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Crisis Info #3

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Crisis Info #3

TIMELINE

  • 30/7: MSF is informed about suspect cases of Ebola near Beni/Mangina, North Kivu.

  • 31/7: An MSF team from the nearby project in Lubero (roughly three hours away by car) arrives on site (with the Ministry of Health) to investigate.

  • 1/8: The Ministry of Health declares an Ebola outbreak in Mangina, North Kivu, in north-eastern Democratic Republic of Congo.
  • 1-3/8: MSF prepares to respond to the outbreak, within the masterplan of the Ministry of Health.
  • 6/8: An MSF isolation unit is installed in Mangina reference health centre, trainings are done on the use of personal protective equipment (PPE), as well as triage, and infection prevention & control (IPC).
  • 7/8: Results of genetic analysis from the national laboratory confirm that the circulating virus is of the Zaire species, but a different strain from the one reported in the Equator outbreak earlier this year.
  • 8/8: Vaccination of frontline health workers begins under WHO’s supervision (not done by MSF).
  • 14/8: MSF’s treatment centre opens in Mangina (in tents 300m from the isolation unit). 37 suspected and confirmed cases are admitted on opening day. Originally designed for 30 beds, its capacity has immediately been extended to 68 beds and can be extended to 74 if needed.
  • 14/08: Decontamination of the local health centre in Mangina in addition to other health centres with confirmed cases.
  • 24/08: MSF begins offering therapeutic drugs to eligible patients in the ETC in Mangina.
  • 28/08: MSF opens a transit centre in Makeke.
  • 08/09: MSF opens an isolation centre in Butembo and begins building an ETC to cater for a possible influx of patients.
  • 09/09: MSF sends a team to Loutu  (one hour from Lumbero) to investigate a recent case and set up a response to future cases in the village.
  • 20/09: MSF opens a 28-bed (12 isolation, 16 hospitalization) Ebola Treatment Centre in Butembo in partnership with the Ministry of Health.
  • 24/09: MSF sends a team to Tchomia, on Lake Albert in Ituri, to attend to 2 confirmed cases (one death and one in isolation). MSF sets up an isolation unit and, in collaboration with the Ministry of Health, is planning to build in collaboration a 12-bed Ebola Treatment Centre.

THE AREA

Mangina, the epicentre of the outbreak, (40,000 inhabitants) is located in North Kivu, in north-eastern Democratic Republic of Congo. Beni, the administrative centre of the area, is 32 km away (45 minutes by car) and is home to approximately 420,000 inhabitants. Butembo, located to the south, is a city of about 1 million inhabitants.

The region of North Kivu is a densely populated area of conflict, where more than one hundred armed groups are estimated to be active. Moving around some areas in the region is quite difficult and sometimes impossible.

Kidnappings and carjackings are relatively common and skirmishes between armed groups occur regularly across the area.

While most of the urban areas are relatively less exposed to the conflict, attacks and explosions have nonetheless taken place in Beni as well, sometimes limiting MSF action.

North Kivu shares a border with Uganda to the east (Beni is approximately 100 km from the border).

This area sees a lot of trade, but also traffic, including “illegal” crossings. Some communities live on both sides of the border meaning that it is quite common for people to cross the border to visit relatives or trade goods at the market on the other side.

THE OUTBREAK

Total number of cases as per Ministry of Health data on the 26/09/18

  • Confirmed (123) + Probable* (31) = 154 total cases

  • Suspect cases: 11
  • Deaths amongst confirmed cases: 70
  • 19 health staff infected

*Probable refers to community deaths that have links to confirmed Ebola cases but which were not tested before burial.

Retrospective investigations point to a likely start of the outbreak back in May. The delay in alert/response can be attributed to several factors, including a breakdown of the surveillance system due to strikes by local health staff whose salaries had not been paid for several months, as well as the difficult security situation (limitations to movement, difficulty of access).

Given that the origin of the outbreak is still being investigated, however, we cannot draw solid conclusions.

The initial alert came after a woman from Mangina was admitted to the local health centre on 19 July for a heart condition. She was discharged but died at home on 25 July with symptoms of haemorrhagic fever.

Members of her family subsequently developed the same symptoms and died. A joint Ministry of Health/WHO investigation on site found six more suspect cases, of which four tested positive. This result led to the declaration of the outbreak on 1 August.

