Wednesday, June 13, 2018

PRO/AH/EDR> Ebola update (34): Congo DR, cases, response, WHO

A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

In this update
[1] Case update
- Epidemiological situation 12 Jun 2018, DRC Ministry of Health
- Ebola virus disease - Democratic Republic of Congo, WHO external
situation report 10
[2] Status of outbreak
- Young reporters of Bikoro mobilizing against Ebola
- Oxfam food support to Ebola effected areas
[3] Research
- Experimental drug trials
- Unusual uses of off-label drugs

[1] Case update
- 12 Jun 2018. Epidemiological situation 11 Jun 2018, DRC Ministry of
Health [in French, machine trans., edited]

The epidemiological situation of the Ebola virus disease dated 11 Jun
- a total of 59 cases of haemorrhagic fever were reported in the
region, including 38 confirmed, 14 probable, and 7 suspected;
- 4 new suspected cases, including 1 in Bikoro, 2 in Iboko, and 1
- no new cases confirmed;
- no new deaths reported [to date total of 28 deaths; 14 of them among
the confirmed cases].

Epidemiological analyses have identified contacts living in nearby
health areas in Bikoro and Iboko. These contacts are followed and
advised to limit their movements during the entire follow-up period of
21 days.

- Negative tests are systematically removed from the summary table.
- The category of probable cases includes all reported deaths for
which it was not possible to obtain biological samples for laboratory

News from the Ebola response
- Vaccination
Since the launch of the vaccination on [21 May 2018], 2507 people have
been vaccinated, including 753 in Mbandaka, 561 in Bikoro, 1163 in
Iboko, and 30 in Ingende.

- Pan-African collaboration
On [Tue 12 Jun 2018], the Minister of Health, Dr Oly Ilunga Kalenga,
met with his counterparts from the Republic of Congo and the Central
African Republic during a teleconference from Kinshasa Emergency
Operations Center.

The teleconference aimed to take stock of the Ebola response in the
Democratic Republic of Congo, share the country's experience in
managing Ebola outbreaks, and address the concerns of health
authorities in neighboring countries. In addition, the 3 ministers of
health also discussed the issue of cross-border collaboration and
agreed that it was important to hold meetings between their respective
technical teams more regularly.

Health ministers plan to hold a regional workshop on cross-border
contingency plan to be complemented by full-scale simulation exercise
of cross-border response.

Communicated by:
ProMED-mail Rapporteur Mary Marshall

[A map showing the location of Ebola outbreaks in DRC and a table of
this outbreak's cases in Bikoro, Iboko, and Wangata (Equateur
province) are available at the source URL above. - Mod.UBA]

- 12 Jun 2018. [data as of 10 Jun 2018]. Ebola virus disease -
Democratic Republic of Congo, WHO external situation report 10
[WHO Health Emergency Information and Risk Assessment, edited]

1. Situation update
Grade 3; cases: 55, deaths: 28; CFR: 50.9 percent
The outbreak of Ebola virus disease (EVD) in the Democratic Republic
of the Congo remains active. One month into the response, there is
cautious optimism about the situation in Bikoro and Wangata
(especially Mbandaka) health zones where the last confirmed EVD case
was reported on 16 May 2018. The primary focus of the response has
moved from the urban areas of Equateur province to the most remote and
hard-to-reach places in Itipo and the greater Iboko Health Zone.

On 10 Jun 2018, 2 new suspected EVD cases were reported in Iboko
Health Zone. 13 laboratory specimens (from suspected cases reported
previously) tested negative. No new confirmed EVD cases and no new
deaths have been reported on the reporting date. Since 17 May 2018, no
new confirmed EVD cases have been reported in Bikoro and Wangata
health zones, while the last confirmed case was reported in Iboko
Health Zone on 2 Jun 2018.

Since the beginning of the outbreak (on 4 Apr 2018), a total of 55 EVD
cases and 28 deaths (case fatality rate 50.9 percent) have been
reported, as of 10 Jun 2018. Of the 55 cases, 38 have been laboratory
confirmed, 14 are probable (deaths for which it was not possible to
collect laboratory specimens for testing), and 3 are suspected. Of the
confirmed and probable cases, 27 (52 percent) are from Iboko, followed
by 21 (40 percent) from Bikoro and four (8 percent) from Wangata
health zones. A total of 5 healthcare workers have been affected, with
4 confirmed cases and 2 deaths.

