H5N1

Beni: Ebola epidemic penalizes operation of blood center

Via Radio Okapi: Beni: Ebola epidemic penalizes operation of blood center. This is like West Africa: Ebola frightens people away from almost any kind of healthcare, thereby amplifying the harm done to the whole population. The Google translation:

The blood transfusion center in Beni is struggling to function as a result of the Ebola epidemic in this part of North Kivu Province. According to its leader, Justin Chiruza, many people are afraid to give blood because of this epidemic. 

"The Ebola virus disease has brought fear to voluntary donors. They do not want to come for blood anymore. We appeal to all donors not to be afraid and to come to give blood," said Justin Chiruza. 

According to him, there are people who die because of the lack of blood bags.  

"The donors to be collected should be over 400 but we rarely get 300 bags taken and this causes that currently there are patients who die for lack of blood," said Chiruza. 

According to him, there is an increase in demand for blood bags in Ebola treatment centers and hospitals to treat the sick. 

"The demand has increased compared to the past years, we were able to transfuse 200 to 300 pockets per month but currently we are more than 400 pockets," he regretted. 

Because of this situation, the blood center is no longer able to provide sufficient pockets in hospitals.  

"With the Ebola treatment centers, there are a lot of transfusions that are done, there are also the cases of malaria that have increased, there are also a lot of bullet wounds that are brought here to the hospital, there is the military pavilion that consumes pockets of blood and we are obliged to serve 5 health zones while there are insecure health zones," said Justin Chiruza.

Ebola in eastern DRC

Via The Lancet Infectious Diseases, a devastatingly critical comment by Pierre E. Rollin: Ebola in eastern DRC.

When the current Ebola outbreak was declared on Aug 1, 2018, in North Kivu, Democratic Republic of the Congo (DRC), confidence was high that the hundreds of experienced responders and the new therapeutics and vaccines would be able to quickly stop this tenth outbreak in DRC. As of July 28, 2019, 2671 probable and confirmed cases and 1790 probable and confirmed deaths have been reported. Leadership and coordination shortfalls, increased insecurity, mistrust, and denial from both the community and the responders are now hallmarks of the response. 

The ineffectiveness of the collection, analysis, and diffusion of epidemiological data, the centrepiece of any response, is predictive of the situation worsening. The different and mainly incomplete databases combined with the absence of accurate and up-to-date chains of transmission makes case counts, monitoring, and intervention difficult or even impossible. 

Many cases of Ebola virus disease are identified late, with many previous transits through unprepared health-care facilities, or are detected as community deaths. Most of the probable cases (death without laboratory confirmation) are not recorded. Research activities are following a parallel agenda, which often differs from timely intervention goals, with numerous data collections kept for exclusive scientific publications and to advance personal careers. 

Laboratory diagnosis is done at multiple sites by the Institut National de Recherches Biologiques. This achievement is tempered by an overconfidence in the capabilities of the laboratories, incomplete sharing of results with patient providers, low quality-control procedures, and unjustified fear of losing control. Rapid field molecular typing of the virus and bedside rapid diagnostic assays, both seen as a crucial support for the control of the 2014–16 west Africa outbreak, are not done to inform the response. 

Early in the outbreak, new therapeutics were made available first under a monitored emergency use of unregistered and investigational interventions (MEURI) protocol, then through a randomised controlled trial supported by the US National Institutes of Health, the Institut National de Recherches Biologiques, and the DRC Ministry of Health. As of July 30, 2019, 682 patients were recruited under the MEURI and 621 patients under the randomised controlled trial protocol. Late admission of cases due to fear from the community or ineffective follow-up of contacts has complicated the use of therapeutics and vaccines and analyses. 

