H5N1

DRC Measles: More than 2,700 deaths in eight months, MSF warns crisis could worsen

Via Actualite.cd: DRC-Measles: More than 2,700 deaths in eight months, MSF warns crisis could worsen. The Google translation:

Doctors Without Borders (MSF) warns about the measles epidemic that continues to wreak havoc in the Democratic Republic of Congo (DRC). 2,758 people have died from the 145,000 infected since January 2019, in 13 provinces of the country, including Mai-Ndombe. Despite the scale of the epidemic, the organization reveals an "alarming lack of actors and funds" to deal with this deadly epidemic.

MSF regrets that only $2.5 million could be mobilized out of the $8.9 million required for the response plan. Because, says the organization, several organizations seem rather attracted by the Ebola epidemic which continues, too, to kill in the east of the country. 

"Just getting vaccines to the point where children need to be vaccinated is a huge task, we need to keep the vaccines cool, which involves putting the cold chain in place. refrigerators, generators, fuel and rapid transport, and therefore also a maintenance system. Several health areas do not receive support from other organizations, despite obvious needs," explains Pierre Van Heddegem, coordinator field of MSF emergency measles team. 

Declared officially in the DRC last June, the current measles epidemic is, according to MSF, the deadliest that the country has known since 2011. Measles is a contagious disease for which no specific treatment exists. The only way to fight this disease is vaccination and symptomatic treatment. In this context, MSF says it has vaccinated 474,863 children aged 6 to 59 months and cared for 27,439 patients. 

But given the evolution of the situation on the ground, the organization fears that it will worsen a few weeks back to school. "The epidemic shows no signs of slowing down, in fact, since July the situation has worsened, with a rise in new cases noted in several provinces.If we want to control this epidemic, it is imperative to strengthen the response now," pleads Karel Janssens, MSF head of mission in the DRC. 

North Kivu: Ebola response agents unpaid since April

Via Radio Okapi: North Kivu: Ebola response agents unpaid since April. The Google translation:

Employees recruited for the Ebola response in Mungurejipa, in Lubero territory (North Kivu) triggered Thursday, August 15 a dry strike to claim the payment of their premiums, not collected since April. 

They made that decision a week after the ultimatum issued to officials of the International Organization for Migration (IOM), which had expired Wednesday (August 14th).  

These approximately 20 employees, recruited and posted at the point of entry at Mangurejipa, work at the Subcommittee of the Point of Entry for Surveillance.  

"We are asking the caregivers, especially at IOM, because we have been told that we are being dumped on IOM's account. The first month, we were paid by WHO, IOM arrived, she took care of us. But until today, she does not want to concretize what she promised us. We want IOM to give us back our rights. If we are not paid, we will not continue to work at the point of entry," said Deputy Chairman Timothée Mayengo. 

The Chief Medical Officer of Mangurejipa Health Zone and coordinator of the sub-coordination in the response, Norbert Muhongya, confirms this information. He said he feared the harmful consequences that this strike could generate, the health zone of Mangurejipa being one of the hot spots of this epidemic. He said he had advised the coordination at Butembo and said wait for the next. 

Contacted by Radio Okapi, the coordinators, they call these agents to patience. According to them, efforts are being made to get them paid.

DRC Ebola: Makayanga treatment center in trouble

Via provinces26rdc.net: DRC / Ebola: Makayanga Treatment Center in Trouble. The Google translation:

The Makayanga treatment center located about 70 kilometers south of Bunia on the Komanda road has been lacking some products and disinfectants since the disengagement of an international NGO that supported the center, the national deputy Jackson Ause said Saturday. He also called on the authorities to endow this organization with substantial resources.  

According to Jackson Ause, elected member of Irumu constituency, six confirmed cases of Ebola and nine suspected cases are being held at the Makayanga treatment center. But the means are insignificant to treat the victims and fight against the spread of this disease. 

The staff is also lacking. Some agents of an international NGO are preparing to leave this medical structure in ten days. And yet, the number of cases has peaked and new patients from Mambasa, Lolwa and elsewhere continue to be referred to this center. 

Jackson Ause invites the authorities to mobilize the necessary means: 

"This is a situation that has never existed since the outbreak of the epidemic: a month ago the partner Samaritan's Purse retired. That put the situation in the hands of the health zone, which has no means. If there is not a solution in capacity building, I assure you that we are going to witness an unprecedented situation." 

