WHO TB News

On 17 July 2019, the Director-General convened the Emergency Committee under the International Health Regulations (IHR) to review the situation on the Ebola outbreak in the Democratic Republic of the Congo (DRC).
From 1 through 31 May 2019, the National International Health Regulations (IHR) Focal Point of Saudi Arabia reported 14 additional cases of Middle East respiratory syndrome (MERS-CoV) infection, including five deaths. Of the 14 cases reported, four cases were associated with two separate clusters. Cluster 1 involved two cases (case no. 6 and case no. 7) living in the same household in Alkharj, Riyadh, and cluster 2 involved one patient (case no. 9) and one healthcare worker (case no. 11) in Riyadh.

The link below provides details of the 14 reported cases:
The outbreak of Ebola virus disease (EVD) in North Kivu and Ituri provinces, Democratic Republic of the Congo continues this past week with a similar transmission intensity to the previous week.
The outbreak of Ebola virus disease (EVD) in North Kivu and Ituri provinces, Democratic Republic of the Congo continued with a steady transmission intensity this week. Indicators demonstrated the early signs of transmission easing in intensity in some major hotspots, such as Butembo and Katwa. The current hotspots are the health zones of Beni, Mabalako, and Mandima, with some cases being exported from these hotspot areas into unaffected health zones. There is a slight but notable increase in the number of new cases occurring in areas that previously had lower rates of transmission, such as the Komanda, Lubero, and Rwampara/ Bunia health zones. On 30 June, a case who had travelled overland from Beni was confirmed in Ariwara, more than 460 kilometres north of Beni, towards the borders with Uganda and South Sudan. This is the first confirmed case in this health zone, and a response team was deployed from Bunia to investigate and implement public health actions in Ariwara. Uganda and South Sudan have mobilized quickly, building on the preparedness efforts during the last months. Arua district in Uganda shares a border with Ariwara health zone, with high volume of trade and population movement. The Arua District Task Force in Arua mobilized on 2 July to agree on a plan of action, the Ministry of Health (MoH) immediately dispatched the National Rapid Response Team for needs assessment, and the vaccination team from Kasese was also dispatched to Arua district on 3 July to start vaccinating the front-line health workers. In South Sudan, WHO and the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) convened a joint meeting with implementing partners on 2 July to plan and coordinate field missions. Joint teams were dispatched to Kei State on 3 July to support operational readiness activities.

In the 21 days from 12 June through 02 July 2019, 73 health areas within 20 health zones reported new cases, representing 11% of the 664 health areas within North Kivu and Ituri provinces (Figure 2). During this period, a total of 285 confirmed cases were reported, the majority of which were from the health zones of Mabalako (30%, n=85), Beni (27%, n=76), Mandima (8%, n=23), Lubero (6%, n=16) and Kalunguta (5%, n=14). As of 02 July 2019, a total of 2369 EVD cases, including 2275 confirmed and 94 probable cases, were reported (Table 1). A total of 1598 deaths were reported (overall case fatality ratio 68%), including 1504 deaths among confirmed cases. Of the 2369 confirmed and probable cases with known age and sex, 56% (1334) were female, and 29% (691) were children aged less than 18 years. Cases continue to rise among health workers, with the cumulative number infected rising to 130 (6% of total cases).
On 25 April 2019, the local administration in Larkana district was alerted by media reports of a surge in human immunodeficiency virus (HIV) cases among children in Ratodero Taluka, Larkana district, Sindh province, Pakistan. A screening camp was initially established at Taluka’s main hospital. Later, screening was expanded to other health facilities including selected Rural Health Centers (RHCs) and Basic Health Units (BHUs). HIV rapid test kits that were initially used were replaced with pre-qualified WHO test kits.

From 25 April through 28 June 2019, a total of 30,192 people have been screened for HIV, of which 876 were found positive. Eighty-two per cent (719/876) of these were below the age of 15 years. During the screening, several risk factors were identified, including: unsafe intravenous injections during medical procedures; unsafe child delivery practices; unsafe practices at blood banks; poorly implemented infection control programs; and improper collection, storage, segregation and disposal of hospital waste.
The Ebola virus disease (EVD) outbreak in the North Kivu and Ituri provinces continues at a stable pace this week. Although response operations were temporarily interrupted in Beni following two days of insecurity in the surrounding areas, operations have largely resumed. However, in the town of Musienene, violent threats persist against healthcare workers (HCW) and local security forces providing assistance to the response efforts. Furthermore, response activities in Kambau health area, Manguredjipa health zone were also suspended following security incidents.