The outbreak has remained localised to the 3 health zones initially
affected: Iboko (24 confirmed cases, 3 probable, 2 suspected, 7
deaths), Bikoro (10 confirmed cases, 11 probable, 1 suspected, 18
deaths), and Wangata (4 confirmed cases, 3 deaths). The number of
contacts requiring follow-up is progressively decreasing with many
completing the required follow-up period. As of 10 Jun 2018, a total
of 634 contacts were under follow up, of which 633 (99.8 percent) were
reached on the reporting date.

On 8 May 2018, the Ministry of Health of the Democratic Republic of
the Congo notified WHO of an EVD outbreak in Bikoro Health Zone,
Equateur Province. The event was initially reported on 3 May 2018 by
the Provincial Health Division of Equateur when a cluster of 21 cases
of an undiagnosed illness, involving 17 community deaths, occurred in
Ikoko-Impenge health area. A team from the Ministry of Health,
supported by WHO and Medecins Sans Frontieres (MSF), visited
Ikoko-Impenge health area on 5 May 2018 and found 5 case-patients, 2
of whom were admitted in Bikoro General Hospital and 3 were in the
health centre in Ikoko-Impenge. Samples were taken from each of the 5
cases and sent for analysis at the Institute National de Recherche
Biomedicale (INRB), Kinshasa on 6 May 2018. Of these, 2 tested
positive for Ebola virus, _Zaire ebolavirus_ species, by reverse
transcription polymerase chain reaction (RT-PCR) on 7 May 2018, and
the outbreak was officially declared on 8 May 2018. The index case in
this outbreak has not yet been identified and epidemiologic
investigations are ongoing, including laboratory testing.

This is the 9th EVD outbreak in the Democratic Republic of the Congo
over the last 4 decades, with the most recent one occurring in May

Current risk assessment
WHO considers the public health risk to be very high at the national
level due to the serious nature of the disease, insufficient
epidemiological information and the delay in the detection of initial
cases, which makes it difficult to assess the magnitude and
geographical extent of the outbreak. The confirmed case in Mbandaka, a
large urban centre located on a major national and international
river, with road and air transport access, increases the risk both of
local propagation and further spread within Democratic Republic of the
Congo and to neighbouring countries. The risk at the regional level is
therefore considered high. At global level, the risk is currently
considered low.

The IHR Emergency Committee met on [Fri 18 May 2018] and concluded
that the conditions for a public health emergency of international
concern (PHEIC) had not been met. However, if the outbreak expands
significantly, or if there is international spread, the Emergency
Committee will be reconvened to re-evaluate the situation.

The risk assessment will be re-evaluated by the 3 levels of WHO
according to the evolution of the situation

Strategic approach to the prevention, detection and control of EVD
WHO recommends the implementation of proven strategies for the
prevention and control of Ebola outbreaks. These include (i)
strengthening the multisectoral coordination of the response, (ii)
enhanced surveillance, including active case finding, case
investigation, contact tracing, and surveillance at points of entry
(PoE), (iii) strengthening diagnostic capabilities, (iv) case
management, (v) infection prevention and control in health facilities
and communities, including safe and dignified burials, (vi) risk
communication, social mobilization and community engagement, (vii)
psychosocial care, (viii) immunization of risk groups and research
response, and (ix) operational support and logistics.

2. Actions to date
Coordination of the response:
- On 11 Jun 2018, the WHO Director General (DG) and the Minister of
Health visited Itipo health area (the remaining hotspot with active
transmission) in Iboko Health Zone to conduct on the spot assessment
and support response operations. The DG and the Minister of Health met
the local coordination commission and the National Association of
Ebola Winners (people who were cured). The mission also visited the
newly established Ebola treatment centre (ETC) in Itipo.
- Daily coordination meetings continue at the national, sub-national,
and local levels to review the evolution of the outbreak, identify
gaps in the response and propose key actions to accelerate the
implementation of public health measures.
- As of 11 Jun 2018, WHO has deployed a total of 271 technical experts
in various critical functions of the Incident Management System (IMS)
to support response to the EVD outbreak.
- WHO continues to conduct daily IMS team meetings and hold 3-level
conference calls to review response operations and support field
- Active surveillance activities are ongoing, including active case
search at community and health facility levels, real-time
investigation of suspected cases and alerts, and collection of
specimens for laboratory confirmation and/or exclusion. Rigorous
contact tracing activities continue in all areas.
- The Ministry of Health, with the support of WHO, CDC, Epicentre and
other partners, continue to maintain an up-to-date EVD outbreak
database, including line lists, contact lists, etc.