Ring vaccination of contacts and contacts of contacts of confirmed Ebola cases using rVSV-ZEBOV was rapidly implemented. As of July 27, 2019, 178 121 people have been vaccinated, 31 016 of whom were frontline workers, the rest being contacts and contacts of contacts of Ebola cases. The epidemiological data generated by the vaccination and the contact tracing teams are mostly not shared. As a result, daily field reports have noted at least 651 identified contacts of confirmed cases who were not vaccinated and became cases (among them 205 deaths) between Dec 31, 2018, and July 30, 2019. Vaccination coverage among health-care workers is high but incomplete. 

The initial response should be to generate, maintain, and constantly update the primary databases, then sharing them among all players. Parallel databases should not exist. Because of the field difficulties and the inadequate personnel resources, a single team staffed by the most experienced partners should oversee this task. During the autumn of 2014, a Conakry informal taskforce, consisting of one member from each main partner (Guinea Ministry of Health, WHO, Médecins Sans Frontières, Centers for Disease Control and Prevention) met at least once a week, allowing real fact-based understanding and management of the Ebola situation. This approach needs to be replicated for this outbreak at each level. 

Laboratory support from national and external partners is needed and should provide timely support for clinical management of patients receiving experimental therapeutics or difficult epidemiological investigations, such as cases with multiple or unknown origins. As in the west African outbreak, point-of-care rapid diagnostic tests should be fielded, at least as an evaluation of community deaths. 

The existing vaccination strategy and implementation on the ground, should be drastically changed. A single combined team should follow and vaccinate contacts and contacts of contacts. This policy, combined with a rapid and complete inclusion of all high-risk contacts, should reduce, or at least improve the outcome of, secondary Ebola cases and affect the transmission curve. 

Even if the infection prevention and control efforts have yielded some progress, the relatively large proportion of cases due to reuse of material (eg, syringes, needles, and perfusion tubes) is unacceptable. More emphasis on the multiple risks of this practice should be advertised among the care providers and the population. 

Helping the existing local health-care providers to regain the population's confidence is crucial. This should be done by introducing a comprehensive health system with actions that encompass the health-related problems encountered daily by the population—eg, malaria, vaccine-preventable diseases, childbirth, and quality of care. 

Together with the presence of violence and insecurity, Ebola virus disease has a real chance of becoming endemic in this part of DRC. Only multiple and immediate changes, starting within the leadership and coordination of all the partners involved through inclusive, flexible, and unified response efforts, will be able to reverse the trend.

Typhoons, disease outbreaks and now escalating protests: Hong Kong isn’t ready for a citywide disaster

An op-ed in the South China Morning Post: Typhoons, disease outbreaks and now escalating protests: Hong Kong isn’t ready for a citywide disaster. Excerpt:

The UN Office for Disaster Risk Reduction launched a worldwide “Making Cities Resilient” campaign in 2010, identifying 10 essential points. This was evaluated locally in the 2018 study “Assessing the Disaster Resilience of Megacities: The Case of Hong Kong”. 

Unfortunately, Hong Kong’s disaster preparedness was judged to have failed on three counts. Specifically, the city came up short in “institutional capacity” and “risk identification”; and, under “organising for disaster resilience”, Hong Kong was said to have inadequate governance and a lack of a strategic “city vision”. 

Infrastructure development and financial resourcing were seen as the strengths. But, notably, new and unpredictable risks precipitated by unstable sociopolitical dynamics were flagged as challenges comparable to climate change.  

The emergency and disaster response system in Hong Kong is administered by the Security Bureau, and consists of three tiers. The first level is based on primary emergency services. Aggravated risk to property or life requires the second tier, involving government monitoring by a Security Bureau duty officer and emergency support unit.  

In the event of large-scale threats to property, life, public order or security, the third-tier response is triggered, coordinating emergency services, security control, civil support actors (including auxiliary medical staff and hospitals) and maintenance of essential infrastructure, supervised by the chief executive’s security committee. 

This system is designed to operate the three phases of emergency response – rescue, recovery and restoration – under one umbrella. Events requiring more assets than those used on a day-to-day basis by emergency services are deemed major incidents; when the capacity is overwhelmed by the number of injured, the situation becomes a mass-casualty incident. 

