Ebola – DRC+
Public Health Emergency of International Concern (PHEIC)

Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 18 October 2019
…The WHO Secretariat provided details on the latest risk assessment. Risk remains very high at national and regional levels but still low at global level. In recent weeks, the incidence of EVD cases has consistently declined, with 15 new confirmed cases, reported in North Kivu and Ituri provinces during the last epidemiological week of 7–13 October, in comparison with 128 confirmed cases per week reported at the peak of the outbreak in April 2019. There is a shift in hot spots from urban settings to more rural, hard-to-reach communities, across a more concentrated geographical area. At present, 10 health zones are affected. These areas pose major security challenges. When response activities are suspended, the likelihood of underreporting and the potential for the disease to spread to new areas increases. In addition, continued transmission in remote areas where access is difficult creates the possibility of transmission chains going undetected.

The ring vaccination strategy is proving efficient and successful. Issues related to vaccine supply were reviewed. Given the uncertainty of the evolution of the epidemic, current supplies should be managed carefully.  The Secretariat also welcomed the commencement of Johnson and Johnson vaccine studies in Uganda and the imminent commencement of similar studies in the Democratic Republic of the Congo, in addition to continuing to track progress with other vaccine candidates.

The United Nations Ebola Emergency Response Coordinator gave an update on the situation and efforts to maintain an enabling environment to improve access and acceptance of Ebola response in communities. He re-emphasized the need for stronger community engagement and access in all areas, increased multisectoral collaboration, and more financial and human resources. Insecurity remains the greatest concern. Efforts to increase security are underway. There is a need to focus both on intervention gaps and the quality of interventions. Identifying areas where the virus might migrate and securing these areas constitutes a major priority.

The Committee was also appraised by the WHO Secretariat on progress on preparedness efforts in the nine neighbouring countries (priority 1: Burundi, Rwanda, South Sudan, and Uganda, and priority 2: Angola, Republic of the Congo, Central African Republic, Tanzania, and Zambia).  Bilateral roadmaps for cross-border coordination between DRC and the priority 1 countries are being implemented. On 21 October 2019, a high-level ministerial meeting will be held in Goma, DRC, to further strengthen alignment and coordination of cross-border surveillance across all nine high-risk neighbouring countries. A major challenge is the lack of funding for preparedness, particularly in the priority 2 countries. Of the US$ 66.6 million required for all the 9 countries, only US$ 4.5 million has been pledged. Compliance with IHR requirements for notification and verification of alerts was highlighted, in particular with regards to transparency and timely sharing of public health information.

Context and Discussion
The Committee commended the response to date, under the leadership of the Democratic Republic of the Congo Ministry of Health, and appreciated the progress made under the multisectoral coordination commission established in July 2019. Support provided by WHO, UN agencies, NGOs and other partners has also contributed to limiting the spread and impact of this virus in a difficult context in many areas in the Democratic Republic of the Congo. The courage and commitment of all frontline workers were specifically praised by the Committee.

While the Committee commended the efforts made by the neighbouring countries to strengthen preparedness, it remained deeply concerned by the lack of sustained financial support for these activities.

The committee noticed with appreciation that the general compliance of all states with the WHO recommendations to keep borders open and air travel meant operations could continue and economies in the area were not harmed by border closures.

However, the Committee is concerned that a year into the outbreak, the access and security situations on the ground could hinder final efforts to eliminate the virus from rural communities.

Conclusions and Advice
It was the view of the Committee that this event still constitutes a public health emergency of international concern (PHEIC) under the IHR (2005).

…Based on this advice, the reports made by the affected State Party, and the currently available information, the Director-General accepted the Committee’s assessment and on 18 October 2019 maintained the Ebola outbreak in the Democratic Republic of the Congo as a Public Health Emergency of International Concern (PHEIC).

The Director-General endorsed the Committee’s advice and issued them as Temporary Recommendations under IHR (2005) to reduce the international spread of Ebola, effective 18 October 2019.


Major milestone for WHO-supported Ebola vaccine
18 October 2019 News release Geneva
The World Health Organization (WHO) welcomes the European Medicines Agency (EMA) announcement recommending a conditional marketing authorization for the rVSV-ZEBOV-GP vaccine, which has been shown to be effective in protecting people from the Ebola virus.

Today’s announcement by EMA, the European agency responsible for the scientific evaluation of medicines developed by pharmaceutical companies, is a key step before the European Commission decision on licensing. In parallel, WHO will move towards prequalification of the vaccine.

“The conditional authorization of the world’s first Ebola vaccine is a triumph for public health, and a testimony to the unprecedented collaboration between scores of experts worldwide,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “My deepest gratitude is to the studies’ volunteers, researchers, health workers in Guinea, other countries and the Democratic Republic of the Congo who have put themselves at risk to ensure people are protected with this vaccine.”

In the past five years, WHO has convened experts to review the evidence on various Ebola vaccine candidates, informed policy recommendations, and mobilized a multilateral coalition to accelerate clinical evaluations. The EMA review was unique in that WHO and African regulators actively participated through an innovative cooperative arrangement put in place by WHO, which will help accelerate registration for the countries most at risk.

