Ebola Situation Report - 10 June 2015

Total confirmed cases (by week, 2015)

 

 
 
 

SUMMARY

  • In recent weeks, the decline in case incidence and the contraction of the geographic area affected by Ebola virus disease (EVD) transmission that was apparent throughout April and early May has stalled. In total, 31 confirmed cases of EVD were reported in the week ending 7 June: 16 cases in Guinea and 15 in Sierra Leone. This is the second consecutive weekly increase in case incidence, and the highest weekly total number of cases reported from Sierra Leone since late March. In addition, cases were reported from a widening geographical area in Guinea and Sierra Leone, and the continued occurrence of cases that arise from unknown sources of infection highlights the challenges still faced in finding and eliminating every chain of transmission.
  • A total of 16 cases were reported from 5 western prefectures of Guinea in the week to 7 June. Half of all cases were reported from the south western prefecture of Forecariah, which borders Sierra Leone. In the north west of the country, on the border with Guinea-Bissau, a case was reported from the prefecture of Boke for the fourth consecutive week. The capital, Conakry, reported 2 cases, as did the neighbouring coastal prefecture of Dubreka, with the remaining 3 cases reported from the inland prefecture of Kindia, which borders the Sierra Leonean district of Bombali. Conakry and Kindia had previously not reported a case for over 40 days.
  • A total of 5 of the 16 cases reported from Guinea arose from unknown sources of infection, including all 3 cases reported from Kindia. Investigations are ongoing to trace the origin of those cases. In addition, 3 cases in Guinea, including 1 of those from Kindia, were identified after post-mortem testing of community deaths. As at 7 June, there were 1693 contacts being monitored across 8 prefectures in Guinea.   
  • Sierra Leone reported a total of 15 confirmed cases from 2 districts in the week to 7 June. Similar to the previous week, most cases (7) were reported from quarantined homes in a small area of Kaffu Bullom chiefdom in the district of Port Loko. However, a cluster of 3 cases was also reported from the Bureh Kasseh Ma chiefdom of the same district. The cases are not thought to be directly linked to Kaffu Bullom, but rather to a chain of transmission in the neighbouring district of Kambia. After reporting its first case in more than 2 weeks the previous week, 5 cases were reported from 2 chiefdoms in Kambia during the week ending 7 June.
  • The Western Urban Area of Sierra Leone, which includes the capital Freetown, reported no cases for the first time since August 2014. However, there were still 195 contacts under follow-up in the district as at 7 June, and a total of 392 contacts nationally in 3 districts (Kambia and Port Loko are the other 2 districts).
  • Efforts are ongoing to augment the ability of contact tracing and case-investigation teams to engage effectively with affected communities in Guinea and Sierra Leone. In Guinea, 19 unsafe burials were reported during the week to 7 June. Although no unsafe burials have been reported for many weeks in Sierra Leone, investigations into recent cases in Kambia have found clear evidence that they are still taking place in some areas. Improved communication with local communities is essential to understand and address any concerns that prevent cases and deaths from being reported, and chains of transmission from being detected.  
  • All contacts associated with the case confirmed in Italy on 12 May have now completed the 21-day follow-up period.  
  • The last health worker infections in Guinea and Sierra Leone were reported on 6 April and 14 May, respectively. There have been a total of 869 confirmed health worker infections reported from Guinea, Liberia, and Sierra Leone since the start of the outbreak, with 507 reported deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

  • There have been a total of 27 237 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11 158 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 16 new confirmed cases were reported in Guinea and 15 in Sierra Leone in the 7 days to 7 June. The outbreak in Liberia was declared over on 9 May.
  • The total number of confirmed cases is similar in males and females (table 2). Compared with children (people aged 14 years and under), people aged 15 to 44 are approximately 3 to 4 times more likely to be affected. People aged 45 and over are 4 to 5 times more likely to be affected than children.
  • A total of 869 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 507 reported deaths (table 5).

Figure 1: Confirmed, probable, and suspected EVD cases worldwide 

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Table 1: Confirmed, probable, and suspected EVD cases in Guinea, Liberia, and Sierra Leone

Country Case definition Cumulative cases Cases in past 21 days Cumulative deaths
Guinea Confirmed 3239 38 2018
Probable 419 * 419
Suspected 12 *
Total 3670 38 2437
Liberia§ Confirmed 3151 0
Probable 1879 *
Suspected 5636 *
Total 10 666 0 4806
Sierra Leone Confirmed 8635 30 3549
Probable 287 * 208
Suspected 3979 * 158
Total 12 901 30 3915
Total Confirmed 15 025 68
Probable 2585 *
Suspected 9627 *
Total 27 237 68 11 158