Relevant here are the concepts of “population at risk” and the “casualty estimate”. Recent public demonstrations have involved hundreds of thousands, even millions – and violent confrontations with police are taking place. A misjudgment in protest control by law enforcement officers, causing a crowd crush or stampede, or an overly vigorous ballistic response, could result in a (conservative) casualty rate of 0.1 per cent, potentially creating many hundreds of victims.  

This should be considered in the context of the overall “casualty handling capacity” of Hong Kong’s hospitals, where intensive care unit beds – totalling perhaps 300 – would be quickly overwhelmed. 

When the response system itself becomes impaired, it can lead to a compound disaster. Given the critical role of police in disaster management – in terms of cordon, control and co-ordination (with ambulance and first aid responders for triage and casualty evacuation) – a conflict where there is widespread hostility between the public and law enforcement officers involves an amplified risk of a crisis during the handling of victims. 

The right to medical care for injured civilian protesters is provided under international human rights law (and these protections extend to the humanitarian work of identified first aid volunteers embedded within the protests). These global norms would still apply even if martial law were declared.

Nigeria not prepared for another Ebola outbreak, says Tomori

Via The Guardian, a Nigerian newspaper: Nigeria not prepared for another Ebola outbreak, says Tomori. Excerpt:

A virologist and World Health Organisation (WHO) consultant, Professor Oyewale Tomori has said Nigeria is not prepared for another Ebola outbreak, contrary to Federal Government’s assurances that the country was better prepared for another outbreak than in 2014. 

Tomori, a former Vice Chancellor of Redeemers University and Chairman, Expert Review Committee on Polio Eradication in Nigeria, told The Guardian that the country was lucky in 2014, adding that claims of preparedness by the Nigeria Centre for Disease Control (NCDC) should be taken with a pinch of salt. 

His words: In spite of government assurances, I remain unconvinced that we are prepared for another Ebola outbreak. First time, it was a combination of luck as the index case arrived already sick and admitted to a private hospital, with public health facilities shut as a result of doctors’ strike. 

“It also followed a national morbid fear of Ebola that roused and compelled government commitment and massive funding, After the country was declared free, structures that aided our ability to contain the outbreak were dismantled. 

“Today, perhaps only the Federal and Lagos State governments are rebuilding infrastructure for preparedness against disease outbreaks. Nigeria has assessed its ability to find, stop and prevent health threats and identified significant gaps.”

He said in the self-assessment done under Joint Evaluation Exercise (JEE) Nigeria had Finding and Verifying Outbreaks (51 per cent); Stopping Outbreaks (31 per cent), Preventing Outbreaks (39 per cent) and Protecting from Other Health Threats (37 per cent) with a total score of 39 per cent. 

“This means we are not ready to find, stop and prevent epidemics,” he added. Tomori, however, said the country was showing commitment to improving epidemic preparedness, such as enacting then bill establishing the NCDC and great efforts by NCDC to address identified gaps still remain especially at state and council levels in biosafety and biosecurity, preparedness, medical countermeasures/personnel deployment, emergency response operations, laboratory system and financing, among others. 

He, however, warned that the occurrence of any disease outbreak could cause numerous deaths and perhaps spread to neighboring countries, examples yellow fever, Lassa fever and meningitis. 

But Director General of the NCDC, Dr. Chikwe Ihekweazu, disagreed, saying: “Compared to July 2014, we are better prepared for an Ebola outbreak. You know about outbreak preparedness, you don’t actually prepare for Ebola outbreak. You prepare for outbreaks that happen commonly and through the response to common incidents you prepare for the unusual. 

“In July 2014 we didn’t have a National Reference Laboratory (NRL) in Nigeria, We had a few laboratories in specific universities that have developed their capacities like the Redeemer’s University and the Lagos University Teaching Hospital (LUTH), but we didn’t have a NRL. 

