H5N1

North Kivu, DRC: MSF scales up patient care activities amid growing tensions and decreased access to healthcare

Via ReliefWeb, a report from MSF: North Kivu, DRC: MSF scales up patient care activities amid growing tensions and decreased access to healthcare. Excerpt:

Almost six months after the declaration of the Ebola epidemic in north-eastern DRC, response teams on the ground, including Médecins Sans Frontières (MSF), are still struggling to gain control of the outbreak. So far, 619 people have been infected with the virus and 361 of them have died in what is the second-largest Ebola outbreak on record since the virus was discovered in this country in 1976. 

As the number of new confirmed Ebola cases keeps growing, a heightened climate of unrest linked to the presidential elections has further restricted the population’s access health care in and around the city of Beni, where several health centres were damaged during protests. This is making the prompt identification of new Ebola cases more challenging, as remaining health centres become overloaded. 

“In this situation people might have no other choice than to seek medical help in health facilities that do not have adequate triage or infection prevention and control measures in place, which makes the risk of contamination higher,” says Laurence Sailly, MSF emergency coordinator in Beni. 

“We are talking about a population that has endured many years of conflict. On top of that, they are now faced with the deadliest Ebola outbreak the country has ever seen. The unrest of these past weeks adds even more to their plight by limiting their chances of finding adequate medical care.” 

Since the outbreak was declared on 1 August, MSF has been steadily scaling up patient care activities to tackle the increasing number of confirmed Ebola cases, most recently in the Butembo, Katwa and Komanda health zones. This includes the expansion of the Ebola treatment centre (ETC) in Butembo from 64 to 96 beds, the opening of a new ETC in Katwa – east of Butembo – and the opening of a transit centre in Bwana Sura in Komanda, Ituri province, where new hotspots have been identified.  

“With more and more cases coming from the city of Butembo, which has a population of almost a million people, it was necessary to set up a second treatment centre very rapidly,” says Emmanuel Massart, MSF project coordinator in Katwa. 

“We are also addressing the need to gain the trust of the affected communities. We designed the Katwa treatment centre with the aim of offering greater capacity for patient care. Large windows allow our patients to see the faces of the doctors and nurses treating them and make family visits easier, reestablishing some of the human contact that is so hard to maintain in Ebola treatment centers”.

Inside efforts to prevent a regional Ebola crisis in central Africa

Credit: IRIN

An IRIN report: Inside efforts to prevent a regional Ebola crisis in central Africa. Excerpt:

At the Kasindi border between eastern Congo and Uganda, a line of people waits to make the crossing. Before they get their documents checked, they stand – forehead first – in front of a hygiene official in a surgical mask who screens them with an infrared thermo-gun. Those found to have higher-than-normal body temperatures are tested further for Ebola-like symptoms. 

This screening station – just a simple wood and tarp gazebo, some plastic outdoor furniture, and a makeshift water tank for hand-washing – represents the front line of the cross-border system trying to prevent the deadly Ebola virus from spreading from one country to the next. More than a dozen similar stations are now dotted along the Congo-Uganda border, health ministers from both countries told IRIN. Across the border in Uganda, 22 of the highest risk areas have implemented additional monitoring measures to try and ensure Ebola stays out. 

Between 20,000 and 30,000 back-and-forth crossings – most by informal traders or people with cultural and family links – take place between the two countries each day, according to Congolese border officials. These large human flows have become a major challenge for those involved in the Ebola response. 

“People are crossing borders all the time,” Peter Salama, the WHO’s deputy director-general for emergency preparedness and response, told IRIN. “The challenge really is just the sheer volume of people. It requires a real level of cross-country collaboration to be able to ensure that a case on one side of the border is adequately traced on the other side of the border.”  

Fears of a cross-border epidemic aren’t restricted to Uganda, which is closest to the current outbreak. They also stretch to Rwanda, Burundi, and South Sudan. 

Up to 60,000 people cross between Rwanda and Congo daily, according to the Red Cross; while Congo’s ministry of health said more than 24,000 people cross between Congo and Burundi each month, and another 3,000 each month between Congo and South Sudan.  

Travel within Congo is also a concern – Ebola has already spread from an initial epicentre near Beni to more densely populated areas, such as the major trading hub of Butembo, home to more than one million people.  

“The context for this outbreak is a perfect storm,” said Salama. “There’s the combination of great insecurity that has been going on for decades – now increasing in severity and frequency – a highly mobile and also very dense population in urban areas, proximity to international borders, major logistical challenges, and of course the fact that all of this is occurring in an election period.”