The national laboratory (INRB) confirmed on 7 August that the current outbreak is the Zaire strain of the virus, the most deadly virus and the same that affected West Africa in 2014-2015 as well as Equator province, in western DRC, earlier in 2018 – although the virus’ strain was different from one outbreak to another. 

Eight weeks after the declaration of the epidemic, the epidemiological situation in North Kivu is still concerning and nine health zones in North Kivu and Ituri provinces (Mandima, Mabalako, Beni, Oicha, Butembo, Kalunguta, Masareka and Musienene) have so far reported confirmed or probable cases of Ebola.

It does appear that the epidemic is calming in the epicentre of Mangina, in the Mabalako health zone, but it’s not over yet: a new confirmed case was recorded on 23 September.

The spread of the disease to Butembo, a city of about 1,000,000 people, is a cause for real alarm; another reason for concern is the geographically scattered pattern of the outbreak. Likewise, Beni continues to see new cases diagnosed regularly.

A new case emerged in Tchomia on 20/09, 60 km south of Bunia in Ituri province. The infected patient died in the Hospital of Tchomia, but was probably infected in Beni and travelled all the way up north. The epidemic is now getting very close to the Ugandan border, increasing the risk of a spill over into this country.

Epidemiological teams are still working on identifying all active chains of transmission. This is not simple given that the local community in the affected areas is highly mobile and moves from village to village for work and family reasons, as well as to seek health care. 

Sick people have been known to visit more than one health centre before being identified as suspect cases and referred to an Ebola Treatment Centre.

Since the beginning of the outbreak more than 1,842 contacts have been identified and more than 1,704 are being followed up by the Congolese Ministry of Health. The contact tracing and follow-up is done by the Ministry of Health with a team of epidemiologists.

We also don’t have a clear idea of how many unreported deaths could happen at community level especially in villages where people from the larger towns reportedly return when they fall sick.


Health workers are preparing themselves and putting on the PPE outfit to enter the high-risk zone of the centre. Photo: Carl Theunis/MSF

MSF’S ROLE

At the Ministry of Health’s request, MSF is part of the task force coordinating the intervention and is focusing on caring for patients affected by the virus, vaccination of frontline workers, as well as protecting local health structures (and their workers) by helping with triage, decontamination and trainings.

In total, over 330 staff are currently working in MSF’s Ebola projects in North Kivu and Ituri.

MSF first improved an isolation unit for suspect and confirmed cases in the Mangina health centre, the epicentre of the outbreak where patients were isolated and cared for while a treatment centre was built. A treatment centre opened on 14 August.

Teams have been progressively increasing the level of supportive care (oral and IV hydration, treatment for malaria and other coinfections as well as treatment of the symptoms of Ebola) and have also been able to offer new experimental therapeutic treatments to patients with confirmed Ebola infection under the MEURI protocol.

These treatments are given only with the informed consent of the patient (or a family member if they are too young or too sick to consent) and are provided in addition to the supportive care.

The centre has a capacity of 68 beds and can extend to 74 if required.

Likewise Butembo, a town estimated to be home to 1,000,000 people, has seen imported cases from Beni. MSF responded immediately, setting up an isolation centre in a local hospital, followed by an Ebola Treatment Centre – jointly operated by the MSF and the Ministry of Health – on 20 September. There have been two confirmed cases and 4 suspect patients are currently being treated.

As of 22 September, MSF had treated 74 patients confirmed to be suffering from Ebola and admitted a total of 195 patients for testing for the virus in Mangina and Butembo. Of the patients confirmed Ebola positive in MSF’s Ebola Treatment Centre, 33 have recovered and returned to their families while 5 confirmed patients and 8 suspect patients remained under treatment.

Another isolation centre was built by MSF in Beni and handed over to the Ministry of Health, who assigned it to another NGO – it is now a treatment centre.

Health centres in Mangina and Beni that have seen positive cases are also being decontaminated – MSF is also involved in these infection prevention and control activities.

Furthermore, there are MSF teams working in the Beni and Mangina areas as well as in Ituri, between Mambasa and Makeke (on the border with North Kivu) and Bunia – Tchomia axes, visiting health centres and training staff on the proper triage of Ebola suspects, as well as setting up isolation areas in case of need.