“But now we have a full fledged NRL at Jabi in Abuja where we have the capacity to do diagnoses of most causes of epidemic diseases both bacterial and viral causes. So, our capability of making diagnoses in Nigeria has increased exponentially. We have a mobile laboratory that we can deploy to any part of the country if needed.”

Ituri: Nurses plan a strike on Monday protesting their lack of state support

The Ebola dashboard is still stuck at August 1, and the daily update hasn't been published in a couple of days (except on WhatsApp, which I don't use). Meanwhile, via 7sur7.cd: Ituri: Nurses plan a strike on Monday protesting their lack of state support. The Google translation:

The nurses of the province of Ituri and other health professionals gathered within the National Union of Cadres, Agents and Amplified Services "SYNCAS" have decided to start a strike from Monday, August 05, 2019.  

This decision was taken at a general meeting held on Wednesday, July 31st.  

The provincial executive secretary of this union who made this announcement on Saturday, August 03, 2019 at 7SUR7.CD, indicates that several reasons have contributed to the making of this decision.  

And among these reasons, the epidemiologist Dr. Justin Issamba mentions:  

- Bad faith on the part of the National Budget Minister who was instructed to unblock the situation of risk premium of the staff unjustly removed from the payroll, but nothing has been done; 

- In the territory of Mahagi, the listing of health professionals has arrived since January 2019, but they have never been paid until now; 

- Part of the Ituri budget would have been allocated to other provinces, according to a report of a mission by the Inspector General of Health in Kisangani a few months ago.  

However, a minimum service will be rendered during this strike period which will last one month, says the same source. 

"The emergencies will be supported but also the activities of the response to Ebola and measles must continue normally, until we have an improvement in our living conditions," said the trade unionist.

MSF: DRC Ebola outbreak response struggling one year on

Via MSF.org: DRC Ebola outbreak response struggling one year on. Excerpt:

As the worst Ebola outbreak in Democratic Republic of Congo’s (DRC) history approaches its second year, the number of new Ebola cases recorded each week is hovering near its highest levels since the beginning of the epidemic. 

In July 2019, between 80 and 100 people were diagnosed with the disease every week. The outbreak is also continuing to spread geographically. Uganda saw its first Ebola patients in June, though they had travelled from DRC, while Goma, a city of 1.5 million people, recorded its second case just this week.

Following the declaration of the epidemic on 1 August 2018, a massive response was rapidly launched, aided by tools that were either unavailable or severely limited in previous Ebola outbreaks, such as an investigational vaccine and developmental treatments. 

Despite this, the outbreak seems headed in the wrong direction and in July was declared a Public Health Emergency of International Concern (PHEIC). Since last August, Ebola has infected over 2,600 people, and killed 1,700 in DRC. 

A year on, we must review what must now be done to bring the outbreak to an end.  

Building trust amidst insecurity 

Insecurity is frequently mentioned as one of the main challenges for the Ebola intervention. Northeastern DRC has been an area of active conflict for the past quarter century and is rife with the presence of armed groups. 

Alongside this, healthcare workers associated with the Ebola response are still not trusted. They have been specifically targeted, sometimes resulting in crucial activities such as contact tracing, alert investigation or vaccination campaigns to be suspended, limited or cancelled. 

Médecins Sans Frontières (MSF) knows this all too well. In February, the Ebola treatment centres in Katwa and Butembo were attacked, forcing us to withdraw our teams from those centres.

Honduras: 1,606 health centres stay open longer to attend to dengue cases

Via El Heraldo: Hasta las 7:00 de la noche atenderán en los 1,606 centros de salud de Honduras por dengue [1,606 Honduras health centres will be open until 7:00 tp care for dengue cases]. Excerpt with my translation:

Los 1,606 centros de salud que hay en el país extenderán ahora su horario de 3:00 a 7:00 de la noche debido a la gran cantidad de pacientes con dengue que llegan al sistema asistencial público. 

The country's 1,606 health centres will extend their hours from 3:00 to 7:00 owing to the great number of dengue patients coming into the public health system.