Of growing concern this week, are the current hotspots of Mabalako, particularly the Aloya health area, and Mandima (Figure 1), which were the first health zones to report EVD cases in August/September 2018. Sporadic reintroduction events in areas such as Vuhovi, which had not reported any new cases in the past 24 days, further compound the evolving situation. Other areas experiencing a similar resurgence in EVD cases after a period of prolonged absence include Komanda and Masereka.
This week saw a continued, gradual decrease in the number of new Ebola virus disease (EVD) cases from the hotspots of Katwa and Butembo compared to the previous weeks. However, these encouraging signs are offset by a marked increase in case incidence in Mabalako Health Zone, and especially in Aloya Health Area (Figure 1). While the spread of EVD to new geographic areas remains low, in the health zones of Bunia, Lubero, Komanda and Rwampara, recent reintroduction events illustrate the high risks in previously affected areas. Along with the rise in cases in Mabalako, there was also an accompanying increase in healthcare worker (HCW) and nosocomial infections. These findings highlight the ongoing need to comprehensively strengthen the infection prevention and control measures in the various healthcare facilities operating in these areas. The occurrence of EVD infections in these health areas also place a strain on the already limited security resources needed to facilitate access for effective response activities to continue.

In addition to operational challenges encountered on the ground by healthcare workers during the past ten months, the overall EVD outbreak response effort is confronting substantial difficulty in maintaining scale in the context of a US $54 million funding shortage. Without adequate funding to fill this gap, response activities will be compromised, negatively impacting the entire response, resulting in a drastic reduction in vital health services available and a cessation of operations during a critical time of the outbreak. Member States and other donors are strongly encouraged to help meet this funding gap in order to ensure that hard won progress in containing this EVD outbreak will not suffer a potentially devastating setback due to financial limitations.
The Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo (DRC) continues to show a decrease in the number of new cases in hotspots such as Katwa, Beni and Kalunguta health zones. However, in other areas such as Mabalako and Butembo, moderate rates of transmission continue. With ongoing EVD transmission within communities in 12 health zones in North Kivu and Ituri provinces, factors such as persistent delays in case detection, approximately a third of cases dying outside of Ebola treatment or transit centres, and high population mobility, pose a high risk of geographical spread both within the DRC and to neighbouring countries. This was highlighted by the recent exportation of cases to Uganda – the first confirmed cases detected outside of North Kivu and Ituri province since the onset of the outbreak over 10 months ago. For more information, please see Disease Outbreak News

Weekly decreases in the incidence of new cases have been reported in several health zones; however, increase or a continuation of the outbreak has been observed in others (Figure 1). In the 21 days, between 22 May to 11 June 2019, 62 health areas within 12 health zones reported new cases, representing 9% of the 664 health areas within North Kivu and Ituri provinces (Figure 2). During this period, a total of 212 confirmed cases were reported, the majority of which were from the health zones of Mabalako (33%, n=69), Butembo (18%, n=39), Katwa (14%, n=30) Mandima (11%, n=23) and Beni (9%, n=20). Single confirmed cases were also reported from Rwampara and Komanda health zones this past week following a prolonged period since the last reported case, with both cases acquiring the infection in the aforementioned hotspots.
On 11 June 2019, the Ugandan Ministry of Health (MoH) has confirmed a case of Ebola Virus Disease (EVD) in Kasese district, Uganda. The patient is a 5-year-old child from the Democratic Republic of Congo (DRC) who travelled with his family from Mabalako Health Zone in DRC after attending, on 1 June 2019, the funeral of his grandfather (confirmed EVD case on 2 June 2019). On 10 June 2019, the child and the family entered the country through Bwera border post and sought medical care at Kagando hospital where health workers identified Ebola as a possible cause of illness. The child was transferred to Bwera Ebola Treatment Unit (ETU) for management. The confirmation of Ebola Virus was made on 11 June 2019 at the Uganda Virus Research Institute (UVRI), and the child has deceased in the early hours of 12 June 2019. Two other suspected cases, a 50-year-old female (grandmother of the first case) and 3-year-old male (younger brother of the first case) part of the family members who travelled together with the first confirmed child were also admitted in the same ETU and were confirmed for EVD by UVRI on 12 June 2019. The 50 year-old-male has deceased during the night between 12 and 13 June. 27 other contacts have been identified and are being monitored. Healthcare workers from both health care facilities where the child was treated have been previously vaccinated.