MSF teams also built a 7-bed transit centre in Makeke (on the North Kivu-Ituri border), where suspect patients could be isolated and tested for the virus and transferred to Ebola Treatment Centres in Mangina or Beni. The centre has now been closed because the Ministry of Health and IMC (International Medical Corps) opened an Ebola Treatment Centre in Makeke.

Further south, MSF sent a rapid response team to Luotu, a village outside of Lubero, on 9 September in response to alerts of a positive case. The team was composed of a doctor, nurse and water and sanitation expert and was not only involved in case investigation but also in building a small isolation unit in an existing structure to receive suspected cases.

The positive case had spent time in the health centre before dying at home, many of the health centre staff, as well as family, are high-risk contacts. Fortunately, no confirmed cases were registered and MSF withdrew its staff on 27/09 from this centre, leaving the structure to the Ministry of Health.

MSF is also vaccinating frontline workers (health staff, religious leaders, burial workers etc.) from Makeke on the Ituri-North Kivu border up to Biakato.

Given that the population from Mangina move often in this direction, it is hoped that this vaccination will help to stop the infection spreading further into Ituri. So far, 360 frontline workers have been vaccinated by MSF.

Currently, MSF is also collaborating with the Ministry of Health to contribute to the intervention launched in Tchomia (Ituri) in response to new confirmed cases.

MSF’s teams in Uganda have also been mobilized to be ready in case the outbreak spills over across the border. They have installed an isolation tent in Bwera, a small town directly across the border from Beni and Butembo. MSF’s regular project in Hoima (Uganda) has also set-up an isolation tent.

Likewise, all MSF regular projects in the North Kivu and Ituri areas have also been supplied with Ebola equipment including PPE and have put proper hygiene and infection control protocols in place to safeguard staff and patients from the risk of contamination should the epidemic spread further.


Very important, but they often don’t get a lot of credit in an Ebola intervention: the washing team (hygienists). 
Photo: Carl Theunis/MSF

TALKING POINTS  

NB: We are not doing any leverage communication, just speaking about what we see and do at this stage, this is not 2014 and we don’t feel the need to push on anything specific for now. Furthermore, the Ministry of Health (MoH) is leading the response so all of our activities are done in conjunction with them, DON’T FORGET THIS.

  • The epidemiological situation in North Kivu and Ituri is concerning, with cases having spread to Butembo (a city estimated to be home to 1,000,000 people), the Uganda border on Lake Albert and other areas – from a geographic point of view, the virus is spreading even if the number of cases is not booming. Epidemiologists are still working on identifying all active chains of transmission. This is not simple, given that some cases have occurred in highly insecure areas and local people move frequently between villages and towns for work and family reasons. They also tend to return to their villages of birth when they are sick or fear they may die. The fact that we are not seeing thousands of cases or an increase in the number of new cases cannot be a reason to let our guard down. We will not be able to say that the epidemic is under control until all chains of transmission are identified and all contacts followed up closely.

 

  • One of the most important parts of any Ebola epidemic is earning the trust of the community. This is done through transparency in the careful implementation of the six pillars: isolation are proper care for the sick, surveillance, health promotion, contact tracing, safe burials and the protection of the regular health care system. In every Ebola outbreak we face issues of resistance from a community that is afraid and uncertain. This is understandable because Ebola is a terrifying disease with a survival rate of less than 50%. Community resistance is a sign we need to work more closely with local residents, the community should not be blamed for the spread of the outbreak.

 

  • This is the first time that an Ebola epidemic has occurred in an area of conflict. As such, there were practical challenges in mounting the response. When we began working in Mangina we did not have a good understanding of the dynamics in the local context which is rife with violence and heavily militarized. This was compounded by the fact that we also struggled to find available, experienced people to be quickly deployed in the field. As such we prioritized caring for the 40+ Ebola positive patients we received in the first week of operations and took the decision to work only inside the treatment centre rather than out in the community. Beni has been subject to a major incident recently which disrupted the Ebola response for a few days. In any Ebola response, community outreach and health promotion activities are key in gaining the trust of the community.

Complementary point, to add context if needed without proactive push: the outbreak is in the area where four MSF national staff were kidnapped in 2013. MSF has still not ascertained the whereabouts of our three staff and is without news. Their safety is of the utmost importance of MSF. (https://www.msf.org/drc-release-our-colleagues-abducted-four-years-ago).