- A full mobile laboratory was deployed to Bikoro Reference Hospital
on 12 May 2018 and was fully operational by 16 May 2018. A 2nd mobile
laboratory is active in Mbandaka and a 3rd one in Itipo since 30 May
- A National Laboratory Strategy has been developed, focusing on
GeneXpert for confirmatory testing in key sites such as Ebola
Treatment Centres (ETC). GeneXpert is now fully functional in Bikoro
Health Zone and Mbandaka.
- Additional GeneXpert machines are being sent to the affected areas.

Case management:
- MSF has set up ETCs in Mbandaka and Bikoro, while 2 other ETCs are
being set up in Iboko (MSF) and Itipo (ALIMA/Alliance for
International Medical Action).
- WHO is providing technical advice on the use of investigational
therapeutics under the monitored Emergency Use of Unregistered
Interventions (MEURI) framework and provision of essential medical
supplies. 4 of the 5 investigational therapeutics are in-country and
all protocols have been approved by the Ethics Review Board (ERB).
This is the 1st time such treatments have been available during an
Ebola outbreak. Clinicians working in the treatment centres will make
decisions on which drug will be most helpful to their patients, and
appropriate for the setting. The treatments can be used as long as
informed consent is obtained from patients and protocols are followed,
with close monitoring and reporting of any adverse events. 4 of the 5
approved drugs are currently in the country. They are Zmapp, GS-5734,
REGN monoclonal antibody combination, and mAb114.

Infection prevention and control and water, sanitation, and hygiene
(IPC and WASH):
- Infection prevention and control supplies, including personal
protective equipment and disinfectants, have been provided to health
facilities in 8 health areas, namely: Mapeke, Bokongo, Itipo, Londo,
Bokando-Bouna, Mpangi, Lokango, Boutela.
- A comprehensive triage plan for health facilities in Itipo health
area has been developed. Red Cross is finalizing rehabilitation of an
operational base for dignified and safe burials in Bikoro.
- There is continued support from MSF and the Congolese Red Cross in
the organization of safe and dignified burials.

Implementation of ring vaccination protocol:
Since the launch of the vaccination exercise on 21 May 2018, a total
of 2295 people have been vaccinated in Wangata (713), Iboko (1054),
and Bikoro (498), as of 10 Jun 2018. The targets for vaccination are
front-line health professionals, people who have been exposed to
confirmed EVD cases and contacts of these contacts.

Risk communication, social mobilization and risk communication:
- In Mbandaka, 65 women leaders including women's groups, women army
officers and wives of military men were trained to support EVD social
mobilization activities.
- Ongoing risk communication and social mobilization activities
mass awareness campaign through television, radio, and social
mobilization teams going to communities; training response teams in
the communities; training local journalists; meeting with local

- WHO provided 4 ambulances to facilitate referral of patients, which
were deployed in Mbandaka (3) and Kinshasa (1). 3 additional utility
vehicles have been provided to support activities in Kinshasa.
- MONUSCO [UN Stabilization Mission in the DR Congo] has set up tents
to accommodate responders in Iboko to address the acute shortage of
accommodation in the area.