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Table 2: Cumulative number of confirmed cases by sex and age group in Guinea, Liberia, and Sierra Leone

Country Cumulative cases
By sex*
(per 100 000 population)
By age group
(per 100 000 population)
Male Female 0-14 years 15-44 years 45+ years
Guinea 1557
(29)
1677
(31)
505
(11)
1846
(40)
838
(54)
Liberia§ 1911
(96)
1838
(93)
561
(33)
2060
(121)
703
(132)
Sierra Leone 4648
(163)
4953
(171)
1912
(79)
5459
(211)
2061
(279)

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Figure 2: Geographical distribution of confirmed cases reported in the week to 7 June 2015

Geographical distribution of new and total confirmed cases

Table 3: Cases and contacts by district/prefecture over the past 4 weeks

Table 4: Location and epidemiological status of confirmed cases reported in the week to 7 June 2015

chiefdomtable.png

 

Figure 3: Geographical distribution of new and total confirmed cases

Geographical distribution of new and total confirmed cases

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Table 5: Ebola virus disease infections in health workers in Guinea, Liberia and Sierra Leone

Country Cases Deaths
Guinea 187 94
Liberia* 378 192
Sierra Leone 304 221
Total 869 507

GUINEA

  • Key performance indicators for the EVD response in Guinea are shown in table 6.
  • A total of 16 confirmed cases were reported from 5 prefectures in the west of the country in the 7 days to 7 June (table 3, table 4, figure 2, figure 3), compared with 13 cases from 4 prefectures the previous week and 9 cases from 3 prefectures the week before that (table 3, figure 4). This is the most prefectures to report active transmission since late April this year.
  • Half of all cases (8) were reported from the prefecture of Forecariah, which borders the Sierra Leonean district of Kambia to the south and the Guinean prefectures of Conakry, Coyah, and Kindia to the north. As was the case in the previous week, the sub-prefectures of Farmoriah (1 case), Kaliah (2 cases), and Moussayah (5 cases) reported cases, with transmission centred on an area where the three sub-prefectures intersect (figure 2). A total of 6 cases were registered contacts of a previous case, with the remaining 2 arising from an as-yet unknown source of infection.
  • In the north west of the country, on the border with Guinea-Bissau, a single case was reported from the prefecture of Boke. The case was a registered contact of a previous case in the sub-prefecture of Kamsar, which has been the site of a localised cluster of cases for the past month. However, the contact was lost to follow-up during a period of civil unrest in the area, and was later re-identified post mortem as a community death. An intensive search for the many high-risk contacts thought to be associated with this case is underway. 
  • The remaining 7 cases were reported from Dubreka (2 cases), the capital, Conakry (2 cases), and Kindia (3 cases; figure 2, table 3, table 4). The cases in Conakry and Kindia were the first to be reported from those prefectures for over 40 days. Both cases in Conakry were registered contacts of previous cases from outside the capital (Boke and Forecariah), but all 3 cases from Kindia arose from an as-yet unknown source or sources of infection (table 4). Investigations are ongoing to trace the origin of the cases.
  • Community engagement remains challenging in most affected prefectures of Guinea. A total of 3 of the 16 nationally reported cases were identified only after post-mortem testing of community deaths, and, as described above, one of those community deaths was discovered to be a registered contact lost to follow-up during civil unrest. A total of 19 unsafe burials were reported during the week to 7 June, representing 5% of 355 recorded community deaths; up from 4% of 394 recorded community deaths the previous week.
  • As at 7 June, a total of 1693 contacts associated with reported confirmed cases were under follow-up in 8 Guinean prefectures (table 3), up from 6 prefectures the previous week.  
  • Given the proximity to Guinea-Bissau of the recent cluster of cases in the north west Guinean prefecture of Boke (figure 2, figure 3), two response teams from Guinea-Bissau have been deployed to the border with Guinea to assess several points of entry and sensitize the communities.
  • A total of 602 laboratory samples were tested in the week to 7 June, including both initial and repeat testing. Including repeat positive samples taken from patients undergoing treatment, 6% of samples tested positive for EVD, compared with 4% the previous week. Over 80% of samples were collected from dead bodies, and 49% of all samples tested were collected in the capital, Conakry.
  • Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7; 1 new ETC is under construction in Boke. No health worker infections were reported in Guinea in the week to 7 June.
  • Locations of the 9 operational laboratories in Guinea are shown in figure 8.