UN health chief orders probe into misconduct

Thanks to Mary Marshall for sending me the link to this alarming report from The Associated Press: AP Exclusive: UN health chief orders probe into misconduct. Excerpt (but you'd better read the whole story):

The head of the World Health Organization has ordered an internal investigation into allegations the U.N. health agency is rife with racism, sexism and corruption, after a series of anonymous emails with the explosive charges were sent to top managers last year. 

Three emails addressed to WHO directors — and obtained by the Associated Press — complained about “systematic racial discrimination” against African staffers and alleged other instances of wrongdoing, including claims that some of the money intended to fight Ebola in Congo was misspent.  

Last month, WHO Director-General Tedros Adhanom Ghebreyesus told staffers he had instructed the head of WHO’s office of internal oversight to look into the charges raised by the emails. He confirmed that directive to the AP on Thursday.  

Critics, however, doubt that WHO can effectively investigate itself and have called for the probe to be made public.  

The first email, which was sent last April, claimed there was “systematic racial discrimination against Africans at WHO” and that African staffers were being “abused, sworn at (and) shown contempt to” by their Geneva-based colleagues. 

Two further emails addressed to WHO directors complained that senior officials were “attempting to stifle” investigations into such problems and also alleged other instances of wrongdoing, including allegedly misspent Ebola funds. 

The last email, sent in December, labeled the behavior of a senior doctor helping to lead the response against Ebola as “unacceptable, unprofessional and racist,” citing a November incident at a meeting where the doctor reportedly “humiliated, disgraced and belittled” a subordinate from the Middle East.  

Tedros — a former health minister of Ethiopia and WHO’s first African director-general — said investigators looking into the charges “have all my support” and that he would provide more resources if necessary.  

“To those that are giving us feedback, thank you,” he told a meeting of WHO’s country representatives in Nairobi last month. “We will do everything to correct (it) if there are problems.”  

But Tedros refuted claims that WHO’s hiring policies are skewed, arguing that his top management team was more geographically diverse and gender-balanced than any other U.N. organization after adopting measures to be more inclusive. 

“There is change already happening,” he said during the December staff meeting, according to an audio recording provided to the AP. 

WHO’s in-house investigation into misconduct comes after other U.N. agencies have been rocked by harassment complaints.  

At UNAIDS, chief Michel Sidibe agreed to step down after an independent report concluded in December that his “defective leadership” had created a toxic working environment, with staffers asserting there was rampant sexual harassment, bullying and abuse of power. 

The author of the anonymous WHO emails also charged there were “crooked recruitment and selection” processes that were “tantamount to fraud, corruption and abuse of authority.”  

In the latest anonymous message, the author singled out the supposedly flawed hiring process of a senior director in WHO’s emergencies department, suggesting that might have led to mistakes being made by incompetent officials involved in efforts to stop Ebola in Congo.

WHO AFRO: Ebola update, week 2

WHO AFRO has published its Weekly Bulletin on Outbreaks and Other Emergencies for week 2 (January 5-11 2019). Excerpt:

The Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces, Democratic Republic of the Congo persists and continues to be closely
monitored. Since the last report on 4 January 2019 (Weekly Bulletin 1),twenty new confirmed and one new probable EVD cases have been reported. During this period there have also been an additional 16 deaths.

On 12 January 2019, nine new confirmed cases were confirmed from Butembo (1) and Katwa (8), of which one was a known contact of a
confirmed case. A probable case was reported from Kalunguta on the same; it was an 8-years old child who died on 2 January 2019 and had been in contact with a confirmed case prior to his death. On 12 January 2019, five deaths were reported among confirmed cases in the Ebola Treatment Centre (ETC) in Beni (1) and in the community in Butembo (1) and Katwa (3). An additional healthcare worker has been infected since the last weekly report, bringing the number of infected healthcare workers to 56, with 18 deaths.

As of 12 January 2019, there have been a total of 644 EVD cases, including 595 confirmed and 49 probable cases. To date, confirmed cases have
been reported from 16 health zones: Beni (218), Biena (2), Butembo (47), Kalunguta (40), Katwa (98), Kyondo (8), Mabalako (89), Masereka (7),
Musienene (4), Mutwanga (3), Oicha (25), and Vuhovi (9) in North Kivu Province; and Komanda (24), Mandima (17), Nyankunde (1), and Tchomia
(2) in Ituri Province. Nine of the 16 affected health zones reported at least one new confirmed case in the previous 21 days (23 December 2018 to 12 January 2019). A total of 390 deaths were recorded, including 343 among confirmed cases, resulting in a case fatality ratio among confirmed cases of 58% (343/595).