A randomized trial for the vaccine began during the West Africa Ebola outbreak in 2015. When no other organization was positioned to run a trial in Guinea during the complex emergency, the government of Guinea and WHO took the unusual step to lead the trial.

A global coalition of funders and researchers provided the critical support required. Funders included the Canadian Government (through the Public Health Agency of Canada, Canadian Institutes of Health Research, International Development Research Centre, Global Affairs Canada); the Norwegian Ministry of Foreign Affairs (through the Research Council of Norway’s GLOBVAC programme); the Wellcome Trust; the UK government through the Department for International Development; and Médecins Sans Frontières.

The trial was successfully run using an innovative ring vaccination design. In the 1970s, this ring strategy helped to eradicate smallpox, but this was the first time that an experimental vaccine was evaluated this way…

Merck Receives EU CHMP Positive Opinion for Investigational V920 Ebola Zaire Vaccine for Protection Against Ebola Virus Disease
October 18, 2019
[See Industry Watch below for detail]


Ebola Outbreak in DRC 63: 15 October 2019
Situation Update
In the past week, from 7 to 13 October, 15 new confirmed Ebola virus disease (EVD) cases were reported from five health zones in two affected provinces in the Democratic Republic of the Congo. While it is encouraging to see another week of relatively low numbers of newly confirmed cases (Figure 1), these are occurring in a concentrated area where limited access and insecurity pose challenges for the response. In such environments, risks of resurgence remain very high, as do the risks of re-dispersion of cases. For example, this past week, several people who were eventually confirmed as positive for EVD sought healthcare in health zones which are no longer experiencing ongoing transmission, such as Beni…


Public Health Emergency of International Concern (PHEIC)

Polio this week as of 16 October 2019
:: Preparations for World Polio Day taking place next week on 24 October are in full swing. On that day, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) is expected to declare poliovirus type 3 (WPV3) as globally eradicated. The event will be broadcast on the internet. Viewers are welcome to follow the proceedings through a WebEx broadcast that will be available here.

:: The Polio Oversight board (POB) met on 6 September 2019 for its third meeting of the year to discuss the current status of work within the programme. The meeting summary is now available.

Summary of new viruses this week:
:: Pakistan — two WPV1-positive environmental samples;
:: Philippines — two cVDPV1-positive environmental samples.


Meeting of the Polio Oversight Board (POB)—Teleconference
6 September 2019 | 16h00-18h00 GVA time
The Polio Oversight Board held its third meeting of the year by teleconference to discuss the status of polio eradication efforts and preparations for the upcoming GPEI pledging moment in Abu Dhabi on November 19th, 2019.

[Excerpt below; full report available at title link above]
1. Key Challenges/Risks to Polio Programme
Michel Zaffran gave POB members an update on the status of global polio eradication, which is of great concern.
:: In Afghanistan, the lack of access due to the Taliban’s ban on house to house vaccination and more recently on all WHO/ICRC activities is leading to a large, vulnerable cohort of unvaccinated children. Even in the areas where vaccination activities are ongoing, the inability of the programme to have outside experts participate, in both training and supervision, as well as conducing post campaign monitoring, is leading to declines in campaign quality. The upcoming leadership transitions at all levels—from national elections to turnover in WHO and UNICEF staff—is both a potential risk and opportunity.

:: In Pakistan, the program is on, what the recent Technical Advisory Group meeting called a “failing trajectory”. Issues such as community resentment and mistrust, combined with sub-optimal SIA quality in certain areas is resulting in sizeable pockets of unimmunized children. This is leading to ongoing widespread virus circulation and a substantial increase in the number of polio cases (58 as of August 31st, compared to 12 reported in all of 2018). The program needs to be transformed, with national unity and all-party consensus at all levels to be effective. On an encouraging note, high levels of national commitment are now seen in Pakistan—what remains to be seen is if this commitment will translate to all levels and action.

:: Nigeria has made remarkable strides against the wild poliovirus, with the last case seen over three years ago—meaning that the entire continent has likely been Wild Poliovirus (WPV) type 3 free since September 2016. However, the Circulating Vaccine Derived Polio Virus (cVDPV) situation is extremely worrying. There appears to be a lack of political support and slow and poor-quality responses, exacerbated by a reluctance, in some countries, to declare an emergency and limited availability/access of trained experts to deploy rapidly. The budget reduction in the country is a real risk, given the increase in outbreaks and lack of ability to rapidly control them. The announcement of the certification of WPV3 eradication will need to be carefully communicated taking into account cVDPV outbreaks .

