WHO TB News

The incidence of Ebola virus disease (EVD) cases in the Democratic Republic of the Congo continued to increase this week; however, it remained confined to a limited geographical area within North Kivu and Ituri provinces. This recent trend is likely attributable, in part, to past and ongoing security issues, unrest amongst certain local populations, and lingering community mistrust towards outbreak response teams. Improved case detection and response activities have been observed in previously inaccessible hotspots.

In the 21 days between 27 March and 16 April 2019, 55 health areas within 11 health zones reported new cases; 39% of the 143 health areas affected to date (Table 1 and Figure 2). During this period, a total of 249 confirmed cases were reported from Katwa (124), Vuhovi (40), Mandima (28), Butembo (24), Beni (16), Oicha (6), Mabalako (5), Kalunguta (2), Masereka (2), Musienene (1), and Lubero (1).
In Brazil, seasonal increases of yellow fever have historically occurred between December and May.
The rise in number of Ebola virus disease (EVD) cases observed in the North Kivu provinces of the Democratic Republic of the Congo continues this week. During the last 21 days (20 March to 9 April 2019), 57 health areas within 11 health zones reported new cases; 40% of the 141 health areas affected to date (Table 1 and Figure 2). During this period, a total of 207 probable and confirmed cases were reported from Katwa (83), Vuhovi (41), Mandima (29), Beni (21), Butembo (15), Oicha (8), Masereka (4), Lubero (2), Musienene (2), Kalunguta (1), and Mabalako (1).

As of 9 April, a total of 1186 confirmed and probable EVD cases have been reported, of which 751 died (case fatality ratio 63%). Of the 1186 cases with reported age and sex, 57% (675) were female, and 29% (341) were children aged less than 18 years. The number of healthcare workers affected has risen to 87 (7% of total cases), including 31 deaths. To date, a total of 354 EVD patients who received care at Ebola Treatment Centres (ETCs) have been discharged.
This past week saw a marked increase in the number of Ebola virus disease (EVD) cases in the Democratic Republic of the Congo. During the last 21 days (13 March to 2 April 2019), 57 health areas within 12 health zones reported new cases; 42% of the 135 health areas affected to date (Table 1 and Figure 2). During this period, a total of 172 confirmed cases were reported from Katwa (50), Vuhovi (34), Mandima (28), Masereka (18), Beni (13), Butembo (12), Oicha (8), Kayna (3), Lubero (3), Kalunguta (1), Bunia (1) and Musienene (1). WHO and partners will continue to adapt our strategies and strengthen response efforts to limit the further spread of EVD in these health areas.

As of 2 April, a total of 1100 confirmed and probable EVD cases have been reported, of which 690 died (case fatality ratio 63%). Of the 1100 cases with reported age and sex, 58% (633) were female, and 29% (320) were children aged less than 18 years. The number of healthcare workers affected has risen to 81 (7% of total cases), including 27 deaths.
From 1 through 28 February 2019, the National IHR Focal Point of Saudi Arabia reported 68 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 10 deaths. Of the 68 MERS cases reported in February, 19 cases occurred in cities other than Wadi Aldwasir.

This Disease Outbreak News update describes the 19 cases. Among these cases, fifteen were sporadic, and four were reported as part of two unrelated clusters. Cluster 1 involved two cases in Buridah city; and Cluster 2 involved two cases in Riyadh city. The link below provides details of the 19 reported cases.
The ongoing Ebola virus disease (EVD) outbreak in the North Kivu and Ituri provinces saw a rise in the number of new cases this past week. At this time, response teams are facing daily challenges in ensuring timely and thorough identification and investigation of all cases amidst a backdrop of sporadic violence from armed groups and pockets of mistrust in some affected communities. Despite this, progress is being made in areas such as Mandima, Masereka and Vuhovi, where response teams are gradually able to access once again and acceptance by the community of proven interventions to break the chains of transmission is observed.

During the last 21 days (6 – 26 March), a total of 125 new cases were reported from 51 health areas within 12 of the 21 health zones affected to date; 38% of the 133 health areas affected to date (Figure 2). The majority of these cases were from remaining hotspot areas of Katwa (36), Butembo (14), and three emerging clusters in Mandima (19), Masereka (18) and Vuhovi (17), in addition to a limited number of cases in other areas (Table 1). All cases link back to chains of transmission in hotspot areas, with onward local transmission observed in a limited number of towns and villages within family/social networks or health centers where cases have visited prior to their detection and isolation.
The Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces has recently shown an increase in the number of cases reported by week, after many weeks of overall decline (Figure 1). This rise is not unexpected and, in part, likely a result of the increased security challenges, including the recent direct attacks on treatment centers, and pockets of community mistrust, which slowed some response activities in affected areas for a few days.