Table 6: Key performance indicators for Guinea

guinea_facet_plot.png

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SIERRA LEONE

  • Key performance indicators for the EVD response in Sierra Leone are shown in table 7.
  • A total of 15 confirmed cases were reported from 2 districts in the week to 31 May, compared with 12 cases from 3 districts the previous week (table 3, figure 2, figure 3, figure 5, figure 6). The weekly total is the highest since March.
  • As was the case the previous week, most (7) cases were reported from a densely populated area of the Kaffu Bullom chiefdom in Port Loko. All of the cases were registered contacts of previous cases within quarantined houses in the chiefdom (table 4). However, a cluster of 3 cases was also reported from the Bureh Kasseh Ma chiefdom of the same district, 2 of which arose from an as-yet unknown chain of transmission. These cases are not thought to be directly linked to those in Kaffu Bullom, but rather to a chain of transmission in the neighbouring district of Kambia.
  • After reporting its first case in more than 2 weeks the previous week, 5 cases were reported from 2 chiefdoms in Kambia during the week ending 7 June (figure 2, table 3, table 4). A total of 4 cases, all of whom were registered contacts, were reported from the Tonko Limba chiefdom. However, the single case reported from the Magbema chiefdom arose from an as-yet unknown chain of transmission, and was detected only after post-mortem testing of a community death (table 4). Community engagement has continued to be challenging in several chiefdoms in Kambia, and investigations into recent cases there have documented the occurrence of unsafe burials that have previously gone unreported. Improved communication with local communities is essential to understand and address any concerns or disincentives that prevent cases, deaths, and burials from being reported.  
  • The Western Urban Area of Sierra Leone, which includes the capital Freetown, reported no cases for the first time since August 2014. However, there were still 195 contacts under follow-up in the district as at 7 June, and a total of 392 contacts nationally in 3 districts (Kambia and Port Loko are the other 2 districts).
  • No health worker infections were reported in the week to 7 June.
  • Laboratory indicators continue to reflect a heightened degree of vigilance, with 1752 new samples tested in the week to 7 June. Less than 1% of samples tested positive. As in Guinea, over 80% of samples were collected from dead bodies, although samples were more evenly distributed among districts: all 14 districts collected and tested sampled in the week to 7 June.
  • Locations of the 10 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7.
  • Locations of the 11 operational laboratories in Sierra Leone are shown in figure 8. 

Table 7: Key performance indicators for Sierra Leone

 

Figure 5: Confirmed weekly Ebola virus disease cases reported nationally and by district from Sierra Leone

sl_facet_plot.png

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Figure 6: Days since last confirmed case by district in Guinea, Liberia, and Sierra Leone

Days since last reported confirmed case by district in Guinea, Liberia, and Sierra Leone

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OTHER AFFECTED AND PREVIOUSLY AFFECTED COUNTRIES

  • Six countries (Mali, Nigeria, Senegal, Spain, the United Kingdom and the United States of America) have previously reported a case or cases imported from a country with widespread and intense transmission.
  • On 12 May, WHO received notification of a laboratory confirmed EVD case in Italy (table 7). The case is a volunteer health worker who returned to Italy from Sierra Leone on 7 May. The patient developed symptoms on 10 May, and was transported on 11 May to the infectious diseases ward of the Hospital of Sassari, Sardinia. Clinical samples were confirmed as EVD positive on 12 May, and the patient was securely transferred to the National Institute for Infectious Diseases in Rome. All 19 contacts associated with the case have now completed 21-day follow-up (table 8).
  • The EVD outbreak in Liberia was declared over on 9 May. The country, which had previously experienced widespread and intense transmission, completed 42 days without any new confirmed cases since the burial of the last confirmed case on 28 March. The country has now entered a 3-month period of heightened vigilance. In the week to 7 June, an average of 25 laboratory samples were tested per day. Just over 60% of samples were collected from dead bodies, compared with over 80% in both Guinea and Sierra Leone. Over half (55%) of all samples were collected from Montserrado county, which includes the capital, Monrovia.

Table 8: Ebola virus disease cases in Italy

Country Cumulative cases Contact tracing
Confirmed Probable Suspect Deaths Health-care workers Contacts under follow-up Contacts who have completed 21-day follow-up Date last patient tested negative Number of days since last patient tested negative
Italy 1 0 0 0 100% - 19 - -

Figure 7: Location of Ebola treatment centres in Guinea, Liberia, and Sierra Leone

Location of Ebola treatment centres in Guinea, Liberia and Sierra Leone

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PREPAREDNESS OF COUNTRIES TO RAPIDLY DETECT AND RESPOND TO AN EBOLA EXPOSURE

  • The introduction of an EVD case into unaffected countries remains a risk for as long as cases are reported in any country. With sufficient levels of preparation, however, such introductions of the disease can be contained with a rapid and adequate response.
  • WHO’s preparedness activities aim to ensure all countries are ready to effectively and safely detect, investigate, and report potential EVD cases, and to mount an effective response. WHO provides this support through country visits by preparedness-strengthening teams (PSTs), direct technical assistance to countries, and the provision of technical guidance and tools.

