Ebola – DRC+
Public Health Emergency of International Concern (PHEIC)
Ebola Outbreak in DRC 60: 24 September 2019
In the past week, from 16 to 22 September, 39 new confirmed Ebola virus disease (EVD) cases, with an additional 22 deaths, have been reported from nine health zones in three affected provinces in the Democratic Republic of the Congo.
Pockets of insecurity in the affected areas, along with localised security incidents, continue to hinder response activities, including safe and dignified burials (SDB), vaccination, contact tracing and case reporting. For instance, a recent major security incident in Lwemba, within Mandima health zone is still preventing response activities in this area. Overall, these incidents underscore the need for continued and proactive engagement and sensitizing of local communities, especially in the high risk areas that may not currently be affected…
…The Democratic Republic of the Congo health authorities have endorsed the use of a second investigational Ebola vaccine with at-risk populations in areas that do not have active EVD transmission. Regular vaccination activities in EVD-affected areas will continue…
Implementation of ring vaccination protocol
As of 23 September 2019, 225 719 people at risk have consented to and received the rVSV-ZEBOV-GP Ebola vaccine. Of those, 55 801 are contacts and 154 689 contacts-of-contacts. The total number of vaccines includes 47 533 HCWs/FLWs.
The Democratic Republic of the Congo health authorities have endorsed the use of a second investigational Ebola vaccine, manufactured by Johnson & Johnson. This vaccine, which is administered as a two-dose course, 56 days apart, will be circulated in at-risk populations in areas that do not have active EVD transmission. Regular vaccination activities in EVD-affected areas will continue. The Merck/MSD vaccine will continue to be provided to all people at high risk of Ebola infection including those who have been in contact with a person confirmed to have Ebola, all contacts of contacts, and others determined to be at high risk of contracting Ebola…
Second Ebola vaccine to complement “ring vaccination” given green light in DRC
23 September 2019 Statement Geneva, Switzerland
The health authorities in the Democratic Republic of the Congo (DRC) have announced plans to introduce a second experimental Ebola vaccine, manufactured by Johnson & Johnson, from mid- October. This vaccine, which is given as a 2-dose course, 56 days apart, will be provided under approved protocols to targeted at-risk populations in areas that do not have active Ebola transmission as an additional tool to extend protection against the virus.
“The DRC authorities, in deciding to deploy the second experimental vaccine to extend protection against this deadly virus, have once again shown leadership and their determination to end this outbreak as soon as possible,” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus.
“The evaluation of the second Ebola vaccine will help ensure that we have potentially an additional tool to prevent the expansion of the outbreak and also a potential tool to protect populations before outbreaks hit areas at risk,” said Dr Matshidiso Moeti, WHO’s Regional Director for Africa.
The Johnson & Johnson vaccine will complement the current vaccine (rVSV-ZEBOV-GP, manufactured by Merck), which has proven highly effective and safe, and which has helped protect thousands of lives. The Merck vaccine will continue to be provided to all people at high risk of Ebola infection including those who have been in contact with a person confirmed to have Ebola, all contacts of contacts, and others determined to be at high risk of contracting Ebola. To date over 223,000 people have received this vaccination during the current outbreak.
In May 2019, WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) reviewed use of vaccines in the ongoing Ebola outbreak and issued recommendations. These included adjusting the dose of the Merck vaccine, evaluating a second vaccine under appropriate protocols, changing strategies when insecurity makes it difficult to reach people – such as providing pop-up vaccination stations — and increasing the number of people vaccinated within communities with ongoing transmission, sometimes vaccinating whole villages.
“In everything we do, we are driven by science,” Dr Tedros said. “The advice we were given by SAGE in May has been applied, always taking into account community needs and preferences, as we know this will make the approach more effective. The changes made have saved thousands of lives in this outbreak.”
New therapeutics and better use of treatment protocols have also saved many lives. “To date, 973 people have been successfully treated and released from Ebola treatment centres, and we expect that the 1000th survivor will return to his or her community in the coming weeks,” Dr Moeti said.
Innovative vaccine strategies
The introduction of the second experimental vaccine is in line with the SAGE recommendations as are a number of other innovations.
The main vaccination strategy used with the rVSV-ZEBOV-GP vaccine is a ‘ring strategy’ where all people who have come into contact with someone with a confirmed case of Ebola are given the vaccine. Where people are stigmatized or feel under threat protected, temporary ‘pop-up’, vaccination sites are set up, often at health posts, rather than near the homes of individuals infected with Ebola. This allows people to come for vaccination at a safe, more anonymous site, but also increases protection for vaccinators in areas where there is ongoing conflict and insecurity.