Katwa, Butembo, Masereka and Mandima account for over 80% of all cases in the last 21 days. A total of 97 confirmed cases were reported during the last 21 days from 38 of the 130 health areas affected to date (Table 1, Figure 2). This week, EVD was confirmed in an infant who died in Bunia Health Zone, but whose parents are in good health. This is the first confirmed case from this health zone; a previous case was identified from neighbouring Rwampara Health Zone in early February. While investigations are ongoing to determine the source of the infection, teams in place have rapidly implemented response activities including contact tracing, vaccination and heightened surveillance. Given the geographical spread of the epidemic and the high mobility in this region, the risk of Ebola spreading to unaffected areas or being reintroduced to previously affected areas remains high.
The public health response to the Ebola virus disease (EVD) outbreak continues to make gains. During the last 21 days (20 February – 12 March 2019), no new cases have been detected in 10 of the 20 health zones that have been affected during the outbreak (Figure 1). There has also been fewer new cases observed over the past five weeks compared to January 2019 and earlier in the outbreak (Figure 2).

Currently, the greatest concern centres on the neighbouring urban areas of Katwa and Butembo, which continue to contribute about three-quarters of recent cases. Clusters in other areas of North Kivu and Ituri provinces have been linked to chains of transmission in Katwa and Butembo, and have thus far been contained to limited local transmissions with relatively small numbers of cases. A total of 74 confirmed cases were reported during the last 21 days from 32 of the 125 health areas affected to date (Table 1). Risk of further chains of transmission and spread remain high, as highlighted by the recent spread to Lubero Health Zone, and reintroduction to Biena Health Zone following a prolonged period without new cases.
The Ebola virus disease (EVD) outbreak is continuing with moderate intensity. Katwa and Butembo remain the major health zones of concern, while small clusters continue simultaneously in some geographically dispersed locations. During the last 21 days (13 February – 5 March 2019), 76 new confirmed and probable cases have been reported from 31 health areas within nine health zones (Figure 1), including: Katwa (44), Butembo (17), Mandima (6), Masereka (3), Kalunguta (2), Beni (1), Vuhovi (1), Kyondo (1), and Rwampara (1). The emerging cluster in Mandima health zone is occurring in a previously unaffected village, with five of the recent cases epidemiologically linked and the sixth case likely exposed in Butembo; nonetheless, there remains a high risk of further spread. Similarly, recent cases (two confirmed and one probable) in Masereka stem from a Butembo chain of transmission. These events highlight the importance for response teams to remain active across all areas, including those with lower case incidence, to rapidly detect new cases and prevent onward transmission.

As of 5 March, 907 EVD cases1 (841 confirmed and 66 probable) have been reported, of which 57% (514) were female and 30% (273) were children aged less than 18 years. Cumulatively, cases have been reported from 121 of 301 health areas across 19 health zones of the North Kivu and Ituri provinces. Overall, 569 deaths (case fatality ratio: 63%) have been reported, and 304 patients have been discharged from Ebola Treatment Centres (ETCs). Although declining trends in case incidence are currently being observed, the high proportion of community deaths reported among confirmed cases, relatively low proportion of new cases who were known contacts under surveillance, persistent delays in detection and isolation in ETCs (related as well to recent violent incidents), and challenges in the timely reporting and response to probable cases, all increase the likelihood of further chains of transmission in affected communities and continued spread.
On 12 February 2019, the Pan American Health Organization / World Health Organization (PAHO/WHO) received a report regarding surgical site infections caused by antibiotic-resistant Pseudomonas aeruginosa after invasive procedures performed in Tijuana, Mexico.
Between 12 and 18 February 2019, the National IHR Focal Point of Oman reported eight additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection. Four cases were reported from South Sharquia governorate, and four cases were reported from North Batinah governorate where a MERS-CoV cluster was recently identified. Details of the additional eight cases can be found in the attached excel sheet.