Figure 8: Location of laboratories in Guinea, Liberia, and Sierra Leone

Location of Ebola treatment centres in Guinea, Liberia and Sierra Leone

View interactive map »

Priority countries in Africa

  • The initial focus of support by WHO and partners is on highest priority countries – Côte d’Ivoire, Guinea Bissau, Mali and Senegal – followed by high priority countries – Burkina Faso, Benin, Cameroon, Central African Republic, Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Mauritania, Nigeria, South Sudan, Niger, and Togo. The criteria used to prioritize countries include geographical proximity to affected countries, trade and migration patterns, and strength of health systems.
  • Since 20 October 2014, PSTs have provided technical support in Benin, Burkina Faso, Cameroon, Central African Republic, Côte d'Ivoire, Ethiopia, Gambia, Ghana, Guinea Bissau, Mali, Mauritania, Niger, Senegal, South Sudan, and Togo. Technical working group meetings, field visits, high-level exercises, and field simulations have helped to identify key areas for improvement. Each country has a tailored plan to strengthen operational readiness. WHO and partners are deploying staff to the priority countries to assist with the implementation of national plans.
  • Follow-up missions in the four highest priority countries (Côte d’Ivoire, Senegal, Mali, and Guinea Bissau) were able to strengthen cross-border surveillance and the sharing of outbreak data under the framework of the International Health Regulations (IHR: 2005), as well as support other technical areas.
  • A programme to roll-out longer term support to countries is ongoing, with staff levels being increased in WHO country offices to coordinate preparedness activities. EVD preparedness officers have been recruited to WHO country offices in Benin, Côte d’Ivoire, Ethiopia, Guinea Bissau, Ghana, Gambia, Mali, Senegal, and Togo. Deployments to all other priority countries are being finalized, and three subject-matter experts are also providing dedicated support to countries in the areas of infection prevention and control, outbreak logistics, and coordination.
  • WHO personal protective equipment (PPE) modules contain minimum stocks to cover staff protection and other equipment needs to support 10 beds for 10 days for all staff with essential functions. PPE modules have been delivered and forwarded to strategic locations in Senegal, Mauritania, Mali, Guinea Bissau, Cote d’Ivoire, Ghana, Togo, Niger, and Cameroon. PPE modules are currently in country and awaiting delivery to strategic locations in Benin, Gambia, and Burkina Faso. PPE modules have been dispatched to both Central African Republic and Ethiopia.
  • Further modules are being dispatched to all other unaffected countries in the WHO African Region and seven countries on the African continent in the WHO Eastern Mediterranean Region. Contingency stockpiles of PPE are in place in Accra and in Dubai, and will be made available to any country in the event that they experience a shortage.

Follow-up support to priority countries

  • Following the initial PST assessment missions to the 14 priority countries undertaken in 2014, a second phase of preparedness strengthening activities has been initiated to achieve the following goals:
    • Provide tailored, targeted technical support to strengthen EVD capacities in human resources; operationalize plans; test and improve procedures through field exercises and drills; and support the implementation of preparedness plans with financial and logistics support;
    • Provide leadership and coordinate partners to fully support one national plan;
    • Contribute to the International Health Regulations (2005) strengthening of national core capacities and the resilience of health systems.
  • In Guinea Bissau, WHO is supporting the Ministry of Health by setting up 2 sub-offices in the districts bordering Guinea: Gabi and Tombali. In addition, 2 epidemiologists and 2 community engagement experts have been deployed to the 2 border districts to provide additional support, and strengthen capacity for surveillance, contact tracing, rapid response, case management, safe burials, infection prevention and control, and communications.  
  • In Côte d’Ivoire, WHO deployed a logistician from 20 May to 16 June to support the implementation of correct waste management systems at ETCs, and evaluate current PPE stocks and stock management capabilities.  
  • In Mauritania, epidemiological support for surveillance continues to be provided to the ministry of health, including training surveillance focal points on case definitions, surveillance protocols, and data management.

EVD preparedness officers

  • Dedicated EVD preparedness officers have been deployed to support the implementation of country preparedness plans, coordinate partners, provide a focal point for inter-agency collaboration, provide specific technical support in their respective areas of expertise, and provide capacity development to national WHO staff. Preparedness officers are currently deployed to Benin, Cameroon, Cote d’Ivoire, Ethiopia, The Gambia, Ghana, Guinea-Bissau, Mali, Mauritania, Senegal, and Togo.