Resource mobilization:
- WHO's rapid response and initial scale up of operations in the
Democratic Republic of the Congo has been funded by a USD 4 million
disbursement from the WHO Contingency Fund for Emergencies (CFE).
- WHO and partners are appealing for rapid funding of USD 57 million
for the current response to rapidly stop the spread of EVD. The amount
of funding needed for the overall Ebola Strategic Response Plan has
increased from USD 26 million to USD 57 million, based on the new
planning assumption and requirements following the spread of the
disease to Mbandaka (an urban area on a major transport route), the
increased needs for community engagement, expanded number of contacts
to be traced and followed up, and increased number of points of entry
(PoE) (airports and water/land points) to be monitored.
- Funding towards the strategic response has been provided to WHO from
Italy (Euro 300 000/about USD 350 000), CERF [Central Emergency
Response Fund] (USD 800 000), GAVI (USD 1 million), USAID (USD 5.3
million), Wellcome Trust and UK DFID [Department for International
Development] (USD 4.1 million), UK-DFID (GBP 5 million/about USD 6.7
million), Germany (Euro 5 million/about USD 5.9 million), Norway
(Krone 8 million/about USD 100 000), Canada (CAD 1 million/about USD
770 000), World Bank PEF [Pandemic Emergency Financing] (USD 6.8
million) bringing the total to around [USD 32 million].
- Germany's contribution is in recognition of the critical role the
WHO CFE [Contingency Fund for Emergencies] has played in responding to
the EVD outbreak in the Democratic Republic of the Congo and will go
to replenish the CFE, which has so far provided USD 4 million to Ebola
response efforts.
- In-kind contributions for medevac have been received from Norway and
EU ECHO [European Civil Protection and Humanitarian Aid Operations]
for flights between Kinshasa and Mbandaka. Technical expertise has
been provided by Guinea, the UK, and Germany through the GOARN [Global
Outbreak Alert and Response Network] network.
- Firm pledges to the overall Ebola response have been received from
ECHO, Ebola MPTF [UN Ebola Response Multi-Partner Trust Fund], and the
African Development Bank.
- There is a growing need to support operational readiness for PoEs in
surrounding countries to prevent further spread and WHO has launched a
Regional Strategic Plan for EVD Operational Readiness and

WHO is supporting neighbouring countries to systematically assess and
take action on Ebola preparedness, and to develop national contingency
response plans. A regional readiness and preparedness plan has been
developed and published, outlining activities to ensure that the 9
neighbouring countries can detect and contain Ebola should it be
introduced. The regional readiness and preparedness plan requires USD
15.5 million.

Operations partnership:
GOARN Operational Support Team and the AFRO operational partnerships
team continue to conduct twice weekly conference calls to share
information and coordinate response actions of partners involved in
the response.