Since 27 January 2019, a total of 13 MERS cases were reported from Oman, including nine from North Batinah (five cases were previously reported in the Disease outbreak News 11 February 2019) and four from South Sharquia.
The Ebola virus disease (EVD) outbreak is continuing with moderate intensity. Katwa and Butembo remain the major health zones of concern, while simultaneously, small clusters continue to occur in various geographically dispersed locations. During the last 21 days (6 – 26 February 2019), 77 new cases have been reported from 33 health areas within nine health zones (Figure 1), including: Katwa (45), Butembo (19), Vuhovi (4), Kyondo (3), Kalunguta (2), Oicha (1), Beni (1), Mandima (1), and Rwampara (1).

Although there are decreasing trends in case incidence (Figure 2), the high proportion of community deaths reported among confirmed cases and relatively low number of new cases who were known contacts under surveillance could increase the risk of further chains of transmission in affected communities. Response teams must maintain a high degree of vigilance across all areas with declining case incidence and contact tracing activity, as well as in areas with active cases, to rapidly detect new cases and prevent onward transmission. Following attacks this week on the treatment centres in Katwa and Butembo, WHO is working with partners to ensure the safety of the patients and staff. These incidents are disruptive to the response on many levels and can also hamper surveillance activities in the field.
On 12 February, a circulating vaccine-derived poliovirus type 1 (cVDPV1) has been confirmed in Papua province, Indonesia. Two genetically-linked VDPV1 viruses were isolated from a child with acute flaccid paralysis (AFP) with onset of paralysis on 27 November 2018 and in a healthy community contact, a child whose stool sample was collected on 24 January 2019. The location of this healthy child, with the VDPV isolation, is in a remote village, approximately 3–4 km away from the AFP case with onset of paralysis on 27 November 2018. Even though this province shares a border with Papua New Guinea, this outbreak is not linked to the cVDPV1 outbreak currently affecting its neighbouring country.

WHO and partners are supporting the Ministry of Health (MoH) and local public health authorities in conducting a field investigation, a thorough risk assessment and planning an outbreak response. The exact extent and timing of the outbreak response is being finalized. Initial outbreak response immunization (ORI) has been conducted in Yahukimo district and 5718 children under 15 years of age have been immunized with bivalent oral polio vaccine (bOPV). Disease surveillance, including conducting retrospective and active searches for additional acute flaccid paralysis (AFP) cases, has been further strengthened in community health centres, hospitals and other health facilities including all districts and cities in Papua province. Surveillance has also been strengthened at entry and exit ports and monitoring notification and reporting through the Early Warning, Alert, and Response System (EWARS) has been reinforced. Other provinces have been alerted to improve immunization and AFP surveillance.
On 6 February 2019, the National IHR Focal Point of The Kingdom of Saudi Arabia notified WHO of an ongoing outbreak of MERS-CoV infection in Wadi Aldwasir city and one of its hospitals (referred to as Hospital A). Between 29 January and 13 February 2019, 39 cases of MERS-CoV infection, including four deaths, were reported. At the time of writing, this outbreak remains ongoing. Human-to-human transmission has occurred between the index patient and health care workers, patients in the emergency department and intensive care unit (ICU) of Hospital A, and from patients to household contacts. As of 13 February, nine health care workers have been infected. Descriptions of the outbreak are based on information WHO has received as of 13 February 2019; further updates will be provided as they become available.

Details regarding each of the cases are provided in the file linked below.
The Ebola virus disease (EVD) outbreak is continuing with moderate intensity. Katwa and Butembo remain the major health zones of concern, while simultaneously, small clusters continue to occur in various geographically dispersed locations. During the last 21 days (30 January – 19 February 2019), 79 new cases have been reported from 40 health areas within 12 health zones (Figure 1), including: Katwa (46), Butembo (15), Kyondo (4), Vuhovi (4), Kalunguta (2), Oicha (2), Biena (1), Mabalako (1), Manguredjipa (1), Masereka (1), Mutwanga (1), and Rwampara (1).1

No new cases have been reported from the Beni in the last three weeks. This is a significant achievement given the previous intensity of the outbreak in this area. Elsewhere, trends in the case incidence (Figure 2) have been encouraging; however, other indicators (such as the continued high proportion of community deaths, persistent delays in case detection, documented local travel amongst many cases, and relatively low numbers of cases among contacts under surveillance) suggest a high risk of further chains of transmission in affected communities. Response teams must maintain a high degree of vigilance across all areas with declining case and contact tracing activity, as with areas with active cases, to rapidly detect new cases and prevent onward transmission.
On 26 June 2018, an outbreak of circulating vaccine-derived poliovirus type 1 (cVDPV1) was declared in Papua New Guinea following laboratory confirmation of cVDPV1 isolation in two healthy community contacts of the index case. Since the declaration, a total of 26 confirmed cVDPV1 cases have been reported in the following nine provinces: Eastern Highlands (six), Enga (five), East Sepik (four), Madang (three), Morobe (three), Jiwaka (two), Gulf (one), Southern Highlands (one), and National Capital District (NCD) (one). The last laboratory-confirmed case reported having experienced the onset of paralysis in late October 2018. Environmental surveillance continues on a bimonthly basis in Port Moresby and Lae to complement active acute flaccid paralysis (AFP) case search efforts.