:: The world is facing more cVDPV2s than our modeling predicted at the time of the switch. Three years after the global withdrawal of Oral Poliovirus type 2 from National immunization programmes, the population mucosal immunity against type 2 poliovirus has waned dramatically. While monovalent OPV type 2 (mOPV2) is the only tool currently available to stop these outbreaks, the programme is now facing two challenges: i) the stockpile is being depleted and ii) the use of mOPV2 is seeding new VDPV2 outbreaks. A new vaccine that is less likely to revert to neurovirulence and cause outbreaks, the novel OPV (nOPV), is showing great promise in clinical trials and its use will be expedited under WHO’s Emergency Use License (EUL), but time will be needed to scale up production to phase out the use of mOPV2 altogether. Financing is a big challenge, as funds are not available currently. With the number of outbreaks higher than expected, funds are being pulled from preventative SIAs, which of course raises other risks. (GPEI lacks flexible funding). To ensure the responses being conducted are as effective as possible, new guidelines are being put into action to ensure rapid access to technical expertise as well as local financing…

[Excerpt from POB Discussion]
Seth Berkley (POB member, CEO, Gavi) asked GPEI to provide further details on plan B if nOPV doesn’t work or is delayed. We all know that scaling up vaccine production is a challenge and not without risks of delays. He agreed with Dr Elias that WHO needs to ensure EUL is ready to be rolled out without any problems. He expressed his concern that he felt the POB needed to really discuss, as a Board, what needs to be done to turn things around and get eradication back on track. He also noted his concern that the current investment case is based on a strategy that assumed the last case of WPV would be in 2020, which is now no longer a feasible assumption. He expressed that he thought donors would be expecting GPEI to be rethinking its approach in light of this and coming up with new ideas, and that the POB, as highest-level body, should ensure that happens. This means rethinking strategies, not just towing the line that getting access will solve all our problems. Dr Berkley requested that the management report done by McKinsey be circulated to the POB as a critical input to this rethink and prior to any POB visits to the field.


Editor’s Note:
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 19 Oct 2019]

Democratic Republic of the Congo
:: Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 18 October 2019
:: Ebola Outbreak in DRC 63: 15 October 2019
[See Ebola above for detail]

Syrian Arab Republic
:: WHO gravely concerned about humanitarian situation in northeast Syria 13 October 2019
[See Milestones above for detail]

Mozambique floods – No new digest announcements identified
Nigeria – No new digest announcements identified
Somalia – No new digest announcements identified
South Sudan – No new digest announcements identified
Yemen – No new digest announcements identified


WHO Grade 2 Emergencies [to 19 Oct 2019]

Iran floods 2019 – No new digest announcements identified
Libya – No new digest announcements identified

:: Middle East respiratory syndrome coronavirus (MERS-CoV) – The Kingdom of Saudi Arabia
18 October 2019
From 1 through 30 September 2019, the National IHR Focal Point of Saudi Arabia reported 4 additional laboratory-confirmed cases of Middle East respiratory syndrome (MERS-CoV) infection and one associated death…

:: Bi‐weekly Situation Report 20 – 10 October 2019
There are an estimated 911,566 Rohingya refugees in Cox’s Bazar, according to the latest ISCG situation report (August 2019). This includes 34,172 refugees from Myanmar who registered before 31st August 2017. All refugees, including new arrivals, face compounding vulnerabilities, including in health. WHO has been responding to this crisis since September 2017…
A comprehensive review of the work of WHO Health field monitors has taken place, and activities were subsequently revised with the aim of increasing catch up for drop-out and left-out children (through child registration validation) and improvements of reporting/feedback mechanisms…
A campaign strategy for the upcoming Measles-Rubella Supplementary Immunization Activity (MR SIA) in 2020 is under development, as well as implementation plans for major recommendations of the quarterly review meeting which took place in collaboration with the national programme.

occupied Palestinian territory
:: WHO Report – Right to health 2018 Regional Office for the Eastern Mediterranean
…This report analyses some of the major barriers to realization of the right to health for
Palestinians in the occupied Palestinian territory. It focuses on four main topics: provision and
availability of healthcare; access to healthcare; underlying determinants of health; and health
attacks. The West Bank and Gaza Strip have been under Israeli military occupation for over 50 years…

:: Vaccination campaign against cholera kicks off in Sudan
Attributable to the Federal Ministry of Health in Sudan, WHO and UNICEF
KHARTOUM, 11 October 2019 – “Sudan has launched an oral cholera vaccination campaign in response to the ongoing outbreak of cholera. More than 1.6 million people aged one year and above in the Blue Nile and Sinnar states will be vaccinated over the coming five days.
“The announcement of the Federal Ministry of Health in Sudan on the cholera outbreak last month allowed national and state authorities, and health partners, to act quickly and respond to the outbreak…

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
Iraq – No new digest announcements identified
Malawi floods – No new digest announcements identified
Measles in Europe – No new digest announcements identified
Niger No new digest announcements identified
Ukraine – No new digest announcements identified
Zimbabwe – No new digest announcements identified


WHO Grade 1 Emergencies [to 19 Oct 2019]

:: Kenya takes vital step against cervical cancer and introduces HPV vaccine into routi…
18 October 2019
With President Uhuru Kenyatta leading the way, Kenya today joins an increasing number of African countries taking a vital step against a common cause of death among women – in the country and the region – by introducing the human papilloma virus (HPV) vaccine against cervical cancer into its routine immunization schedule…

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 ǀ Flash Update #7, Humanitarian impact of the military operation in north-eastern Syria, 16 – 18 October 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.
Editor’s Note:
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