IHR travel measures and cross border health:
- According to the advice of the International Health Regulations
(IHR) Emergency Committee (EC), which was convened by the WHO
Director-General on 18 May 2018, WHO currently advises against the
application of any travel or trade restrictions to Democratic Republic
of the Congo. In addition, the EC advised that exit screening at
airports and ports on the Congo River is considered to be of great
importance to detect probable cases and to prevent the international
spread of Ebola; however, entry screening, particularly in distant
airports, is not considered to be of any public health or cost-benefit
value. The IHR EC advised that currently the outbreak does not meet
the criteria for a Public Health Emergency of International Concern,
but the vigorous response of the Government should continue to be
supported by the international community.
- WHO recommendations for international travellers related to EVD
outbreak in DRC were published on 29 May 2018. In general the risk of
a traveller becoming infected with Ebola virus during a visit to the
affected areas and developing disease after returning is extremely
low, even if the visit included travel to areas where primary cases
have been reported. Transmission requires direct contact with blood or
fluids of infected persons or animals (alive or dead), all unlikely
exposures for the average traveller. If symptoms consistent with Ebola
disease develop, travellers should seek immediate medical attention
(through specific hotline numbers). Travellers should be informed
about where to obtain appropriate medical assistance at their
destination and whom to inform should they become ill.
- There is a possibility that a person who has been exposed to Ebola
virus and developed symptoms may board a commercial flight or other
mode of transport, without informing the transport company of his/her
status. Such travellers should seek immediate medical attention upon
arrival, mention their recent travel history, and then be isolated to
prevent further transmission. Information of close contacts of this
person on board aircraft should be obtained through collaboration with
various stakeholders at points of entry (such as airline reservation
system) in order to undergo contact tracing.
- As the incubation period for Ebola is between 2 to 21 days,
travellers involved in caring for EVD patients or who suspect possible
exposure to Ebola virus in the affected areas, should take the
following precautions for 21 days after returning: 1) stay within
reach of a good quality healthcare facility; 2) seek immediate medical
attention (such as through hotline telephone numbers) and mention
their recent travel history if they develop EVD like symptoms.
- As of 12 Jun 2018, 26 countries have implemented entry screening for
international travellers coming from Democratic Republic of the Congo,
but there are currently no restrictions of international traffic in
place. WHO continues to monitor travel and trade measures in relation
to this event.
- In collaboration with WHO, IOM, Africa CDC, and other partners, the
Government of the Democratic Republic of the Congo has developed a
comprehensive strategic response plan for points of entry, with the
goal of avoiding the spread of the disease to other provinces or at
the international level. The plan includes mapping strategic points of
entry and the locations of areas where travellers congregate and
interact with the local population, and therefore are at risk of Ebola
virus disease transmission based on population movement. The plan also
includes implementing health measures at the points of entry or
congregation, including risk communication and community engagement,
temperature checks, provision of hand hygiene and sanitation
materials, and the development of alert, investigation and referral
- By 18 May 2018, a total of 115 points of entry/congregation had been
listed and mapped along 3 cordon sanitaires [sanitary cordons] in
Mbandaka, Bikoro, Iboko, Ntonde, Igende, larger Equateur Province, and
Kinshasa/Kisangani). It is unrealistic and impractical to assume that
proper screening can be conducted at all these points, and the efforts
currently focus on the 30 prioritized points of entry/congregation.
Further detail on this plan and implementation to date are available
via the Disease Outbreak News webpage at
<>. Field exercises were also organized
to identify key points of passage and congregation of travellers in
Mbandaka as well as in Bikoro and its surroundings with participation
of representatives from the population such as local authorities,
police, church, trade. This work was facilitated by WHO and PNHF
[National Programme of Hygiene at Borders] and with the support of
- Screening measures of persons departing or arriving from an affected
area include travel health declaration to evaluate the risk of
exposure to Ebola virus, visual observation for EVD like symptoms,
temperature check and travel health promotion measures, as well as
procedures for referral of suspect cases. Any person with an illness
consistent with EVD is not allowed to travel unless the travel is part
of an appropriate medical evacuation. Boarding may be denied based on
public health criteria.
- As of 1 Jun 2018, no cases were detected at ports on the River Congo
closed to Kinshasa (Muluku, Kinkole, Ngobila) as well as in the
international and main national airports in Kinshasa (Ndili, Ndolo).
As of 6 Jun 2018, 374 travellers were screened and sensitized to EVD
in Bikoro, Ntondo, Ingende. As of 9 Jun 2018, 2707 persons were
screened and sensitized to EVD in the key sites in Mbandaka, Bikoro,
Ndonle, Ingende, and Irebu health zones.
- All 30 points of entry (ports and airports) and areas for
congregation (parking, markets, churches, schools) are now assessed
and gaps identified. On 6 Jun 2018, the sub-commission of surveillance
at PoEs was established and meet daily. The focus of the group is to
strengthen screening and sensitization capacity in the 30 prioritized
PoEs and congregation sites: establish and disseminate procedures for
surveillance (visual observation, screening of travellers, hand
hygiene, risk communication); develop a training module for
surveillance at PoEs for PNHF agents deployed and to be deployed;
quantify gaps in terms of equipment and materials at each PoE; on 9
Jun 2018, a training of trainers took place in Kinshasa for PoEs with
PNHF, IOM, WHO, CDC, and JICA [Japan International Cooperation

3. Summary of public health risks, needs, and gaps:
One month into the response, tremendous progress has been made in
containing further spread of the EVD outbreak. Currently, active
transmission is mainly taking place in the remote Itipo health area in
Iboko Health Zone. The situation in Bikoro and Wangata (Mbandaka city)
health zones is being cautiously monitored, with the last confirmed
cases reported in mid-May 2018. Moving forward, the response is
beginning to shift to a 2nd phase where the focus will be enhanced
surveillance, including rapid case investigations of suspected EVD
cases and alerts and thorough contact tracing in the remote areas.
This will imply redeployment of field responders and response

Communicated by:
ProMED-mail Rapporteur Mary Marshall

[2] Status of outbreak
- 12 Jun 2018. Young Reporters of Bikoro are mobilizing against Ebola
[Ponabana, summ., edited]
[Byline: Christophe Yoka Nkumu Daddy]

On 8 May 2018, an Ebola epidemic was declared by the Minister of
Health in Bikoro, a territory located at the heart of Equateur
Province. To date, approximately 23 cases have been recorded in
Bikoro, of which 18 resulted in the death of the patient. More than
250 people have been identified as having come into contact with them
(directly or indirectly) and are under observation in Bikoro. ...

