H5N1

WHO AFRO: Ebola update, November 19

Thanks to Helen Branswell for tweeting about the latest Weekly Bulletin from WHO AFRO. (You should follow her for her excellent daily interpretation of the Ebola numbers and events.) Here's an excerpt from the Bulletin, with my bolding, and then a comment:

The Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces, Democratic Republic of the Congo continues to be closely monitored. Since our last report on 9 November 2018 (Weekly Bulletin 45), 37 new confirmed EVD cases have been reported and nine new deaths have occurred.

As of 17 November 2018, there have been a total of 366 EVD cases, including 319 confirmed and 47 probable cases. To date, confirmed cases have been reported from 14 health zones: Beni (163), Mabalako (67), Kalunguta (25), Katwa (20), Butembo (10), Masereka (6), Kyondo (2), Musienene (2), Oicha (2), Vuhovi (2), and Mutwanga (1) in North Kivu Province; and Mandima (16), Tchomia (2) and Komanda (1) in Ituri Province. A total of 214 deaths were recorded, including 167 among confirmed cases, resulting in a case fatality ratio among confirmed cases of 52% (167/319). A total of 39 health workers have been infected to date, including 11 deaths.

On 17 November 2018, 49 new suspected patients were hospitalized, bringing the total number of patients admitted to 124, including 35 confirmed cases. As of 17 November 2018, the number of patients cured and discharged back into the community is 107. Bed occupancy in Beni Ebola Treatment Centre (ETC) is 100%.

Beni, Kalunguta and Katwa remain the principal hotspots of the outbreak with, respectively, 46% (n=45), 31% (n=30) and 11% (n=11) of the 97 confirmed and probable cases reported in the past 21 days (from 28 October to 17 November 2018).

Contact tracing is still of concern due to insecurity and persistent community resistance. Of the 4 430 contacts listed for followed up, 4 182 (94%) were seen on 17 November 2018. The proportion of contacts seen in the previous 24 hours varies from 80% to 100%.

Branswell points out that the HCW cases last week numbered 30, with just three fatalities; she suspects the new cases are traditional healers, who are often the first consulted. This is a very worrying development.

Antimicrobials in acute and long-term care

An editorial in Eurosurveillance: Antimicrobials in acute and long-term care: a point in time along the way to improved use. Excerpt:

Antimicrobial use is the most important modifiable factor contributing to resistance. One key strategy against antimicrobial resistance that has the potential to improve patient outcomes is to optimise antimicrobial use. Understanding how antimicrobials are being used informs stewardship efforts in acute care, long-term care and outpatient settings. 

In the acute care setting, stewardship programs encompass tracking and reporting aggregate antimicrobial use metrics, such as days of therapy or defined daily doses. Benchmarking use within and across facilities is helpful in identifying where action is needed. Antimicrobial use point prevalence surveys (PPS) complement the aggregate metrics by providing information on patient-level use, such as indication and site of infection during the specified time period. 

This approach is able to reveal more targeted quality improvements and enables comparisons of antimicrobial use at the national, regional or local level. PPS may be particularly useful for resource-limited hospitals and long-term care facilities (LTCF) with restricted capabilities for capturing use data on a continual basis. Since PPS evaluate antimicrobial use during a single time period, they need to be repeated at regular intervals to monitor trends over time. 

On the occasion of the European Antibiotic Awareness Day on 18 November, this issue of Eurosurveillance is dedicated to several studies presenting results from European PPS based on the European Centre for Disease Prevention and Control (ECDC) healthcare-associated infections (HAI) and antimicrobial use protocol for acute care hospitals and the HAI and antimicrobial use protocol for LTCF.