Contacted by Radio Okapi, the coordinator of the Ituri Response Team is aware of this situation. But, he continued, authorities at all levels are already seized to improve the care of patients and find other partners.

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.

Ebola fight: The French Red Cross has given the team the response of the isolation bubbles of suspected cases

Via Actualite.cd: Ebola fight: the French Red Cross has given the team the response of the isolation bubbles of suspected cases. Excerpt from the Google translation:

To reduce the risk of infection between Ebola patients and patients, the French Red Cross has, with the support of the French Ministry of Foreign Affairs, handed over to the Congolese Red Cross a kit consisting of 10 isolation bubbles for safe handling of cases.

The ceremony of handing over this endowment took place this Wednesday, August 7 at the National Headquarters of the Red Cross, in Kinshasa, in the presence of Grégoire Mateso and Mamie Mitanta respective national president and general secretary of this institution.   

According to the head of delegation of the French Red Cross in the DRC, Thibaut San Sebastian, seven of these ten bubbles have already been deployed in the provinces of North Kivu and Ituri where the epidemic is currently raging. 

"At the moment we have 7 deployed on the ground in Beni, Goma etc. 2 others were left to the Ministry of Health for emergency response missions and the tenth is in the hands of the DRC Red Cross for future use. It makes it possible to handle suspect cases, identify them and place them safely without the risk of spread and infection, which is one of the sources of transmission of the disease," said Thibaut Saint Sébastien.  

He also said that the collaboration between the two institutions (Red Cross of DRC and that of France) dates from a very long time, hence their commitment in the response. 

"There is a long-standing collaboration between the DRC Red Cross and the Red Cross France. Generally speaking, we are working alongside the country in the various crises that have been affecting for several months. We are committed to the Ebola response in North Kivu and Ituri," he says.

MSF: Ten facts on a year of the DRC Ebola outbreak

Via MSF.org: Ten facts on a year of the DRC Ebola outbreak. Excerpt:

The Democratic Republic of Congo declared an outbreak of Ebola one year ago, on 1 August 2018; with many challenges still to be addressed, the outbreak is not under control and unfortunately shows no signs of ending soon.  

Below are some of the facts and figures from 12 months of the Ebola response in the country’s northeastern provinces of North Kivu and Ituri.  

1.    The outbreak declared on 1 August 2018 is DRC’s tenth declared Ebola epidemic since the discovery of the virus. Just days before the declaration of the tenth outbreak, the ninth outbreak, in Equateur province, which claimed the lives of 14 people, was declared over. 

2.    This epidemic is now the second-biggest outbreak of Ebola in history, following the 2014-2016 outbreak in West Africa. It is also DRC’s biggest-ever epidemic of the disease.  

3.    Out of 47 health zones across North Kivu and Ituri provinces, 25 have recorded cases of Ebola. Of these, 18 health zones are currently considered ‘active transmission’ zones, meaning they have recorded cases within the last 21 days (the maximum incubation period for the disease).  

4.    New tools have been implemented in response to the Ebola outbreak in eastern DRC. This includes an investigational vaccine, rVSV-ZEBOV, to protect frontline workers and first and second-degree contacts of confirmed Ebola patients. Developmental treatments for confirmed patients admitted to Ebola treatment centres are also available, but both the vaccine and the treatments are subject to strict protocols, as well as informed consent of the recipient.

Ebola: MSF erects largest treatment center in Munigi (North Kivu)

Via Topcongofm.net: Ebola: MSF erects largest treatment center in Munigi (North Kivu). As the map shows, the center is just outside Goma. The Google translation:

It is to talk about any eventuality that Médecins Sans Frontières (MSF) has just built a large center for the treatment of Ebola virus disease located 5km from the city center in the suburb of MUNIGI, North Kivu.  

Built on a surface of one hectare and a half, this new center has a capacity that can house at least 70 patients and includes several screening houses.   

In prefabricated and constituted compartments for the nursing staff and the administration, this medical complex has the peculiarity of having more spacious individual rooms with latrines. 

The Munigi center will be fully completed within a week, according to MSF's technical teams.  

For now, the teams are working to contain Ebola in the home even if the purpose of this center is to meet any eventuality. 

