Ebola Situation Report - 20 May 2015

Total confirmed cases (by week, 2015)

 

 
 
 

SUMMARY

  • The week to 17 May saw the highest weekly total of confirmed cases of Ebola virus disease (EVD) for over a month, with 35 cases reported from Guinea and Sierra Leone. This is a substantial increase compared with 9 cases reported the previous week. The geographical area of transmission has also expanded compared with recent weeks, with a total of 6 districts reporting cases (3 in Guinea, 3 in Sierra Leone), compared with 3 the previous week (2 in Guinea, 1 in Sierra Leone). Capacity for improved community engagement, case investigation, and targeted, active surveillance continues to be strengthened in areas of continuing transmission to ensure that remaining chains of transmission are detected, contained, and brought to an end.
  • Guinea reported a total of 27 cases, compared with 7 cases the previous week. The majority of cases were reported from the western prefectures of Dubreka (11 cases) and Forecariah (11 cases), with the remaining 5 cases reported from the north western prefecture of Boke, which borders Guinea-Bissau. The cases in Boke were tightly clustered in the coastal sub-prefecture of Kamsar, and initial investigations suggest they may have originated from a chain of transmission in Conakry. All 11 cases reported from Dubreka came from the sub-prefecture of Tanene. Although the exact origin of the cluster is unknown, retrospective investigation has linked most of the confirmed cases to 4 probable cases who attended a funeral of another probable case in Dubreka in mid-April, which may have been the source of the outbreak. Difficulty engaging local communities has made case investigation and contact tracing in the area challenging. In Forecariah, 11 cases were distributed across 6 of the prefecture’s 10 sub-prefectures. A total of 9 of the 27 cases reported from Guinea originated from an unknown source, indicating that chains of transmission continue to evade detection in several areas.
  • Because of the proximity to Guinea-Bissau of the recent cluster of cases in the Guinean prefecture of Boke, a response team from Guinea-Bissau has been deployed to the border to assess points of entry. An epidemiological investigation team has also mobilized to ensure any contacts who cross the border are traced.
  • In Sierra Leone, 8 confirmed cases were reported from Freetown (4 cases), Kambia (1 case), and Port Loko (3 cases). In Freetown, cases were clustered in 3 neighbourhoods in the north of the city near to the Moa Wharf area, which was the only part of Sierra Leone to report cases in the previous week. The single case in Kambia was reported from the Chiefdom of Magbema, which had been the main focus of transmission in the district in recent weeks. The 3 cases in the Port Loko Chiefdom of Kaffu Bullom are linked to a chain of transmission in Kambia. A total of 4 of the 8 cases reported from Sierra Leone were registered contacts of a previous case. An additional 3 cases were not registered contacts, but were found on further investigation to have had contact with a previous case. The remaining case, reported from Freetown, was identified after post-mortem testing of a community death. The source of infection is unknown, but the case was found in the Moa Wharf area.
  • The last health worker infection in Guinea was reported on 6 April. However, a new health worker infection in Sierra Leone was laboratory confirmed on 14 May. The case is a Sierra Leone national who was working at an Ebola treatment centre near Freetown at the time of symptom onset. This is the same facility at which the recent Italian health worker case was stationed prior to their return to Italy. Investigations are ongoing into how both health workers came to be exposed to EVD. A total of 13 contacts are currently being monitored in Italy, none of whom are considered to have had a high-risk exposure. 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 26 933 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11 120 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 27 new confirmed cases were reported in Guinea and 8 in Sierra Leone in the 7 days to 17 May. 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 3201 43 1988
Probable 419 * 419
Suspected 15 *
Total 3635 43 2407
Liberia§ Confirmed 3151 0
Probable 1879 *
Suspected 5636 *
Total 10 666 0 4806
Sierra Leone Confirmed 8605 19 3541
Probable 287 * 208
Suspected 3740 * 158
Total 12 632 19 3907
Total Confirmed 14 957 62
Probable 2585 *
Suspected 9391 *
Total 26 933 62 11 120

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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 1540
(28)
1650
(30)
496
(11)
1823
(39)
827
(53)
Liberia§ 1911
(96)
1835
(93)
561
(33)
2056
(120)
704
(132)
Sierra Leone 4641
(163)
4948
(171)
1904
(79)
5454
(211)
2062
(279)