Another approach being used to offer vaccination for people at high risk of contracting Ebola is ‘targeted geographic vaccination’. This strategy involves vaccinating everyone in the neighbourhood, or village, rather than vaccinating only the known contacts and contacts of contacts. Targeted geographic vaccination was used successfully when the outbreak spread to Chowe in South Kivu. Over 90 percent of people who are offered vaccination accept it. Since the start of the outbreak WHO and partners have worked to recruit and train Congolese nationals from within Ebola-affected communities as vaccinators to increase community acceptance and also transfer skills to the region. Now, the majority of ring vaccination team members are trained healthcare workers, doctors and medical students from affected communities who speak local languages and understand community concerns.
There are enough vaccine doses on the ground to meet the current needs, with WHO logisticians ensuring a minimum supply of 10,000 doses at all times, and overall supplies of the vaccine are being constantly monitored. Considering the current number of cases being reported and the doses required to vaccinate around each case, the doses available of the rVSV-ZEBOV-GP vaccine are considered sufficient. Merck has provided WHO with 245,000 doses for DRC and neighbouring countries and built a stockpile of 190,000 doses that are ready to send to DRC. Merck also aims to release 650,000 doses over the next six to 18 months under its replenishment strategy. Under the current SAGE recommendations this means that there are 390,000 doses currently and additional 1.3 million doses will be available.
“The Merck vaccine is highly efficacious, and we’ll soon have a second vaccine to increase the number of those being protected against the virus”, said Dr Tedros. “But vaccine and therapeutics are only some of the tools — the key to ending the outbreak is community ownership. With the communities fully engaged, and with all partners stepping up and rallying behind our common goal, we can and will end this outbreak.”
Médecins Sans Frontières (MSF) – DRC Ebola outbreaks
Independent Ebola vaccination committee is needed to overcome lack of WHO transparency
Press Release 23 Sep 2019
:: The current Ebola outbreak has a mortality rate comparable to the West Africa outbreak, despite new treatments and vaccines being available.
:: Not enough eligible people have been vaccinated, one reason for which is WHO’s strict limits on the number of doses used in the field.
:: We call for the establishment of an international, independent committee to transparently manage Ebola vaccine stocks and their use.
…WHO tightly controlling vaccine supplies and access
MSF’s efforts to expand access to vaccination, in collaboration with the Ministry of Health and according to the recommendations of the Strategic Advisory Group of Experts (SAGE) in May 2019, have been frustrated by the tight controls on supply and eligibility criteria imposed by WHO. MSF vaccination teams have often been forced to remain on standby in North Kivu, waiting to receive a handful of doses reserved to people on a pre-defined list.
“Time is of the essence in an outbreak: medical teams should be able to rapidly provide treatments or vaccines based on what they see on the ground,” says [Dr Natalie Roberts, MSF Emergency Coordinator. “If a mother has been caring for her sick child who is then diagnosed with Ebola, not only do we want to diagnose and treat the child, but also we also want to provide the mother with post-exposure prophylaxis that could potentially prevent her from developing the disease, and vaccinate her whole community so that if she does get sick, they will have already developed immunity.”
“But our capacity to carry out real-time assessments and react accordingly is severely undermined by a rigid system which is hard to comprehend,” Dr Roberts says. “It’s like giving firefighters a bucket of water to put out a fire, but only allowing them to use one cup of water a day. Every day we see known contacts of confirmed Ebola patients who have not received their dose despite being eligible for vaccination.”
Such restrictions seem unjustified: rVSV-ZEBOV vaccine has demonstrated a good safety profile and a high level of protection against the virus in a Phase-3 clinical trial in Guinea in 2015. In the absence of regulatory approval, the Congolese Ministry of Health and WHO allowed the vaccine to be used under an ‘Expanded Access’ framework. Manufacturer Merck recently stated that in addition to the 245,000 doses already delivered to WHO, they are ready to ship another 190,000 doses if required, and that 650,000 additional doses will be available over the next six to 18 months.
Independent coordination committee needed to manage vaccines
“To allow for the best possible use of experimental tools in an outbreak context, transparency is key,” continues Dr Roberts. “How can we support the Congolese authorities in using these tools, how can we expect the Congolese people to trust a system that is not even transparent to front-line health workers like MSF?”
Médecins Sans Frontières calls for the urgent creation of an independent, international coordination committee, based on the model of the International Coordination Group created in 1997 composed of MSF, the International Federation of Red Cross, UNICEF and WHO, which proved successful in managing massive meningitis, cholera and yellow fever outbreaks with limited vaccine supplies. The committee would bring partners together to improve coordination on vaccination, increase transparency in stock management, share data, foster an open dialogue with the manufacturers and ultimately ensure that the vaccine is provided to all those most at risk of being exposed to the virus.
