainties remain with regards to the ability of the surveillance system to identify all new cases in areas faced with ongoing insecurity. 

Operations are still regularly hampered by security issues, and the risk of national and regional spread remains very high.  

Mabalako reported 24% (73/309) of the new confirmed cases in the past 21 days. Nine out of the 12 Mabalako health areas have reported new confirmed cases during this period. In the 21 days between 8 to 28 May 2019, 83 health areas within 14 health zones reported new cases, representing 46% of the 180 health areas affected to date (Table 1 and Figure 2). During this period, a total of 309 confirmed cases were reported, the majority of which were from the Mabalako (24%, n=73), Butembo (21%, n=64), Katwa (14%, n=42), Beni (11%, n=34), Kalunguta (10%, n=31), Musienene (7%, n=23) and Mandima (6%, n=20) health zones. 

As of 28 May 2019, a total of 1945 EVD cases, including 1851 confirmed and 94 probable cases, were reported. A total of 1302 deaths were reported (overall case fatality ratio 67%), including 1208 deaths among confirmed cases. Of the 1945 confirmed and probable cases with known age and sex, 58% (1122) were female, and 29% (572) were children aged less than 18 years. The number of healthcare workers affected has risen to 108 (6% of total cases). 

All alerts in affected areas, in other provinces in the Democratic Republic of the Congo, and in neighbouring countries continue to be monitored and investigated. To date, EVD has been ruled out in all alerts outside the outbreak affected areas. On 3 June, a pilgrimage is planned to Namugongo, Uganda to commemorate the death of Catholics and Anglican martyrs. Preparedness activities surrounding the pilgrimage are ongoing. 

EVD Cases in Under Five-Year Olds  

WHO periodically conducts in-depth epidemiological analyses so that data can help reveal any gaps and drive evidence-based response improvements. An in-depth analysis of EVD cases in children under five-years of age demonstrated some noteworthy trends. As of 28 May, children under the age of five accounted for 15% (300/1949) of EVD cases reported, with children under one year of age accounting for 6% (118/1949). Of the 300 cases in children under the age of five, 19 were probable cases (19/94, 20% of all probable cases). 

Data indicate that children under the age of five are being brought into healthcare facilities sooner than cases over the age of five (2.4 days vs. 3.2 days respectively), but most of these cases are not being referred to ETCs, and instead attend multiple local healthcare facilities. These cases visited on average 1.5 healthcare facilities, compared to 1.2 healthcare facilities for cases aged over five-years of age. 

These observations show that in general, parents are willing to seek medical attention for their children at healthcare facilities but are reluctant to bringing their children to ETCs, perhaps out of fear of being far from home and without the support of family members. More work needs to be done to reduce fear and misunderstanding of ETCs and to reduce any other barriers to access, with a special focus on this age group. 

All cases that may not be adequately isolated including children under five-years of age may pose a considerable transmission risk to healthcare workers, patients, and members of the community.

MSF: DRC Ebola outbreak crisis update

MSF.org has published an excellent report: DRC Ebola outbreak crisis update - May 2019 . Excerpt:

Current situation

More than 20 health zones across Ituri and North Kivu provinces have reported cases of Ebola.   

We have new tools and improvements in the medical management of this epidemic, compared to previous Ebola epidemics, such as new developmental treatments; a vaccine that has given indications of being effective; Ebola treatment centres are more open and accessible for the families of patients; and provision of a higher level of supportive care. The outbreak has not spread to other countries or regions, which can be considered as a success.  

However, ten months into the outbreak, the situation in the Ebola-affected areas of DRC is deteriorating and the number of Ebola cases continues to increase: more than 1,900 cases and more than 1,200 confirmed deaths have been reported to date.  

The response has been marked by community mistrust towards the response; attacks on our Ebola Treatment Centres (ETCs) in Katwa and Butembo in February 2019 led us to withdraw from running these centres.  

The mistrust and violent attacks against the Ebola response show no signs of abating. High levels of insecurity continue to hamper the efforts to control the epidemic and have a negative impact on its evolution: the violence further discourages people from seeking care in Ebola treatment centres, resulting in an increased likelihood of the virus spreading across the healthcare system. 

Many people continue to die in the community – either at home or in general healthcare facilities – and significant numbers of new confirmed cases cannot be traced to an existing contact with Ebola. 

The unrest, such as fighting between the army and armed groups in early May and the killing of a WHO doctor in April in Butembo, have brought many outbreak response activities to a standstill. Vaccination of contacts, contacts of contacts and frontline workers in Butembo and Katwa (the epicentre of the outbreak) is sometimes temporarily suspended because of threats to the safety of vaccination teams.

The response to the current outbreak 

The DRC Ministry of Health (MoH) is leading the outbreak response, with support from WHO. The MoH team sent to coordinate the response in Beni was dispatched from Kinshasa and is the same team that coordinated the response in Equateur province. The WHO emergency pool was mobilised in the area upon the declaration of the outbreak. 

We believe it will not be possible to end this outbreak if there is no trust built between the response and the affected people. Response authorities and workers must listen to the needs of communities, restore people’s choice when it comes to managing their health, and involve the community in every aspect of the Ebola response. This includes integrating Ebola care in the overall provision of healthcare in the region. 

In order to respond to people’s needs, earn their trust and improve our early detection of new cases, those responding to the outbreak need to support local health centres through training to identify suspected cases and manage isolation while people are waiting for their Ebola test results.  

MSF RESPONSE 

MSF has been involved in the outbreak response, working with the Ministry of Health, since the declaration of the epidemic on 1 August 2018. 

Since our withdrawal from Katwa and Butembo following the attacks on our ETCs in February 2019, MSF is no longer running ETCs and is currently not providing care to confirmed Ebola patients. 

We continue to undertake prevention and treatment activities of suspect cases, managing Transit Centres for suspected Ebola patients, and supporting health structures. Our activities include helping the healthcare system to provide support in general healthcare (beyond Ebola) such as treating common illnesses and improving water and sanitation, and implementing and strengthening triage and infection prevention and control activities (IPC).  

In addition, our teams are reinforcing health promotion and community engagement in the areas where we are working. We are also working towards strengthening the disease surveillance system in our regular project areas, including in Goma.