It was essential that the Young Reporters be briefed in the 1st few
days so that they could mobilize without delay. Some children were a
little reluctant... they knew nothing about Ebola, but after some
explanation, fear gave way to motivation.

Raising awareness in schools is absolutely essential for combating the
spread of the Ebola virus. The Young Reporters set up hand-washing
stations and explained to the children the good practices that they
should incorporate into their daily routines. In just a few days, 8
Young Reporters led awareness raising sessions with 2000 students in
schools in the city of Bikoro! What's more, when one child speaks to
another, we can be sure that the message will be understood and easily
taken on board.

Children are discriminated against by other children at the school. I
recall the example of one 12-year-old boy whose father was being
treated at the Ebola Treatment Centre (ETC). Bikoro is a small city,
so when the school's management learnt that this boy's father was in
the ETC, they decided that the boy would no longer be allowed to
attend school. For more than 2 weeks, this 4th-year student had to
stay at home. The Young Reporters then advocated for this
discrimination against the boy to end and for him to be allowed to
return to the classroom. All is well now for this boy. He is back at
school and his father is out of the ETC.

For the moment, the awareness raising activities are only being run in
primary schools, but I think that we should extend them to all
schools. Ebola does not stop at the sixth year of primary school!

In addition to awareness raising activities in schools, we can also
publicize our messages on a larger scale. Unfortunately, unlike in
other districts, Bikoro does not have a community radio station
through which to communicate good practices. That would be too easy.
From one single location, we would be able to reach the most remote
population without having to go there. As it is, how can we possibly
cross hundreds of kilometres so that the Young Reporters can share
their messages?

A community radio station would also enable us to publicize the
International Convention on the Rights of the Child and raise people's
awareness of the waterborne diseases that ravage our territory. We
could easily talk about all this on the radio and reach populations
that would ordinarily be inaccessible.

One thing which we had not considered: since the declaration of the
Ebola epidemic in Bikoro, dozens and dozens of humanitarian workers
have arrived on site. The result is that now we have difficulty
accessing the internet... We would like to tell the outside world
about the situation we face in Bikoro, but how can we do that if we
cannot get online?

Communicated by:
ProMED-mail Rapporteur Mary Marshall

- 12 Jun 2018. Oxfam food support to Ebola effected areas
[UN OCHA, ReliefWeb/Oxfam report, summ., edited]

Oxfam is distributing rice, beans and flour, to about 4525 people. It
has already started in Mbandaka -- the Equateur province capital --
and plans to extend to rural communities. This is in addition
providing clean water and working with communities to ensure they know
how to protect themselves against the virus and prevent its spread.

The outbreak has reduced trade between rural areas such as Bikoro and
Iboko, the places worst affected, and Mbandaka. Many people depend on
this trade for food and other essentials. Households that have been in
contact with a sick person have to rely on assistance because they are
asked to stay in doors and avoid going out for 3 weeks, making it
impossible to find food.

Jose Barahona, the Oxfam Country Director for Democratic Republic of
Congo, said: "Getting food to families who have been in contact with
sick people is vital to allow them to eat while protecting others from
the disease. Failing to provide food means they need to get out to the
market, potentially infecting other people. In the past weeks the
increase of cases has slowed down thanks to joint efforts by the
Government and aid agencies. But there are well over 50 cases of Ebola
and that's far too many. ...

"We need to prepare a post-Ebola response, including helping people
earn a living and providing clean water and sanitation. Oxfam's work
should not stop when the outbreak has ended. ...

Notes to editors:
Oxfam is providing door-to-door information to the most vulnerable
people, working with communities, and carrying out mass awareness
activities including film screenings and working with local community
radio stations.

Oxfam is also installing chlorinated water points in hospitals, health
centres, schools, and ports, and helping to disinfect houses in which
Ebola cases have been detected. It also provides disinfection kits and
hygiene kits to communities.

Communicated by:
ProMED-mail Rapporteur Mary Marshall

[3] Research
- 12 Jun 2018. Experimental drug trials
[The Independent, Bloomberg report, edited]
[Byline: Marthe Fourcade, Naomi Kresge]

As another outbreak of Ebola claims lives in central Africa,
researchers are seeing within it a rare ray of hope: a chance to find
a cure.