Public Health Emergency of International Concern (PHEIC)
Polio this week as of 25 September 2019
:: The Global Polio Eradication Initiative and the Pakistan Polio Programme are looking for innovative ways to help quickly detect, control and/or respond to the spread of anti-vaccination propaganda on social media in an urban population. For more information on how to join this collective effort please click here.
:: Look through the lives of polio vaccinators in Somaliland as they reach out to vaccinate nomadic communities.
Summary of new viruses this week:
:: Afghanistan — one wild poliovirus type 1 (WPV1)- positive environmental sample;
:: Pakistan — four WPV1 cases and seven WPV1-positive environmental samples;
:: Nigeria — one circulating vaccine-derived poliovirus type 2 (cVDPV2)- positive case;
:: Angola — four cVDPV2 cases;
:: Myanmar — two cVDPV1 cases.
WHO has posted a refreshed emergencies page which presents an updated listing of Grade 3,2,1 emergencies as below.
WHO Grade 3 Emergencies [to 28 Sep 2019]
Democratic Republic of the Congo
:: Ebola Outbreak in DRC 60: 24 September 2019
:: WHO and partners launch emergency vaccination campaign to help contain world’s largest measles outbreak 25 September 2019 [link not operative at inquiry]
:: South Sudan validates and costs its National Action Plan for Health Security 26 Sep 2019
With support from the World Health Organization (WHO), South Sudan has developed and costed a National Action Plan for Health Security, which is a comprehensive, multisectoral blueprint to strengthen the country’s core capabilities to manage health risks (as well as save lives and avoid interference to international trade and travel) during emergency situations, as required by the legally binding International Health Regulations (2005).
Syrian Arab Republic
:: WHO statement on mortality in Al Hol camp in Syrian Arab Republic 22 September 2019
:: Greater support needed to ensure accessible quality health services for a quarter of a million Syrian refugees in Iraq 22 September 2019
WHO Grade 2 Emergencies [to 28 Sep 2019]
Measles in Europe
:: WHO urges investments to stop measles transmission in Europe 24-09-2019
The first-ever WHO Strategic Response Plan (SRP) for a measles emergency was launched today to ensure financial commitment to stop the spread of this highly contagious and serious disease in the WHO European Region.
Over 120,000 measles cases were reported between August 2018 and July 2019, which is more than the total number for a 12-month period reported in the Region in over a decade. Of the Region’s 53 countries, 48 reported cases in this period.
As measles continues to circulate in the Region, a stronger response by the international community is needed. In May this year, WHO classified measles outbreaks across the Region as a Grade 2 emergency. The newly launched SRP provides a resource mobilization tool to accelerate tailored interventions in measles-affected and at-risk countries, where investments will have the greatest possible impact…
:: Critical WHO supplies arrive in Sudan to manage cholera outbreak 25 September 2019
[Editor’s Note: No mention of OCV in announcement]
Afghanistan – No new digest announcements identified
Angola – No new digest announcements identified
Burkina Faso [in French] – No new digest announcements identified
Burundi – No new digest announcements identified
Cameroon – No new digest announcements identified
Central African Republic – No new digest announcements identified
Ethiopia – No new digest announcements identified
HIV in Pakistan – No new digest announcements identified
Iran floods 2019 – No new digest announcements identified
Iraq – No new digest announcements identified
Libya – No new digest announcements identified
Malawi floods – No new digest announcements identified
MERS-CoV – No new digest announcements identified
Myanmar – No new digest announcements identified
Niger – No new digest announcements identified
occupied Palestinian territory – No new digest announcements identified
Ukraine – No new digest announcements identified
Zimbabwe – No new digest announcements identified
WHO Grade 1 Emergencies [to 28 Sep 2019]
:: Sense of relief as families embrace malaria vaccine roll out in Kenya 24 September 2019
Chad – No new digest announcements identified
Djibouti – No new digest announcements identified
Mali – No new digest announcements identified
Namibia – viral hepatitis – No new digest announcements identified
Tanzania – No new digest announcements identified
UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises.
Syrian Arab Republic
:: Syria: Rukban Humanitarian Update (As of 25 September 2019)
Yemen – No new digest announcements identified
UN OCHA – Corporate Emergencies
When the USG/ERC declares a Corporate Emergency Response, all OCHA offices, branches and sections provide their full support to response activities both at HQ and in the field.
Ebola in the DRC has bene added as a OCHA “Corporate Emergency” this week:
CYCLONE IDAI and Kenneth – No new digest announcements identified
EBOLA OUTBREAK IN THE DRC – No new digest announcements identified