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Figure 2: Geographical distribution of confirmed cases reported in the week to 17 May 2015

Geographical distribution of new and total confirmed cases

 

Table 3: Location and epidemiological status of confirmed cases reported in the week to 17 May 2015

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Figure 3: Geographical distribution of new and total confirmed cases

Geographical distribution of new and total confirmed cases

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GUINEA

  • Key performance indicators for the EVD response in Guinea are shown in table 4.
  • A total of 27 confirmed cases were reported in the 7 days to 17 May (table 3, figure 3), compared with 7 cases the previous week (figure 4). The number of prefectures that reported a case also increased from 2 to 3 compared with the previous week.
  • Of 26 prefectures that have reported at least one confirmed case of EVD since the beginning of the outbreak, 18 have not reported a confirmed case for over 6 weeks (figure 6). This is one prefecture less than the previous week, after the north western prefecture of Boke reported 5 confirmed cases: its first for over 200 days. The remaining 22 cases reported from Guinea in the week to 17 May came from the western prefectures of Dubreka (11 cases) and Forecariah (11 cases; figure 4).
  • The 5 cases in Boke were tightly clustered in the coastal sub-prefecture of Kamsar (figure 2, table 3), and initial investigations suggest they may have originated from a chain of transmission in Conakry.
  • All 11 cases reported from Dubreka in the week to 17 May came from the sub-prefecture of Tanene. Although the exact origin of the cluster is unknown, retrospective investigation has identified 4 probable cases who attended a funeral of another probable case in Dubreka in mid-April, which may have been the source of the outbreak. Difficulty engaging local communities has made case investigation and contact tracing in the area challenging. 
  • In Forecariah, 11 cases were widely distributed across 6 sub-prefectures. A 4-day active case finding and sensitization campaign began in Forecariah on 16 May, aiming to visit over 7000 households over the course of the campaign.
  • A total of 1078 contacts are currently being monitored daily in the 3 Guinean prefectures that reported a confirmed case: 172 in Boke, 248 in Dubreka, and 609 in Forecariah. In addition, 49 in Conakry are also being monitored.
  • Owing to the proximity to Guinea-Bissau of the recent cluster of cases in the north west Guinean prefecture of Boke (figure 2, figure 3), a response team from Guinea-Bissau has been deployed to the border with Guinea to assess points of entry, and an epidemiology investigation team has been mobilized to ensure the rapid tracing of any contacts who cross the border.
  • Of the 27 cases reported from Guinea, 5 were registered contacts of a previous case, an additional 13 cases were not registered contacts but were found on further investigation to have an epidemiological link with a previous case, and the remaining 9 cases were reported to have originated from an as-yet unknown source of infection. The relatively large proportion of cases reported to have originated from an unknown source of infection indicates that the strengthening of capacity for case investigation and active surveillance must continue in order to uncover all remaining chains of transmission.
  • In total, 6 of the 27 cases reported from Guinea in the week to 17 May were identified after post-mortem testing of deaths in community settings (table 3). The number of reported unsafe burials increased very slightly compared with the previous week, from 23 to 25, but remained stable as a proportion of all reported burials, at 6% of 386.
  • A total of 520 laboratory samples were tested in the week to 17 May, including both initial and repeat testing. Including repeat positive samples taken from patients undergoing treatment, 10% of samples tested positive for EVD.
  • Locations of 8 operational Ebola treatment centres (ETCs) are shown in figure 7. For the fifth consecutive week, no health worker infections were reported in Guinea the week to 17 May.
  • Locations of the 10 operational laboratories in Guinea are shown in figure 8.

Table 4: Key performance indicators for Guinea for Phase 2 of the Ebola Response

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Figure 4: Confirmed weekly Ebola virus disease cases reported nationally and by district from Guinea

 

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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