All three confirmed cases are imported from DRC and belong to the same family who travelled together from Mabalako Health Zone, an area currently affected by Ebola outbreak in North Kivu, DRC. To date, they remain as a single episode of EVD in Uganda, and the geographical spread in Uganda appears to be limited to one district near DRC border. Further investigations are ongoing both in Uganda and DRC to assess the full extent of the outbreak.
On 23 May 2019, WHO received notification through the Global Polio Laboratory Network (GPLN) of the detection of circulating vaccine-derived poliovirus type 2 (cVDPV2) from an environmental sample collected on 20 April 2019 in a hospital in Northern Cameroon which borders Borno state in Nigeria and Chad.
As the Ebola virus disease (EVD) outbreak surpasses the 2000 case mark, indicators over the past two weeks provide early signs of an easing of the transmission intensity. This follows a period of improved security and therefore access to communities, allowing response teams to operate more freely. A total of 88 confirmed cases were reported each week for the past two epidemiological weeks, down from a peak of 126 cases per week observed in April. Declines in the incidence of new cases have been most apparent in hotspots such as Katwa, Mandima and Beni health zones. Concurrently, improvements in the proportion of cases among contacts registered prior to onset (up from 30% three weeks ago to 55% last week), and a lower proportion of cases resulting from transmission within community health facilities (from 31% during the first week of April 2019 to 9% during the last week of May 2019), are encouraging. Nevertheless, both indicators are below where we would aim to be. The outbreak continues to be contained within 12 active health zones in North Kivu and Ituri provinces.

However, substantive rates of transmission continue within affected communities, and further waves of the outbreak may be expected. An increase in the incidence of new cases has been reported from Mabalako Health Zone in recent weeks, and high infection rates continue within Butembo metropolitan. Times between detecting, reporting and admission of cases at Ebola treatment/transit centres (ETCs) remains too long (median 6 days, interquartile range 4–9 days in the past 3 weeks), with about a third (34% in the past 3 weeks) of cases dying outside of ETCs. Collectively these indicators highlight that the risks associated with this outbreak remain very high.
A decline in the number of confirmed Ebola virus disease (EVD) cases has been reported this week (22 to 28 May). Over the past seven days, a total of 73 new confirmed cases were reported compared to the previous where 127 new confirmed cases were reported. This should be interpreted with caution given the complex operating environment and fragility of the security situation. Katwa, one of the epicenters of the outbreak, reported fewer cases this week and other health zones such as Mabalako, Kalunguta and Mandima have also seen a decline in case reporting. Active transmission was reported in 14 of the 22 health zones that have been affected to date. Other initial encouraging findings such as a lower proportion of reported nosocomial infections, a lower proportion of community deaths and a higher proportion of registered contacts at case detection have also been reported. Weekly fluctuations in these indicators have been reported in the past and uncertainties remain with regards to the ability of the surveillance system to identify all new cases in areas faced with ongoing insecurity. Operations are still regularly hampered by security issues, and the risk of national and regional spread remains very high.

Mabalako reported 24% (73/309) of the new confirmed cases in the past 21 days. Nine out of the 12 Mabalako health areas have reported new confirmed cases during this period. In the 21 days between 8 to 28 May 2019, 83 health areas within 14 health zones reported new cases, representing 46% of the 180 health areas affected to date (Table 1 and Figure 2). During this period, a total of 309 confirmed cases were reported, the majority of which were from the Mabalako (24%, n=73), Butembo (21%, n=64), Katwa (14%, n=42), Beni (11%, n=34), Kalunguta (10%, n=31), Musienene (7%, n=23) and Mandima (6%, n=20) health zones.
On 9 May 2019, the Global Polio Laboratory Network (GPLN) notified WHO of the detection of wild poliovirus type 1 (WPV1) from an environmental sewage sample collected on 20 April 2019 in Konarak district, Sistan-Baluchistan province, Islamic Republic of Iran. The virus was detected in an environmental sample only, and to date, no associated cases of paralysis have been detected.