WHO AFRO Ebola update, week 45

WHO AFRO has published its Weekly Bulletin on Outbreaks and Other Emergencies for week 45. Excerpt:

The Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces, Democratic Republic of the Congo continues to evolve. Since our last report on 2 November 2018 (Weekly Bulletin 44), 31 new confirmed EVD cases and 19 new deaths have occurred. Three new health zones have reported confirmed EVD cases during the reporting week: Mutwanga Health Zone close to Uganda border confirmed one new case on 7 November 2018 while Kyondo Health Zone close to Butembo reported one confirmed case on 8 November 2018. Musienene Health Zone (which had a probable case previously) reported a confirmed EVD case on 9 November 2018.

Insecurity persists, with an attack on a safe and dignified burial team by Mai-Mai at Mutembo village, on the road between Beni and Butembo.

As of 10 November 2018, there have been a total of 329 EVD cases, including 294 confirmed and 35 probable cases. To date, confirmed cases have been reported from 14 health zones: Beni (153), Mabalako (73), Butembo (34), Kalunguta (9), Masereka (4), Vuhovi (3), Oicha (2), Kyondo (2), Komanda (1), Musienene (1) and Mutwanga (1) in North Kivu Province; and Mandima (9) and Tchomia (2) in Ituri Province.

A total of 205 deaths were recorded, including 170 among confirmed cases, resulting in a case fatality ratio among confirmed cases of 57% (170/294). Two new health workers were affected on 9 November 2018, bringing the total number of health workers affected to 30, including 29 confirmed, and three deaths.

On 10 November 2018, 28 new patients were hospitalized, bringing the total number of patients admitted to 97, including 37 confirmed cases.

As of 9 November 2018, the number of patients cured and discharged back into the community is 98.

Beni and Butembo remain the main hot spots of the epidemic, reporting 65% and 20% of the 99 confirmed cases reported in the last 21 days, respectively. Contact tracing is still of concern due to insecurity and persistent community resistance. On 10 November 2018, the proportion of contacts followed was 94% (4476/4779), with the proportion varying between 90% and 100%.

DR Congo: Ebola virus disease - External Situation Report 15

WHO AFRO has published Democratic Republic of Congo: Ebola Virus Disease - External Situation Report 15. The situation update:

Ministry of Health (MoH), WHO and partners continue to respond to the Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo, and remain confident that the outbreak can be contained, despite ongoing challenges. Over the past week (reporting data from 5 to 11 November), we observed the continuation of the outbreak in several areas of North Kivu Province, as well as geographical expansion to new areas, including Kyondo (30 km south-east of Butembo) and Mutwanga (50 km south-east of Beni). The initial cases in these areas were exposed through contact with cases in Butembo and Beni, respectively.

During this period, 31 new confirmed cases were reported, among which there were seven newborn babies and infants aged <2 years, three children aged 2-17 years, three women who were pregnant or breastfeeding, and three health workers.  

Furthermore, this week, a review and reconciliation of case records resulted in the addition of 14 probable cases, invalidation of 11 historic deaths previously reported as probable cases, and exclusion of duplicate case counts. Moreover, some confirmed and probable cases were recategorized to health zones where their infection most likely occurred (as opposed to location of Ebola treatment centres (ETCs) where they were admitted) (Table 1). 

Overall trends in the outbreak (Figure 1) reflect the continuation of transmission in several cities and villages in North Kivu. Given the persisting delays in case detection and the ongoing data reconciliation activities, trends in weekly incidence (especially in the most recent weeks) must be interpreted cautiously.  

As of 11 November 2018, a total of 333 EVD cases, including 295 confirmed and 38 probable cases (Table 1), have been reported from 14 health zones in the two neighbouring provinces of North Kivu and Ituri (Figure 2).  

Of the total 333 cases, 209 died, including 171 among confirmed cases, and 101 recovered. As of 11 November 2018, 77 patients (confirmed and suspected cases) were hospitalized in ETCs. Females account for 62% of confirmed and probable cases. A total of 30 health workers have been infected to date, including three deaths. 

The Ministry of Health (MoH), WHO and partners continue to monitor and investigate all alerts in affected areas, 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 and South Soudan. To date, EVD has been ruled out in all alerts from neighbouring provinces and countries. 