SIERRA LEONE

  • Key performance indicators for the EVD response in Sierra Leone are shown in table 6.
  • A total of 8 confirmed cases were reported in the week to 17 May, compared with 2 the previous week (figure 5), ending a sequence of 3 consecutive falls in weekly case incidence.
  • Three districts reported confirmed cases in the week to 17 May, compared with a single district the previous week (figure 3, figure 6). Of 14 districts in Sierra Leone that have ever reported a confirmed case since the beginning of the outbreak, 9 have not reported a confirmed case for over 6 weeks (figure 6). 
  • Half of the cases reported from Sierra Leone occurred in three neighbourhoods in the north of the capital, Freetown (table 3, figure 2). Of these, three have a proven epidemiological link to a previous case. The remaining case, reported from Freetown, was identified after post-mortem testing of a community death. The source of infection is unknown, but the case was found in the Moa Wharf area.
  • The district of Port Loko, just to the north of Freetown, reported cases for the first time in over 3 weeks. All 3 cases were reported from the Chiefdom of Kaffu Bullom, and all were registered contacts with an epidemiological link to a previous case reported from the district of Kambia.
  • The district of Kambia, which borders the Guinean prefecture of Forecariah to the north and Port Loko to the south, and which reported zero cases in the week to 10 May, reported a case from the Chiefdom of Magbema in the week to 17 May. The case was a registered contact of a previous case.
  • A total of 599 contacts are currently being monitored daily in 3 districts: 47 in Port Loko, 82 in Kambia, and 470 in Western Area Urban, which includes Freetown.
  • There were 415 credible alerts of sick people with possible Ebola-like symptoms received in the week to 10 May (the most recent week for which data are available). Of these 415, 404 (97%) were responded to within 24 hours. Over 90% of alerts were reported by the public.
  • After 5 consecutive weeks without reporting a health worker infection, a Sierra Leone national working at an Ebola treatment centre near Freetown was laboratory confirmed as EVD positive on 14 May. The national was working at the same facility as the recent Italian health worker case. Investigations are ongoing into how both health workers came to be exposed to EVD.
  • Laboratory indicators continue to reflect a heightened degree of vigilance, with 1654 new samples tested in the week to 17 May. Less than 1% of samples tested positive.
  • Locations of the 12 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7. An ETC in Kenema closed in the week to 17 May.
  • Locations of the 11 operational laboratories in Sierra Leone are shown in figure 8. 

Table 6: Key performance indicators for Sierra Leone for Phase 2 of the Ebola Response

SierraLeone_KPI_v3.PNG

 

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

 

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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. Because onset of symptoms occurred 72 hours after the case’s last flight, contact tracing of passengers who shared flights with the case was not considered necessary. A total of 13 contacts associated with the case are currently being monitored. None of the contacts are considered to have been at a high risk of exposure.
  • 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 17 May, an average of 27 laboratory samples were tested per day, with 100% confirmed as negative for EVD.

Table 7: 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, preparedness-strengthening teams (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, Guinea Bissau, Ghana, The Gambia, Ethiopia, Mali, and Senegal. Deployments to all other priority countries are being finalized, and two subject-matter experts are providing dedicated support to countries in the areas of outbreak logistics and coordination.
  • Standard viral haemorrhagic fever modules have been delivered to Mali, Guinea-Bissau, Côte d'Ivoire, Senegal, Mauritania, Burkina Faso, Benin, Chad, Gambia, Niger, Nigeria, Togo, Egypt, and Ghana. The 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.
  • Further modules are being dispatched to all other unaffected countries in the African Region and seven countries on the African continent in 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. 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.

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 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.
  • WHO deployed a logistician to Benin to provide logistics support on 12 and 13 May.
  • WHO will deploy a logistician to Guinea Bissau this week to assess PPE stocks and to implement a basic stock-management system. 1500 sets of PPE have been dispatched to replace stocks that were damaged in a warehouse fire.
  • WHO will deploy an expert on 24 May to support the Ministry of Health in Mali in the coordination and planning of a simulation exercise.

Training

  • In The Gambia, training courses for EVD Preparedness and Response will be held at the central and regional level on 18 May.
  • A follow-up visit to Ghana is planned for 8 to 12 June, focusing on rapid response teams, ETCs, infection prevention and control, and logistic support.
  • A follow-up visit is planned for Togo during the second week of June, focusing on infection prevention and control.
  • EMRO has developed a rapid-response field-training course, which will be implemented in Morocco (18–22 May), and Jordan (24–29 May).
  • 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 planned for 8-18 June in Ghana and Senegal, with dates to be confirmed for Burkina Faso, Cote d’Ivoire, Gambia, Guinea Bissau, and Mali.

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
Number of confirmed deaths that occurred in the community # of deaths in the community 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