Esta disposición se toma para hacerle frente al colapso hospitalario debido a los pacientes que están ingresando a diario afectados por el virus que transmite el zancudo Aedes aegypti. 

This measure has been taken to deal with the hospitals' collapse under the number of patients admitted daily with the virus, which is transmitted by the Aedes aegypti mosquito.

Con la ampliación de estas cuatro horas se busca atender a más personas en el nivel primario de salud y así no saturar los hospitales públicos del sistema sanitario. 

The extension of four hours is intended to give more people primary care so that public hospitals in the health system aren't overloaded.

La información fue confirmada a EL HERALDO por la secretaria de Salud, Alba Consuelo Flores. Sumado a lo anterior, se habilitarán 15 Clínicas de Atención de Dengue (CAD), en el interior de establecimientos ya existentes. De este total, dos salas se habilitarán en centros de San Pedro Sula y dos en Tegucigalpa.

The information was confirmed to El Heraldo by Health Secretary Alba Consuelo Flores. In addition, 15 Dengue Care Clinics will be set up inside existing hospitals. Of these, two wards will be established in hospitals in San Pedro Sula and two in Tegucigalpa.

The report goes on to say Honduras has so far counted 34,480 dengue cases. Of these, 26,178 are not serious and 8,662 have required hospitalization.

Another report says that as of July 29, 150 people have died of dengue—58 of them confirmed.

US demand is threatening Canada's drug supply, groups warn feds

Via CBC News, a report by The Canadian Press: U.S. demand is threatening Canada's drug supply, groups warn feds . Excerpt:

Concern over U.S. legislation that allows Americans to import cheaper medicines from Canada has prompted more than a dozen organizations to urge the federal government to safeguard the Canadian drug supply.  

In a letter this week, the 15 groups representing patients, health professionals, hospitals, and pharmacists warn Health Minister Ginette Petitpas Taylor of the potential for increasing drug shortages. 

"The Canadian medicine supply is not sufficient to support both Canadian and U.S. consumers," the letter states. "The supply simply does not, and will not, exist within Canada to meet such demands."

Faced with voter anger over the steep and rising costs of drugs in the U.S., several states — including Florida with the blessing of President Donald Trump — have passed laws allowing residents to import drugs from Canada.  

In the letter to Petitpas Taylor, the groups say the legislation could exacerbate drug shortages that become an increasingly serious concern in the Canadian health care system in recent years.  

'They're not equipped' 

"Hospital and community pharmacies in Canada are resourced to serve the Canadian public," they say. "They are not equipped to support to the needs of a country 10 times its size without creating important access or quality issues."  

Petitpas Taylor did not immediately respond to a request for comment.  

The issue has recently garnered attention on both sides of the border. Sen. Bernie Sanders, a Democratic presidential candidate, has announced plans to accompany diabetics this weekend to Canada to buy life-saving insulin, which costs roughly one tenth the price here than in the United States.

Late last month, another group of Type 1 diabetics from Minnesota crossed the border to buy insulin in London, Ont. One of the organizers said soaring prices south of the border had forced some users to ration their doses with potentially serious health consequences. 

Drug supplies are already an issue in Canada. In recent years, Canadian drug makers have reported thousands of shortages for various reasons  — often because of manufacturing issues but also due to increased demand. U.S. legislative initiatives could make matters much worse, the letter states. 

According to data from the National Academy for State Health Policy, more than 27 different bills have been introduced in the U.S. Congress and state legislatures over the past year allowing Americans to buy drugs from Canadian sources.  

Groups call for assurances from feds 

Signatories to the letter, including the Canadian Pharmacists Association, Canadian Medical Association and the Canadian Patient Safety Institute, urge Ottawa to take action to head off Americans' "draining of Canada's medicine supply."  

"We request that Health Canada provide clarity and assurances to Canadians that U.S. legislation will not inadvertently disrupt  Canada's pharmaceutical supply and negatively impact patient care through greater drug shortages," the letter states.