Training, exercises and simulations

  • Priority countries that have achieved a minimum of 50% implementation of preparedness checklist activities will be encouraged to undertake an outbreak-response exercise. This exercise will involve a series of drills on elements of an EVD response, and a functional exercise to test the coordination of the Ebola operations centre. Outbreak response exercises are ongoing in Ghana and Senegal this week, with dates to be confirmed for Burkina Faso, Cote d’Ivoire, Guinea-Bissau, and Mali. In Togo, support will be provided to the regional training-of-trainers exercise on Ebola infection prevention and control from 5 to 22 June.

Support to other regions

  • From 7 to 8 June, a mission will take place in Khartoum, Sudan to plan an Emergency Operations Centre functional exercise with WHO and the Ministry of Health of Sudan.

International meetings on Ebola preparedness

  • A high-level partner meeting will take place from 13 to 15 July in South Africa. The goal of the meeting is to bring together key national, regional, and international stakeholders to establish a common framework of action to support, coordinate, and intensify the strategic development and maintenance of health security preparedness over the long term. 

Surveillance and preparedness indicators

  • Indicators based on surveillance data, case-management capacity, laboratory testing, and equipment stocks continue to be collected on a weekly basis from the four countries neighbouring affected countries: Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal.
  • An interactive preparedness dashboard based on the WHO EVD checklist is now available online.

 

ANNEX 1: COORDINATION OF THE EBOLA RESPONSE ALONG 4 LINES OF ACTION

WHO continues to work with many partners in response to the EVD outbreak, including the African Union, the Economic Community of West African States, the Mano River Union, national governments, non-governmental organizations and UN agencies. Agencies responsible for coordinating four key lines of action in the response are given below.

Lines of action Lead agency
Case management WHO
Case finding, laboratory services and contact tracing WHO
Safe and dignified burials International Federation of Red Cross and Red Crescent Societies (IFRC)
Community engagement and social mobilization UNICEF

 

ANNEX 2: DEFINITIONS OF PHASE 2 KEY PERFORMANCE INDICATORS

Indicator Numerator Numerator source Denominator Denominator source
Cases and deaths
Number of confirmed cases # of confirmed cases

Guinea: Daily WHO situation reports

Sierra Leone: Daily Ministry of Health Ebola situation reports

N/A N/A
Number of confirmed deaths # of confirmed deaths

Guinea: Daily WHO situation reports

Sierra Leone: Daily Ministry of Health Ebola situation reports

N/A N/A
Proportion of EVD- positive reported community deaths

# of community deaths for which a sample was taken 

# of community deaths with positive EVD swab results

Guinea: Weekly WHO situation reports

Sierra Leone: Daily Ministry of Health situation reports

N/A N/A
Diagnostic services
Number of samples tested and percentage with positive EVD results

# of new samples tested

# of new samples tested with a positive EVD result

Guinea: Laboratory database

Sierra Leone: Daily Ministry of Health Ebola situation reports

N/A

# of new samples tested

Guinea: Laboratory database

Sierra Leone: Daily Ministry of Health Ebola situation reports

Contact tracing
Percent of new confirmed cases from registered contacts # of new confirmed cases registered as a contact

Guinea: Weekly WHO situation reports

Sierra Leone: Weekly Ministry of Health Surveillance Report

of new confirmed cases

Guinea: Daily WHO situation reports

Sierra Leone: Daily Ministry of Health Ebola situation reports

Hospitalization
Time between symptom onset and case hospitalization (days) Time between symptom onset and hospitalization of confirmed, probable or suspected case (geometric mean # of days) Clinical investigation records N/A N/A
Outcome of treatment
Case fatality rate (among hospitalized cases) # of deaths among hospitalized cases (confirmed) Clinical investigation records # of hospitalized cases (confirmed) with a definitive survival outcome recorded Clinical investigation records
Infection Prevention and Control (IPC) and Safety
Number of newly infected health workers # of newly infected health workers

Guinea / Sierra Leone: Daily WHO situation reports

N/A N/A
Safe and dignified burials
Number of unsafe burials reported # of reports/alerts of burials that were not known to be safe

Guinea: Weekly WHO situation reports

N/A N/A
Social mobilization
Number of districts with at least one security incident or other form of refusal to cooperate # of districts with at least one security incident or other form of refusal to cooperate in the past week

Guinea: Daily WHO situation reports

Sierra Leone: UNICEF

N/A N/A