To date, there have been five rounds of Supplementary Immunisation Activities (SIA) conducted from July to December 2018. Consultants from WHO and UNICEF have been deployed to provide technical support during pre-campaign preparations and implementation to ensure high quality SIAs and improve AFP case detection. The first round of SIA targeted children under five years of age in three high-risk provinces. The second round included children under five years of age in all nine provinces. The third and fourth rounds of SIA included National Immunisation Days (NIDs) which were aimed at children less than 15 years of age and achieved a coverage of 93% and 97% respectively. The fifth round of SIA was a sub-national campaign conducted in four priority provinces (NCD, Central, Enga, and Angoram district in East Sepik province). Planning is currently ongoing for additional NIDs in 2019.
From 1 January through 31 January 2019, the International Health Regulations (IHR) National Focal Point of Saudi Arabia reported fourteen additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including three deaths.
From 1 January through 10 February 2019, 327 cases of Lassa fever (324 confirmed cases and three probable cases) with 72 deaths (case fatality ratio = 22%) have been reported across 20 states and the Federal Capital Territory, with the majority of cases being reported from Edo (108) and Ondo (103) States.
Despite slightly fewer cases reported during the past week (Figure 1), current epidemiological indicators highlight that the Ebola virus disease (EVD) outbreak is continuing with moderate intensity. Katwa and Butembo remain the major health zones of concern, while simultaneously, small clusters continue to occur in various geographically dispersed regions. During the last 21 days (23 January – 12 February 2019), 97 new cases have been reported from 13 health zones (Figure 2), including: Katwa (59), Butembo (12), Beni (7), Kyondo (4), Oicha (4), Vuhovi (3), Biena (2), Kalunguta (2), Komanda (1), Manguredjipa (1), Mabalako (1), Masereka (1), and Mutwanga (1).1 The recent case reported in the Komanda health zone was a resident of Katwa who was exposed to the virus, and subsequently travelled to both Bunia and Komanda. This case comes one month after the last reported case in Ituri Province; underscoring the high risks of reintroduction to previously affected areas, as well as the potential for spread to new ones.

As of 12 February, 823 EVD cases2 (762 confirmed and 61 probable) have been reported, including 517 deaths (overall case fatality ratio: 63%). Cumulatively, cases have been reported from 118 of 287 health areas across 18 health zones, of which 37 health areas have reported a case in the last 21 days. Thus far, 283 people have been discharged from Ebola Treatment Centers (ETCs) and enrolled in a dedicated monitoring and support programme. One new health worker infection was reported in Katwa. To date, a total of 68 health workers have been infected.
Brazil is currently in the seasonal period for yellow fever, which occurs from December through May. The expansion of the historical area of yellow fever transmission to areas in the south-east of the country in areas along the Atlantic coast previously considered risk-free led to two waves of transmission (Figure 1). One during the 2016–2017 seasonal period, with 778 human cases, including 262 deaths, and another during the 2017–2018 seasonal period, with 1376 human cases, including 483 deaths.

From December 2018 through January 2019, 361 confirmed human cases, including eight deaths, have been reported in 11 municipalities of two states of Brazil. In the southern part of São Paulo state, seven municipalities:El dorado (16 cases), Jacupiranga (1 case), Iporanga (7 cases), Cananeia (3 cases), Cajati (2), Pariquera-Açu (1), and Sete Barras (1) reported confirmed cases. In the same state, additional cases in Vargem (1) and Serra Negra (1) municipalities were confirmed on the border with Minas Gerais State. Additionally, two cases have been confirmed in the municipalities of Antonina and Adrianópolis, located in the eastern part of Paraná State. These are the first confirmed yellow fever cases reported since 2015 from Paraná, a populous state with an international border. Among these confirmed cases, 89% (32/36) are male, the median age is 43 years, and at least 64% (23/36) are rural workers.

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