Having taken up his duties today after the handover and resumption with the field coordinator Dr. Aruna, Dr. Jean-Jacques Muyembe toured the border points at the small and large barrier in the city of Goma. All sanitary measures have been strengthened and are scrupulously respected.

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.

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.

DRC Ebola: Thoughts about the PHEIC

To no one's surprise, Dr. Tedros has accepted the advice of his committee to declare the Ebola outbreak in DR Congo a public health emergency of international concern. Like most declarations of emergency, this one is intended to trigger new infusions of cash and personnel from the international community. I hope it does.

The international community is unlikely to be concerned, however, if it doesn't know much more about the outbreak and about the people it's afflicting.

That's a challenge, because black Africa has long been terra deliberately incognita to much of the rest of the world. Asia and the West have cared about Africa only to the extent that they could get rich out of its resources; its peoples and cultures have interested them very little. That's how the Rwandan genocide was allowed to happen, and since then the genocide has effectively continued in the DR Congo's northeast, with an estimated 5 million deaths since the 1990s. Western response to this ongoing bloodbath has vindicated La Rochefoucauld's cynical aphorism: "We always find the strength to endure the misfortunes of others."

In West Africa, Ebola triggered a tsunami of Western apathy until the unlucky Liberian Thomas Eric Duncan brought a sample of the disease to Dallas, Texas. That sent the richest, most powerful nation in the world into paroxysms of Ebolanoia, as US politicians vied with one another to impose the stupidest restrictions on returning healthcare workers.

That famous Korean War healthcare worker Hawkeye Pierce once famously asserted: "Never let it be said I didn't do the least I could possibly do." While I admit that minimalism has a certain elegance, the media in both the DR Congo and worldwide need to do a lot more than the least. Local news reports are often only rehashed MoH or WHO news releases, adding nothing. Foreign reporters are few, and as likely to stir mistrust as any other outsider in a badly exploited and terrorized region. UN agencies and NGOs can do only so much to explain the outbreak without running into political minefields.

Speaking as a rank outsider, I would like to see a good chunk of PHEIC funds go into a major expansion of health communication—designed for both the peoples of North Kivu and Ituri, and for the rest of the world. Some of it would go into newspaper, TV, and radio advertising and content, explaining what Ebola is, how to prevent it, and how to deal with it.

Some would also go into recruiting, training, and publishing local journalists. They could talk to locals who wouldn't give the time of day to an outsider; but if the locals thought someone was seriously listening to them, they'd probably talk all day and into the night. The local journalists' stories would also be picked up by health agencies and outside media, offering the rest of the world an intimate look at the real people contending Ebola and a host of other problems. 

Money and expertise ought to go as well into the Ministry of Health website, which at present is an embarrassment. Its "news" stories are from last fall and winter. Its daily Ebola bulletins, on which everyone relies, are buried. Worse yet, those bulletins are far too brief; they lack analysis, and the MoH rarely interprets the numbers. We rarely learn if a group of cases in, say, Beni are a family cluster, from the same neighbourhood, or in the same church.

You might argue that few in the DR Congo spend much time online. But an improved MoH website would be aimed as much at the outside world as at citizens. The site should be at least bilingual, offering visitors concise, up-to-the-minute reports on successes and setbacks alike. Its accuracy and thoroughness would speak well for the ministry's professionalism, creating goodwill among the global health community and ordinary visitors alike.

By keeping us all informed, the ministry could keep Ebola in the news, generating political pressure to keep up support for an effective response. Its stories could single out a few of the many heroes of the response—including the survivors, who often go right back into the ETCs as support staff.

Understanding Ebola means understanding public health issues right across Africa. An effective PHEIC-funded information campaign would certainly point out the DR Congo's other health problems, which could be best resolved by improving the whole healthcare system and access to it. An ounce of prevention is worth a metric tonne of cure.

I realize such an improved information program would be obliged to report on shortcomings as well as achievements, and no one likes bad reviews—least of all governments and agencies dependent on government funding. But the scandals will be fewer and briefer if a powerful response suppresses Ebola in a hurry and the ministry is prepared to transition to expanded general public health programs.

Then, when the next outbreak comes, the local and international responders will be able to tackle it more effectively, knowing that a good health information program is in place to tell the story to the world.