WHO in collaboration with regional and global partners have deployed over 110 experts in the nine neighbouring countries (Angola, Burundi, Central Africa Republic, Republic of Congo, Rwanda, South Sudan, Tanzania, Uganda and Zambia) and in non-affected provinces in the Democratic Republic of the Congo to support EVD preparedness activities. Four of the nine neighbouring countries have been sensitized on EVD vaccination. Uganda received the approval for EVD vaccination of health and frontline workers and initiated vaccination on 7 November 2018. Preparation for vaccination of frontline health workers is ongoing in Rwanda and South Sudan.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published Ebola virus disease – Democratic Republic of the Congo. Excerpt:

As the Ebola virus disease (EVD) outbreak enters the fourth month since declaration, and case numbers surpass 300, substantial progress has been achieved in all aspects of the response. Nevertheless, there remains a challenging road ahead to control intense transmission in the city of Beni and emerging hotspots in villages around Beni and Butembo. 

Security incidents and pockets of community resistance continue to impact civilians and frontline workers, requiring the response to continually adapt to the situation. The UN is committed to staying and supporting the Ministry of Health (MoH), and confident that the outbreak can be contained. This week, the WHO Director-General, UN Under-Secretary-General for peacekeeping, and WHO Deputy Director-General (DDG) Emergency Preparedness and Response travelled to the Democratic Republic of the Congo to review how further support can be offered to strengthen the response.  

Over the past week (31 October – 6 November), 29 new confirmed EVD cases were reported: 15 from Beni, seven from Butembo, four from Kalunguta, two from Mabalako, and one from Vuhovi. The two cases reported in Mabalako were a mother and her new-born child, residing and infected in Beni, but sought treatment at the Mabalako Ebola treatment centre (ETC). Three health workers from health posts in Beni and Kalunguta were among the newly infected; 28 health workers have been infected to date. Ten additional survivors were discharged from the Beni ETC and reintegrated into their communities; 88 patients have recovered to date.  

As of 6 November, 308 EVD cases (273 confirmed and 35 probable), including 189 deaths (154 confirmed and 35 probable), have been reported in eight health zones in North Kivu Province and three health zones in Ituri Province (Figure 1). While fewer cases were reported from Beni this week, new cases continue to be detected daily here and elsewhere, and delays in case detection persist; therefore, trends in weekly incidence must be interpreted cautiously (Figure 2).  

The risk of the outbreak spreading to other provinces in the Democratic Republic of the Congo, as well as to neighbouring countries, remains very high. Over the course of the past week, alerts have been reported from the South Sudan, Uganda and Yemen; EVD has been ruled out for all alerts to date. Uganda (geographically closest to outbreak affected areas), continues to intensify preparedness activities, and this week began to vaccinate health and frontline workers at priority health facilities.

Democratic Republic of Congo: Ebola virus disease - External Situation Report 14

Via ReliefWeb, a WHO report: Democratic Republic of Congo: Ebola Virus Disease - External Situation Report 14. The situation update:

The Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces, Democratic Republic of the Congo continues to be closely monitored by the Ministry of Health (MoH), WHO and partners. Since WHO’s last situation report issued on 30 October 2018 (External Situation Report 13) reporting on data as of 28 October, an additional 26 new confirmed EVD cases and 12 new deaths have been reported. Cases were reported from Beni (n=16), Butembo (n=6), Mabalako (n=2), Kalunguta (n=1) and Vuhovi (n=1) – a health zone between Beni and Butembo. The two cases reported in Mabalako are a mother and her new-born, residing and identified in Beni, who were transferred to the Mabalako Ebola treatment centre (ETC). Among the new confirmed cases from Beni were two nurses, thus bringing the number of affected health workers to 27, including 26 confirmed and three deaths. Among the 12 deaths reported, six occurred in ETCs and six occurred outside of ETCs (4 in Beni, 1 in Butembo, 1 in Vuhovi).  