Butembo, Katwa, and Oicha are the hot spots of the outbreak, reporting respectively 20% (n=13), 36% (n=23), and 17% (n=11) of the 64 confirmed cases reported in the previous 21 days (23 December 2018 to 12 January 2019). No additional cases have been reported from Beni since 31 December 2018.

Contact tracing is ongoing in 13 health zones; however, it remains challenging due to insecurity and continuing pockets of community
reluctance. The number of contacts being followed as of 12 January 2019 was 4 937, of whom 4 318 (87%) had been seen in the previous 24 hours. The proportion of contacts seen in health zones varied between 32% (in Biena) and 100%. An additional 156 new contacts were registered on 12 January 2019.

Ebola DRC - Evolution of the response to the Ebola epidemic in North Kivu and Ituri on Sunday January 13 2018

The Ministry of Health has belatedly published Ebola DRC - Evolution of the response to the Ebola epidemic in North Kivu and Ituri on Sunday January 13 2018. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI 

Sunday, January 13, 2019   

The epidemiological situation of the Ebola Virus Disease  dated January 12, 2019: 

• Since the beginning of the epidemic, the cumulative number of cases is 644, of which 595 are confirmed and 49 are probable. In total, there were 392 deaths (343 confirmed and 49 probable) and 234 people cured. 

• 116 suspected cases under investigation. 

• 9 new confirmed cases, including 1 in Butembo and 8 in Katwa.  

• 1 new probable case in Butembo (deaths having an epidemiological link with a confirmed case but which could not be tested in the laboratory before burial). 

• 5 new deaths of confirmed cases, including:  

º 4 community deaths: 3 in Katwa and 1 in Butembo. 

º 1 at the CTE in Beni 

• 3 new people healed, including 2 outings from Butembo CTE and 1 CTE from Mabalako.

 

 /! \  The data presented in this table is subject to further changes after thorough investigation and after redistribution of cases and deaths in their health areas. 

News of the response 

Evolution of the epidemic 

• We see a positive evolution of the epidemic in Beni which is in its 12 th  day with no new confirmed cases. However, because of the high mobility of the population, there is a risk of importing cases from neighboring health areas, including Mabalako, Butembo, Katwa and Oicha. It was the importation of cases from Beni that caused the resurgence of the epidemic in the health zone of Mabalako after 7 weeks without new confirmed cases.    

Vaccination 

• Since the start of vaccination on 8 August 2018, 59,453  people have been vaccinated , including 19,933 in Beni, 12,250 in Katwa, 6,746 in Butembo, 5,734 in Mabalako, 2,283 in Kalunguta, 1,823 in Komanda, 1,663 in Mandima, 1,435 in Goma, 1,326 at Oicha, 991 at Karisimbi, 825 at Vuhovi, 750 at Masereka, 735 at Kyondo, 700 at Lubero, 599 at Mutwanga, 434 at Bunia, 394 at Musienene, 355 at Tchomia, 167 at Nyankunde, 120 at Biena, 63 at Alimbongo, 54 to Nyiragongo 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.

Logistical challenges in the DR Congo Ebola virus response

For some reason we still don't have today's Ebola update from the Ministry of Health. In the meantime, via The Lancet: Logistical challenges in the DR Congo Ebola virus response - The Lancet.

Although François Lamontagne, a critical-care physician from Université de Sherbrooke in Quebec, Canada, who worked in the DR Congo in October for the non-governmental organisation (NGO) Alliance for International Medical Action (ALIMA), was eventually vaccinated, being a health-care worker, and therefore part of an at-risk group, he was not vaccinated until after he had been providing clinical care to patients with Ebola virus disease for 10 days. 

“You become immune only 10 days after the shot, so I was probably immune when I left”, he said. 

Lamontagne was more concerned that family members and close contacts of individuals with Ebola virus disease were not vaccinated when they showed up to see relatives at the Ebola Treatment Center where he worked in Beni. 

“If there's one bottleneck where you can vaccinate people easily because they're there and because they're, by definition, high-risk, it would be the exit from the Ebola Treatment Center”, Lamontagne said. But no vaccination team was at the ALIMA facility and there was no system to track patients' visitors to ensure they got the vaccine later. 