The subsequent scheduled sewage sample collected from the same site on 4 May 2019 (2 weeks after the positive sample) tested negative for poliovirus.
Although this past week continues to bear witness to a steady rise in the number of Ebola virus disease (EVD) cases in the Democratic Republic of the Congo, the overall security situation has allowed for the resumption of most response activities. While no major insecurity incidents have occurred, outbreak response teams, local healthcare workers, and community members cooperating with response efforts, are increasingly subjected to threats made against them by armed groups present in hotspot areas such as Katwa and Butembo. These threats are often disseminated through leaflets or direct intimidation. Armed groups’ presence, activities and increasing direct threats against response teams continue to be reported in other EVD affected areas, in particular Lubero, Masereka, Mabalako, Kalunguta, and Vuhovi, resulting in some healthcare workers being unwilling to don personal protective equipment or perform critical Infection Prevention Control (IPC) measures out of fear of violence being levied against them or the healthcare facilities where they operate.

During the past three weeks, reports indicate that transmission remains most intense in seven main hotspot areas: Beni, Butembo, Kalunguta, Katwa, Mabalako, Mandima, and Musienene. Collectively, these health zones account for the vast majority (93%) of the 349 cases reported in the last 21 days between 1 - 21 May 2019 (Figure 1 and Table 1). During this period, new cases were reported from 91 health areas within 15 of the 22 health zones affected to date (Figure 2).
On 16 March 2018, WHO was notified by the National International Health Regulations (IHR) Focal Point of France, through the European Commission Early Warning and Response System, of an increase in the number of dengue cases reported on La Réunion Island, France, since the beginning of 2018.
From 9 through 30 April 2019, the National International Health Regulations (IHR) Focal Point of Saudi Arabia reported nine additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including three deaths.
Although the security situation has subsided mildly into an unpredictable calm, the transmission of Ebola virus disease (EVD) continues to intensify in North Kivu and Ituri provinces with more than 100 confirmed cases reported this week.

The main drivers behind the continued rise in cases stems from insecurity hampering access to critical hotspot areas, persistent pockets of poor community acceptance and hesitation to participate in response activities, and delayed detection and late presentation of EVD cases to Ebola Treatment Centres (ETCs)/Transit Centres (TCs).
On 9 May 2019, the Ministry of Health (MOH) in Singapore notified WHO of one laboratory-confirmed case of monkeypox. The case-patient is a 38 year old Nigerian man who arrived in Singapore on 28 April 2019 and attended a workshop from 29-30 April. Prior to his travel to Singapore, he had worked in the Delta state in Nigeria, and had attended a wedding on 21 April 2019 in a village in Ebonyi State, Nigeria.

The patient developed fever, muscle aches, chills and skin rash on 30 April. He reported that he had remained in his hotel room most of the time between 1 and 7 May. He was transferred to a public hospital by ambulance on 7 May and referred to the National Centre for Infectious Diseases (NCID) on the same day, where he was isolated for further management. Skin lesion samples were taken on 8 May and tested positive for monkeypox virus by the National Public Health Laboratory on the same day. He is currently in a stable condition.
On 4 January 2019, the National IHR Focal Point for France informed WHO of five human autochthonous cases of Rift Valley Fever (RVF) diagnosed on Mayotte Island through the Early Warning and Response System of the European Union. The dates of symptom onset ranged from 22 November to 31 December 2018.

From November 2018 to 03 May 2019, 129 confirmed human Rift Valley Fever (RVF) cases and 109 animal foci (23 small ruminants and 86 bovine) have been reported in Mayotte. After a steady decline in cases during the last three weeks of March 2019, a slight increase has been observed in April 2019. As of 3 May 2019, one new human case but no new animal foci have been reported. Both human RVF cases and animal foci are mainly located in the center and the north west of the main island Grande-Terre. However, since the end of March 2019, a few new animal foci have also been detected in the east of Grande-Terre and in Petite Terre of Mayotte.
From 1 March through 8 April 2019, the National International Health Regulations (IHR) Focal Point of Saudi Arabia reported 45 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 13 deaths.

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