As of 4 November 2018, a total of 300 EVD cases, including 265 confirmed and 35 probable cases, have been reported (Table 1). The cases have been reported from eight health zones in North Kivu Province and three health zones in Ituri Province (Figure 3). Among the 300 cases, 186 deaths have been reported among confirmed cases (n=151) and probable cases (n=35) – a case fatality ratio (CFR) of 62% (186/300). 

Among the 295 cases with known age and sex, 59% (n=175) were female, and adults aged 15-44 accounted for 59% (n=174) of cases (Figure 2). Fifteen additional cases have recovered and been discharged this past week; 14 from Beni ETC and one from Butembo ETC. As of 4 November 2018, 88 cases have recovered. On 4 November 2018, 91 patients (61 suspected and 30 confirmed cases) remained hospitalized at the ETCs.  

The MoH, WHO and partners are monitoring and investigating all alerts in affected areas, 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 South Sudan, Uganda and Yemen. To date, EVD has been ruled out in all alerts from neighbouring provinces and countries.

WHO: Uganda vaccinates front-line health-workers against Ebola

WHO AFRO has published Uganda Vaccinates Front-line health-workers against Ebola. Excerpt:

Kampala, 7th November 2018:- The Ministry of Health (MoH) with support from the World Health Organization (WHO) has started vaccinating frontline health workers against the Ebola Virus Disease (EVD). The exercise has begun today in Ntoroko district and will initially be implemented in the five high-risk districts bordering the Democratic Republic of Congo (DRC).  

A total of 2100 doses of the ‘rVSV-Ebola’ vaccine will be administered to the health workers to protect them against the type of Ebola virus strain that is currently circulating in some parts of DRC. Indeed, this particular vaccine is currently being administered in DRC and is demonstrating positive protective results and potency against the Ebola virus-Zaire type. 

In vaccinating frontline health workers against EVD even before Uganda detects a single case, health authorities are being cautious having learnt bitter lessons from previous outbreaks. A number of health workers including the renowned Dr Mathew Lukwiya contracted the disease and died as they cared for EVD patients. These could have been saved had a vaccine been available then. 

Although the ‘rVSV-Ebola’ vaccine is not commercially licensed, it is being used under “expanded access” or what is also known as “compassionate use” in the ongoing Ebola outbreak DRC. This vaccine was also used in the Ebola outbreak in Equateur province in May-July 2018. In 2015, the vaccine was given to more than 16,000 volunteers involved in several studies in Africa, Europe and the United States where it was found to be safe and protective against the Ebola virus. 

Several studies have shown that the vaccine is safe and protective against the Ebola virus but more scientific research is needed before it can be licensed. The vaccine is, therefore, being used on a compassionate basis, to protect persons at highest risk of the Ebola outbreak, under a “ring vaccination” strategy, which is similar to the approach used to eradicate smallpox. In this strategy, informed and written consent is needed from people, for them to be vaccinated which in turn may limit mass media coverage of the exercise. 

It is highly likely that Uganda may import EVD from DRC given the closeness of the current epicenter, the high population movements due to trade, social-cultural connections and easy accessibility of health services in Uganda. 

Uganda begins Ebola vaccinations amid Congo transmission fears

Via Reuters: Uganda begins Ebola vaccinations amid Congo transmission fears. Excerpt:

Uganda says it will start to vaccinate some of its health workers against Ebola on Monday, amid fears that the viral haemorrhagic fever could spread from Democratic Republic of Congo which is battling an outbreak.

The East African country has suffered regular outbreaks of Ebola and Marburg over the years, both high-fatality viral haemorrhagic fevers. 

Parts of Uganda’s western border are about 100 km (62 miles)from sites of an Ebola outbreak taking place in Congo. 

Health Minister Jane Ruth Aceng said authorities would administer about 2,100 vaccinations covering so called frontline health personnel working in districts near the border. 

Tens of thousands cross the border in both directions weekly for trade and family visits and other purposes, Aceng said. 