North Kivu / Ebola: Civil society fears that WHO's health emergency is fatal for regions affected by the epidemic

Via 7sur7.cd: North Kivu / Ebola: Civil society fears that WHO's health emergency is fatal for regions affected by the epidemic. "Civil society" means municipal governments. The Google translation:

In a statement on Saturday, July 20, the civil society / forces of North Kivu reacted to the decision of the World Health Organization of Wednesday, July 17 in Geneva, establishing the Ebola virus disease in North Kivu and in Ituri as "a health emergency of international concern". This, after the detection of a first positive case in the city of Goma.  

Through this media outlet, the North Kivu forces are expressing their concern about the attitude that neighboring countries can show in relation to the areas affected by the virus.  

They fear that the WHO decision will produce and / or become a new concern for populations already suffering from Ebola. 

"Civil society is concerned that this measure will be a new burden that will once again weigh on poor people in the affected areas, and on repetitive and permanent wars, and on Ebola virus disease in the case of neighboring countries. would benefit to restrict the movements of Congolese," they fear. 

However, the civil society says "take note of this so decisive step", while considering "that it will not be a matter of simply being able to mobilize more partners but rather an opportunity to refine new and effective strategies. and efficient in order to achieve the desired result, the eradication of this epidemic."  

Moreover, calling on the actors in the response to focus more on the gaps in the interventions and the quality of these, the driving forces urge that the different problems that impede public health actions in the field of health are also taken into account in the fight against Ebola. 

For them, these problems are insecurity, lack of road infrastructure, poor water supply, lack of electricity, mismanagement of health policy, etc.

MSF: DRC Ebola outbreak crisis update

MSF.org has published DRC Ebola outbreak crisis update. Apart from offering a good current summary, it also provides background. Excerpt and then a comment:

Retrospective investigations point to a possible start of the outbreak back in May 2018 – around the same time as the Equateur outbreak earlier in the year. There is no connection or link between the two outbreaks. 

The delay in the alert and subsequent response can be attributed to several factors, including a breakdown of the surveillance system due to the security context (there are limitations on movement, and access is difficult), and a strike by the health workers of the area which began in May, due to non-payment of salaries.  

A person died at home after presenting symptoms of haemorrhagic fever. Family members of that person developed the same symptoms and also died.  A joint Ministry of Health/World Health Organization (WHO) investigation on site found six more suspect cases, of which four tested positive. This result led to the declaration of the outbreak. 

The national laboratory (INRB) confirmed on 7 August that the current outbreak is of the Zaire Ebola virus, the most deadly strain and the same one that affected West Africa during the 2014-2016 outbreak. Zaire Ebola was also the virus found in the outbreak in Equateur province, in western DRC earlier in 2018, although a different strain than the one affecting the current outbreak.  

First declared in Mangina, a small town of 40,000 people, the epicentre of the outbreak appeared to progressively move towards the south, first to the larger city of Beni, with approximately 400,000 people and the administrative centre of the region. 

As population movements are very common, the epidemic continued south to the bigger city of Butembo, a trading hub. Nearby Katwa became a new hotspot near the end of 2018 and cases had been found further south, in the Kanya area. Meanwhile, sporadic cases also appeared in the neighbouring Ituri province to the north. 

Overall, the geographic spread of the epidemic appears to be unpredictable, with scattered small clusters potentially occurring anywhere in the region. This pattern, along with the lack of visibility on the epidemiological situation, is both extremely worrying and makes ending the outbreak even more challenging.

It happens again and again: poor countries' governments don't pay their healthcare workers enough, or at all. They don't give them adequate training or supplies even to handle routine healthcare needs, and the idea of surveillance never crosses their mind.

Whether the reasons for stiffing HCWs are corruption or incompetence or policy, the effect is the same, and very predictable: people get sick and die. And then the governments discover that people don't like or trust them, and neither do their healthcare workers.