The vaccination programme has evolved. Initially, the DR Congo Ministry of Health and WHO organised vaccinations, but now Médecins sans Frontieres (MSF) also vaccinates front line workers and, occasionally, the Ministry contacts MSF to ask for additional vaccinators, said Yap Boum of MSF Epicentre. At one point, the surveillance team had a dataset for identifying individuals eligible for vaccination and the vaccination team had another, leading to concerns over inconsistencies, so a joint data information unit was created in late October, according to the DR Congo Strategic Response Plan. 

Today, each Ebola treatment unit in the DR Congo has a vaccination team linked to it but the need has grown and the Strategic Response Plan calls for five more vaccination teams. WHO spokesperson Tarik Jašarević told The Lancet that WHO's electronic database shows more than 90% of eligible people have been vaccinated. In general, Formenty said, whether and where more resources are needed is “a question we are discussing every day”. 

In the clinical arena, best practice for patients with Ebola virus disease has benefited from studies conducted during and after the west Africa outbreak— although there is still some debate as to whether the data is definitive enough to change guidelines. In at least one Ebola Treatment Center—the one staffed by ALIMA in Beni—it is now routine for patients with Ebola virus disease who cannot drink to receive intravenous fluids and intravenous medications to support blood pressure as needed. 

However, the biggest hurdle to effective treatment remains that patients do not arrive at treatment units until they are quite sick. “They are afraid to come; they are scared of the treatment so they are coming very late”, said Christophe Clément, a French critical-care physician who was in the DR Congo in August, 2018, working for ALIMA. 

Another problem is that clinicians and laboratory technicians are operating on different timetables. Health-care teams want to monitor patients via standard blood tests including the electrolytes, glucose, and blood gases called for in evidence-based guidelines for Ebola care produced in 2017 by a consensus group that included Lamontagne and Clément. Every Ebola treatment unit now has a laboratory on site, but the two doctors said the laboratory results are often returned too slowly to be very helpful in managing patients. 

“Probably the staff in the laboratory does not understand exactly what we do and why it's so important that we get the results”, said Clément. The laboratory staff are under the DR Congo Ministry of Health, whereas clinicians might work for one of the Ministry's NGO partners, and in the first months of the outbreak, laboratory staff at the ALIMA facility didn't do more than one laboratory test per patient per day because of its limited resources. Eventually the laboratory increased its capacity—it now has four GeneXperts, up from just one—but it did not operate around the clock and results might come back late or with a misspelled name or did not come back at all “The laboratory decision makers were probably a little bit too relaxed about things before it became clear that the outbreak was more serious”, Lamontagne said.

Chronic life-saving medicines in short supply in Sudan

Via Radio Dabanga: Chronic life-saving medicines in short supply in Sudan.

The former head of the Private Pharmacies Association, Dr Nasri Morgos, has reported a scarcity of medicines in Sudan. The ongoing shortage of foreign currency in the country means that especially life-saving chronic medicines and permanent eye drops are running short. 

For the few medicines still available, Dr Morgos predicted further prices rises of about 400 per cent and predicted “a disaster” in the near future. 

“The situation will be catastrophic,” he said. “The current prices of medicines are expensive anyhow”, he said, and reported that Sudan is currently experiencing a 200 per cent increase which he predicts will rise still further to 400 per cent, “which would be considered a major disaster”. 

He attributed the lack of medicines to pharmacies halting importation and sales due the rise in price of the Dollar.  

Dr Morgos told Radio Dabanga that patients with heart disease, kidney failure, and asthma have complained that they do not receive medication and that they are forced to depend on their relatives abroad to provide medicines. 

Pharmacists stop imports  

As reported previously by Radio Dabanga, over the past few months, as the value of the Sudanese Pound has dropped steadily against the US Dollar, pharmaceutical companies have reportedly imported less to no medicines which has led to a scarcity of a number of medicines.  

The Central Bank of Sudan and Market Makers Committee have identified the price of the import of medicines to stand at SDG 47.5 per Dollar for medicine importers.  

Meanwhile the Sudanese board of medicines and toxins has instructed pharmaceutical companies to sell all medicines in the stores at the minimum price.  

In August 2018, people in Sudan complained about the lack and high prices of lifesaving medicines to treat chronic conditions such as blood pressure and diabetes, as well as medicines related to epilepsy and other neurological and psychological conditions.

