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The Ebola virus disease (EVD) outbreak response this past week continues to be hampered by insecurity. On 3 May in Katwa, a Safe and Dignified Burial (SDB) team was violently attacked following the completion of a burial for a deceased EVD case. In Butembo and surrounding health zones, response activities were repeatedly halted due to a number of serious security incidents taking place from 4-6 May. On 8 May, a group of over 50 armed militia infiltrated the city centre. Security forces repelled the attack following intense gunfire in close proximity to staff accommodations. Although activities resumed on 9 May, after almost five consecutive days of suspension, threats of further attacks against EVD response teams and facilities remain prevalent.

These security incidents, and especially the resultant lack of access to EVD affected communities, remain a major impediment to the response, with teams unable to perform robust surveillance nor deliver much needed treatment and immunisations. The ongoing violent attacks sow fear, perpetuate mistrust, and further compound the multitude of challenges already faced by frontline healthcare workers. Without commitment from all groups to cease these attacks, it is unlikely that this EVD outbreak can remain successfully contained in North Kivu and Ituri provinces.
From 1 January through 30 April 2019, the Ministry of Health in Tunisia responded to a large measles outbreak in the country. A total of 3 141 suspected cases, of which 909 (28.9%) were laboratory confirmed and 1 236 (39.4 %) epidemiologically linked cases including 30 deaths (case fatality ratio=1.0 %), have been reported in all of the 24 governorates (range 1 – 1 274). The majority of cases were reported from Kasserine (1 274 cases) and Sfax (212 cases) governorates. In April 2019, four additional governorates were particularly affected with 155, 116, 93 and 69 cases reported from Kairouan, Tunis, Sousse and Nabeul respectively.

The two most affected age groups were those older than 15 years (31%) and infants between the age of 6 and 12 months (28%). The male: female ratio was 1.2. Eighty four percent of affected children between 1 and 5 years were not vaccinated. Death was reported in 30 cases ranging in age from 15 days to 41 years of age (median, 7.5 months).
Globally, between 2016 and 2017, the number of reported measles cases increased by 31%, while in the WHO Western Pacific Region (WPR), the total number of cases reported decreased by 82% during the same period. However, there was an increase in cases reported in WPR, from 11 118 in 2017 to 26 163 cases in 2018. A resurgence of measles cases has been seen in all WHO Regions. An unusually high number of cases reported from countries and areas of the WPR in 2019 have been reported from: 1) several countries/areas where measles has been eliminated due to importation-related outbreaks; and 2) endemic countries such as the Philippines which has ongoing measles outbreak. In WPR, currently nine countries and areas (Australia, Brunei Darussalam, Cambodia, Hong Kong SAR (China), Japan, Macao SAR (China), New Zealand, the Republic of Korea, and Singapore) are verified by the Regional Verification Commission for Measles Elimination as having interrupted endemic measles virus transmission for more than 36 months.

To date, there have been no measles cases reported from the Pacific Island Countries and areas. The majority of countries and areas in WPR have made positive inroads to improve immunization and achieve higher vaccination coverage at the national level. However, with global resurgence of measles and movement of populations, several countries and areas in WPR remain vulnerable to outbreaks of measles due to low coverage of measles-containing-vaccine (MCV), at the subnational level and among vulnerable populations.
In the first two months of 2019, 34 300 measles cases have been reported in 42 countries of the WHO European Region, including 13 measles-related deaths in three countries (Albania, Romania and Ukraine). The majority of cases are reported in Ukraine, with more than 25 000 cases (>70%)1.

As of 28 March 2019, the WHO European Region reported a total of 83 540 measles cases and 74 related deaths for 2018. This is compared to 25 869 cases and 42 deaths in 2017, and 5 273 cases and 13 deaths in 2016. In 2018, eight countries reported over 2 000 cases each including Ukraine (n= 53 218), Serbia (n=5 076), Israel (3 140), France (n=2 913), Italy, (n=2 686), Russian Federation (n=2 256), Georgia (n=2 203) and Greece (n=2 193).
The operating environment has become increasingly insecure and socio-politically complex. Insecurity remains a major impediment to ensuring timely response interventions in the affected communities. Ebola virus disease (EVD) response activities in Butembo and Katwa remained limited; however, are gradually resuming following a comprehensive reinforcement of security measures and community engagement efforts. The overall security situation, nevertheless, remains volatile. While, no significant injuries or damages are reported this week, access and activities in parts of Mandima, Masereka, Kalunguta and Vuhovi, remain irregular due to the presence of armed groups and other security concerns. New EVD cases are expected to continue to increase, in tandem with incidents of insecurity in these hotspot areas over the coming weeks, placing significant strain on response teams and the security resources available to secure their movements.

Incidence of EVD cases in the Democratic Republic of the Congo this week saw a considerable, although not unexpected, rise compared to the week prior. This observation is in line with previous instances where a disruption to response activities was followed by a spike in the number of new cases. Transmission remains most intense in the Katwa, Butembo, and Mandima hotspot areas (Figure 1 and Table 1). In addition, notable recurring re-introduction events having been documented in previously affected health zones such as Mabalako and Musienene, followed by local amplification and extension to affect new heath areas. In the 21 days between 10 – 30 April 2019, 70 health areas within 15 health zones reported new cases; 45% of the 157 health areas affected to date (Table 1 and Figure 2). During this period, a total of 292 confirmed cases were reported, the majority of which were from the health zones of Katwa (47%, n=137), Butembo (13%, n=38), Mandima (11%, n=32), Mabalako (7%, n=20), and Musienene (6%, n=17).
On 9 February 2019, the government of Congo officially declared an outbreak of chikungunya virus disease.
This past week witnessed a notable escalation of security incidents surrounding the Ebola virus disease (EVD) response efforts. On 19 April, an attack on a hospital in Katwa by armed militia resulted in the tragic death of Dr Richard Mouzoko Kiboung, a WHO epidemiologist, and the injury of two other healthcare workers. To ensure the safety of all outbreak responders, Ebola response activities have been temporarily halted in some high-risk health areas until security measures can be reinforced.

WHO, the UN, and the government of the Democratic Republic of the Congo are actively collaborating to review current strategic and operational security measures to ensure the protection of healthcare workers in the field, and improve effective coordination and information sharing amongst all security elements covering the response. Existing operational security measures continue to be implemented and strengthened as well, including the establishment of security perimeters around the residences of EVD response personnel, increasing security at fixed locations, enhancing the joint quick response team (QRT) capacities of local police and UN security forces, and ensuring staff compliance with tracking procedures and adherence to curfew. These measures and other security risk management processes will be continually updated to reflect the needs of the evolving security situation on the ground.
From 14 February through 31 March 2019, the National IHR Focal Point of Saudi Arabia reported 22 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including four deaths, associated with the outbreak in Wadi Aldwasir.
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.

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