Because of this the “risk of cross border transmission was assessed to be very high ... hence the need to protect our health workers with this vaccine,” she told a news conference.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published Ebola virus disease – Democratic Republic of the Congo. Click or tap through for the full extensive report. Excerpt:

The increase over the past four weeks in confirmed case incidence (Figure 1), most notably in the city of Beni and communities around Butembo, is concerning. Security incidents continue to severely impact both civilians and frontline workers. Moreover, pockets of community resistance or reluctance continue to hamper timely detection of new cases and the effectiveness of response operations. 

Nevertheless, the response to the Ebola virus disease (EVD) outbreak has seen significant improvements over the past weeks, including strong performances by field teams conducting case investigations, vaccinations, and community engagement and risk communication in priority areas. 

Since the last Disease Outbreak News (i.e. during 24–30 October), 32 new confirmed EVD cases were reported: 24 from Beni, and seven from Butembo and one from Vuhovi. The seven new cases reported from Butembo reside in suburbs and villages within and surrounding the city. Of the newly reported cases, 14 were known contacts of previously confirmed cases at the time of reporting, one was linked retrospectively to a transmission chain, and 17 remain under investigation. Four health workers, from various health posts and hospitals around Beni, were among the newly infected; 25 health workers have been infected to date, of whom three have died. 

As of 30 October 2018, 279 EVD cases (244 confirmed and 35 probable), including 179 deaths (144 confirmed and 35 probable)1, have been reported in eight health zones in North Kivu Province and three health zones in Ituri Province (Figure 2). Over the past week, 14 additional surivors were discharged from Ebola treatment centres (ETCs) and reintegrated into their communities; 81 patients have recovered to date. 

With ongoing transmission in communities in North Kivu, the risk of the outbreak spreading to other provinces in the Democratic Republic of the Congo, as well as to neighbouring countries, remains very high. Over the course of the past week, alerts have been reported from the Tanganyika Province, Republic of the Congo, South Sudan, Uganda and Yemen. To date, EVD has been ruled out for all alerts from neighbouring provinces and countries.

WHO EMRO: Rapid response team training for MERS

Via ReliefWeb, WHO EMRO has published Weekly Epidemiological Monitor: Volume 11, Issue 43 (28 October 2018). Excerpt:

Current major event 

Rapid Response Team training for MERS 

Since the emergence of Middle East respiratory syndrome coronavirus (MERSCov) in September 2013, Saudi Arabia has reported over 80% of the cases. Current scientific evidence suggests that dromedary camels are a major reservoir for MERS-Cov and an animal source of infection in humans has been implicated. 

Although there is no evidence of sustained human-to-human transmission, sporadic outbreaks and clusters of cases have been reported mainly in health care settings. This signifies the need for having a trained Rapid Response Team (RRT) on stand by for investigation of any suspected cluster in the community or in healthcare settings. Recently, the ministry of health of Saudi Arabia and WHO jointly organized two rounds of training for its RRTs specially focussing on investigation of cluster of Middle East respiratory syndrome (MERS). 

Editorial note 

Middle East respiratory syndrome (MERS) is a viral respiratory disease caused by a novel coronavirus (MERSCov) that emerged in September 2012. It causes severe human infections resulting in high mortality in about 40% of reported cases. By end of September 2018, more than 2,200 laboratory-confirmed MERS cases were reported globally including 800 deaths (Case fatality rate is 36%). More than 90% of these cases that have been reported, globally, are from 12 countries in the WHO Eastern Mediterranean Region.

MERS is an emerging zoonotic infection. The current scientific evidence suggests that dromedary camels are major reservoir for MERS-Cov. However, currently it remains unknown how the virus spills over to humans from camels. 

Although no efficient human-to-human transmission has been seen or documented to be associated with MERS-Cov, clusters of infection have repeatedly occurred in health care settings amongst the unprotected close contacts of a case who had documented animal exposure. So far, 877 confirmed cases of MERS were reported to be part of clusters, mainly in health care settings.