Ebola DRC - Evolution of the response to the Ebola epidemic in North Kivu and Ituri on Friday January 11 2018

The Ministry of Health has published Ebola DRC - Evolution of the response to the Ebola epidemic in North Kivu and Ituri on Friday January 11 2018. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI 

Friday, January 11, 2019   

The epidemiological situation of the Ebola Virus Disease  dated January 10, 2019: 

• Since the beginning of the epidemic, the cumulative number of cases is 632, of which 584 are confirmed and 48 are probable. In total, there were 386 deaths (338 confirmed and 48 probable) and 227 people cured. 

• 58 suspected cases under investigation. 

• 2 new confirmed cases, including 1 in Oicha and 1 in Vuhovi.  

• 1 new case death confirmed at Butembo CTE. 

• 1 new person healed out of Katwa CTE. 

 /! \  The data presented in this table is subject to further changes after thorough investigation and after redistribution of cases and deaths in their health areas. 

News of the response    

Vaccination 

• Since vaccination began on August 8, 2018, 58,340  people have been vaccinated , including 19,818 in Beni, 11,883 in Katwa, 6,746 in Butembo, 5,611 in Mabalako, 2,283 in Kalunguta, 1,740 in Komanda, 1,663 in Mandima, 1,365 in Goma, 1,272 at Oicha, 791 at Vuhovi, 750 at Masereka, 735 at Kyondo, 774 at Karisimbi, 700 at Lubero, 599 at Mutwanga, 434 at Bunia, 394 at Musienene, 355 at Tchomia, 167 at Nyankunde, 70 at Biena, 63 at Alimbongo, 54 to Nyiragongo 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.

Dr. Justus Nsio: 'Transit center for treatment of Ebola virus disease completely rehabilitated in Beni'

Via Radio Okapi: Dr. Justus Nsio: "Transit Center for Treatment of Ebola Virus Disease Completely Rehabilitated in Beni". Excerpt from the Google translation:

Dr Justus Nsio is Deputy Coordinator of the Ebola Response in North Kivu and Ituri Provinces. He recalls the attack a few days ago the transit center for treatment of Ebola virus disease where the Ebola suspects are kept in the city of Beni.  

Goods such as chairs, tables and other tools were taken away that day by the protesters who had also released about twenty patients interned in the center, according to Justus Nsio. 

With 29 people hospitalized out of 48 beds available, Dr. Justus Nsio says that "the center is 100% functional," after noting that the patients who had left on the day of the events were all recovered. 

The protesters' claim had many negative impacts, the response coordinator said. The first impact is at the level of the transit and treatment center, says the doctor. "Like, you know, the treatment center was damaged. It took three days of work at the transit center to allow us to work and correct," he added.  

The events also had an impact on the teams' work. "Our teams were the target, our teams could not get down on the ground to follow up contacts, to do active case research, and also to deal with community deaths," he lamented.     

The coordinator of the Ebola response is confident, however, that the response continues to improve dramatically.

Non-urgent patients wait up to 8 hours at Hong Kong’s public hospitals amid flu surge

Via the South China Morning Post: Non-urgent patients wait up to 8 hours at Hong Kong’s public hospitals amid flu surge – and things unlikely to get better before Lunar New Year. Excerpt:

Overcrowded public hospital wards are bracing for an even heavier winter flu load ahead of the Lunar New Year holiday next month, with non-urgent patients having to wait up to eight hours to see a doctor. 

The health authority last week announced the city had entered the winter peak season for influenza and warned virus activity could further increase in coming weeks. So far the surge has claimed eight lives. 

The Department of Health said the peak flu season normally lasted for at least a month, meaning the problem of packed wards could worsen ahead of the holiday, during which many doctors usually took a break. 

As of Friday, one child and seven adults had died of flu. Another 18 adults had severe cases of flu, while a six-year-old girl was critically ill with severe paediatric influenza. 

The overall occupancy rate at public hospitals was 109 per cent on Saturday, which meant temporary beds had to be laid along corridors or in between fixed ones. Tseung Kwan O Hospital had the highest occupancy, at 128 per cent, followed by Queen Elizabeth Hospital in Yau Ma Tei with 121 per cent. 

There were waiting times of up to eight hours at all accident and emergency units, according to Hospital Authority data. 

That came as a survey of 356 residents by the Business and Professionals Alliance found that more than a third were unsatisfied about perennially long waiting times at public hospitals and over half had waited at least two hours at casualty units. 

“The authority should seriously review the health care system, and assess whether they can cope with the shortage in resources and manpower. This is the root of the problem,” alliance community organiser Li Sze-man said. 

Also, 66 per cent reported having to wait an extra 30 minutes to pick up medication from the pharmacy while 20 per cent waited two hours or more for prescriptions.