For the 1st time, 5 experimental medicines are poised to undergo a
real-life clinical trial against the virus at makeshift treatment
centres in remote areas of the Democratic Republic of Congo, where
most of the 59 new cases originated. The country's health ministry
cleared all the treatments for use as of last week [week of 4 Jun

Hundreds of vials of drugs in development by Gilead Sciences Inc.,
Regeneron Pharmaceuticals Inc., and others are on their way or in
place. Some have only been tested on animals and a handful of healthy
volunteers, and none have been proven to work against the severe viral
disease in a standard clinical test. Now, scientists are seeking a way
to offer compassionate treatment for patients with few options while
doing painstaking data collection to evaluate the drugs.

Health officials have already begun using an experimental vaccine,
donated by US drugmaker Merck, in hopes it will protect people who may
have been exposed to infection. The efforts could yield the 1st-ever
weapons against a disease that has no cure and kills about half of the
people it infects. At least 27 deaths have been confirmed from this

"There's a consensus that we really need to move forward," says Vasee
Moorthy, an infectious diseases doctor at the World Health
Organisation (WHO) who coordinated vaccine research during the last
Ebola epidemic. "We hope that by the end of this outbreak we gradually
have more information about which drugs provide benefits to

The obstacles are steep. Normally, researchers test an individual drug
against a placebo, but they'd forego it in this case for ethical
reasons. They must also devise a way to randomly assign patients to
various treatment groups while taking into account individual medical
needs and watching for side effects.

Carrying out a trial that pits multiple untested medicines against one
another would be challenging in the best of conditions. This one would
take place in an impoverished, equatorial nation of 78 million that is
home to the river that gave Ebola its name and much of the world's
2nd-largest tropical forest.

Drugs will need to be shipped by riverboat, on unpaved roads or by
helicopter to overcome a lack of infrastructure inland. Some must be
kept cold in the hot, humid climate. "This is no simple piece of
work," Peter Salama, WHO deputy director-general of emergency
preparedness and response, said at a briefing in Geneva last week [8
Jun 2018]. "But if we don't learn now, then we'll never know which are
the better drugs to use."

One of the medicines, called ZMapp, has been through another potential
pitfall of testing experimental treatments during a public-health
crisis. Because it was only tried toward the end of the last Ebola
outbreak -- just as international aid agencies were getting the
contagion under control -- it wasn't given to enough patients to reach
conclusive results. That epidemic, the largest in the disease's
history, ended in 2016 after killing more than 11 000 people in West

Still, the drug showed promise. 8 of 36 people who took it died,
compared with 13 of 35 who had standard care alone. Larry Zeitlin,
president of closely held Mapp Biopharmaceutical, which developed the
treatment with the US and Canadian governments, says the need for
clinical data must not eclipse treatment priorities.

Another 3 medicines found suitable by a group of independent experts
assembled by the WHO and cleared by the DRC's health ministry are
Gilead's antiviral remdesivir; a Regeneron cocktail of 3 monoclonal
antibodies known as REGN-EB3 that has only been tested in healthy
people; and the antiviral favipiravir, made by Japan's FujiFilm Corp.,
that's already sold to treat influenza and was used in the West
African outbreak.

Gilead shipped 360 doses of remdesivir to the DRC on [28 May 2018].
The intravenous drug, which requires monitoring of liver and kidney
function, has been used just twice in Ebola patients, and Gilead is
testing its safety in healthy volunteers. Regeneron completed a single
test of its drug in healthy patients last year and hasn't published
the results. Gilead says the DRC's Institut National de Recherche
Biomedicale in Kinshasa would distribute its drug for emergency

Another experimental treatment, an antibody against Ebola isolated
from a survivor of the 1995 outbreak in the DRC and developed by
scientists at the US National Institute of Allergy and Infectious
Diseases, was also approved for use.

Clinicians will evaluate patients on a case-by-case basis to determine
their eligibility for receiving the drug candidates, says Jess Ilunga,
a spokeswoman for the DRC's health ministry. Doctors Without Borders
and other aid groups with emergency facilities will likely handle
treatment. The DRC's national research institute will help collect and
collate the data, backed by the WHO, and drugmakers are supplying
their treatments for free, according to Moorthy.