  • A really troubling aspect of this outbreak is the continued infection of health care workers working in regular (non-Ebola) health structures across the affected region. Many confirmed cases are being found admitted in regular wards where there are likely to infect patients seeking care for health conditions like malaria, pneumonia or complications of pregnancy, as well as the staff that care for them. As such, beyond caring for patients infected with the virus, MSF is supporting the local health system with infection prevention and control (IPC). This means that we are working to support health centres and general hospitals to quickly identify suspect Ebola patients in order to isolate them in purpose-made structures. This will protect staff and non-Ebola patients from infection and ensure continuity of care for other types of health issues because health centres will not be closed following positive cases.  This activity is called infection prevention and control and is one of the six pillars of an Ebola outbreak response. Furthermore, a functioning health system with staff educated about Ebola is much more likely to pick up cases early. Hospitalizing and treating a patient as soon as possible after the onset of symptoms helps to halt the spread of the virus.

 

  • MSF is vaccinating frontline workers (health staff, religious leaders, burial workers etc.) from Makeke on the Ituri-North Kivu border up to Biakato. Given that the population from Mangina often travels in this direction, it is hoped that this vaccination will help to stop the infection spreading further into Ituri. So far 360 frontline workers have been vaccinated.
  • While there is yet no confirmed treatment for Ebola, MSF is offering developmental drugs on a case by case basis: Five new drugs (Favipiravir, Remdesivir (GS5734), REGN3470-3471-3479, ZMapp and mAb114) are available in DRC under the MEURI protocol. These drugs have also been approved by the Congolese ethical review board and MSF’s own ethical review board for use in patients with confirmed Ebola.
    • Each therapeutic has specific requirements in terms of cold chain, logistics and monitoring with some requiring long infusions and storage at temperatures below - 20 and others consisting of tablets that can be kept at room temperature and taken orally. Likewise, they have different side effects. Some are better than others for use in pregnant women or for patients suffering from specific symptoms.
       
    • As such, the decision on which drug to offer a patient is taken by the treating clinicians and requires the informed consent of the patient or their parent/guardian if they are under 18. The clinicians are supported by a scientific committee made up of WHO, MoH, INRB and MSF.
       
    • So far, 20 patients have received one of these drugs in in Mangina and 4 in Butembo. For reasons of patient confidentiality, we will not be commenting on their clinical status.

Georgie works already since the opening as a hygienist in the ETC of Mangina. Photo: 
Carl Theunis/MSF

NB: MEURI is not a clinical trial but a framework set up following the West African Ebola epidemic to allow drugs not yet registered but showing promising results in early stage trials to be offered to patients during outbreaks of diseases with high mortality rates like Ebola. As such, conclusions about the efficacy of any of these drugs cannot be determined by the survival rates of those who receive them. Further trials will be needed before the can be officially registered.
 

MSF PRESENCE IN EASTERN DRC

MSF has been operational in North Kivu since 2006. Today, we have regular projects in

North Kivu:

  • Bambo: ER, paediatrics, nutrition and support 3 health centres.

  • Kibirizi: ER, paediatrics, nutrition and support 2 health centres.

  • Lubéro: ER, paediatrics, nutrition and support 2 health centres.
  • Rutshuru (planned): surgery, ER, paediatric nutrition.
  • Goma: HIV support at Virunga Hospital + 5 health centres, Eprep for mass casualty plans, cholera treatment centres.
  • Masisi: support regional hospital, health centres and mobile clinics for malaria care
  • Mweso: support 12 health centres and the general hospital.
  • Walikale: general hospital on pediatric, nutrition, maternity and laboratory services and 4 health centers.

We also have pre-existing projects in nearby provinces:

Ituri:

  • Bunia: support to 9 health centres in 2 health zones - primary healthcare and referrals.

  • Mambasa: medical care for victims of sexual violence and treatment for sexually-transmitted infections (The regular project in Mambasa is currently on standby, with teams supporting the Ebola intervention)

  • Adi: healthcare to South Sudanese refugees and local population

 

South Kivu:

  • Lulingu: post-conflict assistance to both displaced and host communities in the area.
  • Kalehe: primary and secondary health care.
  • Mulungu-Kaniola: primary and secondary health care, EPI, pediatrics, referrals.