Communicated by:
ProMED-mail Rapporteur Mary Marshall

- 12 Jun 2018. Unusual uses of off-label drugs
[Popular Science, summ., edited]
[Byline: Anna Brooks]

On [4 Jun 2018], an ethics committee in the Democratic Republic of the
Congo approved the use of favipiravir, a drug originally developed by
a pharmaceutical company in Japan to fight influenza, for treating
Ebola patients. The experimental therapy comes too late for the 11 000
people killed during the last major outbreak of the virus, which swept
West Africa in 2014. But after evaluation by the World Health
Organization (WHO), favipiravir and 4 other experimental drugs that
showed promise in animal models are now being administered to Ebola
patients in the Congo, where the disease emerged in early May.

"This is the 1st time such treatments are available in the midst of an
Ebola outbreak," says WHO spokesperson Tarik Jasarevic. "Under normal
circumstances, such interventions undergo testing in clinical trials
that are capable of generating reliable evidence about safety and
efficacy," Jasarevic says. "However, in the context of an outbreak
characterized by high mortality, it can be ethically appropriate to
offer individual patients investigational interventions on an
emergency basis outside clinical trials."

So how could a drug used for the flu potentially treat a rare and
deadly disease like Ebola? Favipiravir is an antiviral drug that
possesses the unique ability to prevent RNA-based viruses, like Ebola
and influenza, from replicating. Viruses are made up of either DNA
(deoxyribonucleic acid) or RNA (ribonucleic acid). The ability to
rapidly reproduce and mutate at a high rate is what makes RNA-based
viruses both so deadly, and so difficult to treat.

Animal studies suggest the drug has a high level of resistance to the
Ebola virus. While there's no conclusive evidence yet that favipiravir
will be the magic pill that ends Ebola, there was a case study during
the last outbreak of a French nurse successfully treated using a
number of experimental drugs, including favipiravir.

Using a drug approved for one ailment (like the flu) to treat another
(Ebola) is known as off-labelling. ...

Communicated by:
ProMED-mail Rapporteur Mary Marshall

[At present, continued implementation of control measures, along with
the 'wait and watch' approach for emergence of any new cases or foci
thereof can help control the ongoing EVD outbreak in DRC. - Mod.UBA

HealthMap/ProMED-mail map: Iboko, Équateur, Democratic Republic of
the Congo: <>]

[See Also:
Ebola update (33): Congo DR, cases, response, WHO, diagnosis
Ebola update (32): Congo DR, cases, preparation, research
Ebola update (31): Congo DR, cases, response, WHO
Ebola update (30): Congo DR, cases, WHO, action
Ebola update (29): Congo DR, cases, MSF, antivirals
Ebola update (28): Congo DR, cases, WHO, response, treatment, funding
Ebola update (27): Congo DR, cases, travel screening, children
Ebola update (26): Congo DR, border controls, bat reservoir
Ebola update (25): Congo DR, case update, intl. travel screening
Ebola update (24): Congo DR, case update, African aid response
Ebola update (23): Congo DR, cases, vacc. campaign targets, vaccine
Ebola update (22): Congo DR, cases, cures, domestic and international
Ebola update (21): Congo DR, update, WHO, vaccination, therapeutics
Ebola update (20): Congo DR, case update, lessons, logistics,
financing, flights
Ebola update (19): Congo DR, case update
Ebola update (18): cases, Uganda NOT, Congo DR vaccination campaign
Ebola update (17): case update, public fears, government responses
Ebola update (16): cases, Congo DR cultural factors, vaccine impl.,
case terminology
Ebola update (15): case update, quarantine breaches, border controls,
Ebola update (14): case update, response, prediction, maps
Ebola update (13): case update, prevention
Ebola update (12): update, USA, response
Ebola update (11): WHO, vaccination, response
Ebola update (10): urban case Congo DR, response, support
Ebola update (09): update, alerts, prevention
Ebola update (08): summary, emergency plan, vaccine, roads
Ebola update (07): Congo DR, nurse, Uganda susp, WHO, border, vaccine
Ebola update (06): Congo DR, susp, RFI, vulnerability, response,
Ebola update (05): Congo DR, outbreak update, vaccine, preparedness,
Ebola update (04): Nigeria, Kenya, Congo DR (ET), WHO
Ebola update (03): Congo DR (ET), WHO
Ebola update (02): Congo DR (ET)]
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