Ebola Situation Report - 22 July 2015

Total confirmed cases (by week, 2015)

 

 
 
 
 

SUMMARY

  • There were 26 confirmed cases of Ebola virus disease (EVD) reported in the week to 19 July: 22 in Guinea and 4 in Sierra Leone. Liberia reported no new cases. For the second consecutive week more than half of all cases were reported from the capitals of Guinea and Sierra Leone, Conakry and Freetown. By contrast, other recent hotspots of transmission such as Boke in Guinea and Kambia in Sierra Leone have now reported no cases for 18 and 9 days, respectively. There are also indications of a continuation of the improvements in contact tracing and case investigation seen in recent weeks, with all but 2 cases arising among registered contacts of previous cases, including all 13 of the cases reported from the Guinean capital Conakry. This is the highest proportion of cases to arise among contacts since the beginning of the outbreak. However, one of the 2 cases reported from Freetown arose from an unknown source of infection, and is considered to represent a high risk of further transmission. In addition, 2 cases, both from Guinea, were identified as EVD-positive only after post-mortem testing of community deaths.
  • In Guinea, cases were reported from the prefectures of Conakry, Coyah, and Forecariah. Thirteen cases were reported from Conakry, all of whom were registered contacts associated with 2 chains of transmission. Two of these cases were health workers. In the neighbouring prefecture of Coyah 2 cases were reported from the sub-prefecture of Maneah. These are the first cases reported from Coyah since April. Both are registered contacts associated with a chain of transmission that stems from the sub-prefecture of Benty in Forecariah. Six of the 7 cases reported from Forecariah were registered contacts associated with the same chain of transmission in Benty. The remaining case from Forecariah arose from an unknown source in the sub-prefecture of Alassoyah.
  • No new cases were reported from Liberia in the week to 19 July. Of the 6 confirmed cases reported since 29 June, 2 have died, 2 have been discharged after treatment, and 2 remain under observation in an Ebola Treatment Centre. As of 21 July, 56 contacts associated with the chain of transmission are under follow-up. A total of 18 contacts have completed the 21-day follow up period. If there are no further cases all contacts will have completed follow-up on 2 August.
  • The 4 cases confirmed in Sierra Leone were reported from Freetown and Port Loko. The first of 2 cases from Freetown was a health worker who tested positive for EVD whilst residing in a voluntary quarantine facility. The second case was found with advanced disease (symptoms including vomiting and diarrhoea) outside a community health facility near the Magazine Wharf neighbourhood of the city, which reported 8 cases in the previous week. However, the case is not a registered contact of any case from the Magazine Wharf transmission chain. Contact tracing has been complicated by the fact that the case has no fixed address and was infectious for an unknown period prior to identification. The remaining 2 cases in Sierra Leone were reported from the chiefdom of Marampa in Port Loko. Both are registered contacts associated with a transmission chain linked to an EVD-positive mother who died during childbirth in mid-June.
  • On 20 July, Italy was declared free of EVD transmission after the completion of 42 days without a case since the country’s first and only case of EVD to date was confirmed EVD-negative and discharged from hospital.
  • Two new health worker infections were reported from Guinea and one from Sierra Leone in the week to 19 July. There have been a total of 879 confirmed health worker infections reported from Guinea, Liberia, and Sierra Leone since the start of the outbreak, with 510 reported deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

  • There have been a total of 27 705 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1) up to 19 July, with 11 269 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 22 new confirmed cases were reported in Guinea and 4 in Sierra Leone in the week to 19 July.
  • The total number of confirmed cases is similar in males and females (table 2). Compared with children (people aged 14 years and under), adults aged 15 to 44 are approximately four times more likely to be affected in Guinea and Liberia, and three times more likely to be affected in Sierra Leone.
  • Three new health worker infections were reported in the week to 19 July: 2 in Guinea and 1 in Sierra Leone. Since the start of the outbreak a total of 879 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 510 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 3322 53 2062
Probable 450 * 450
Suspected 11 *
Total 3783 53 2512
Liberia§ Confirmed 3151 -
Probable 1879 -
Suspected 5636 -
Total 10 666 - 4806
Liberia** Confirmed 6 6 2
Probable 0 *
Suspected *
Total 6 6 2
Sierra Leone Confirmed 8692 27 3583
Probable 287 * 208
Suspected 4271 * 158
Total 13 250 27 3949
Total Confirmed 15 171 86
Probable 2616 *
Suspected 9918 *
Total 27 705 86 11 269

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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 1587
(29)
1730
(32)
526
(11)
1889
(41)
857
(55)
Liberia§ 1911
(96)
1838
(93)
561
(33)
2060
(121)
703
(132)
Sierra Leone 4792
(168)
5081
(175)
1978
(82)
5592
(216)
2129
(288)

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Figure 2: Geographical distribution of confirmed cases reported in the week to 19 July 2015

Geographical distribution of new and total confirmed cases

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

district_table.png

Data are based on official information reported by ministries of health. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. *Data as of 19 July for Guinea and Sierra Leone and data as of 21 July for Liberia. Includes Freetown.

 

Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 19 July 2015

chiefdom_table.png

Sub-prefectures/chiefdoms/districts that reported one or more confirmed cases in the 7 days to 19 July are highlighted. *Epi-link refers to cases who were not registered as contacts of a previous case (possibly because they refused to cooperate or were untraceable), but who, after further epidemiological investigation, were found to have had contact with a previous case, OR refers to cases who are resident or are from a community with active transmission in the past 21 days. Includes cases under epidemiological investigation. §A case that is identified as a community death can also be registered as a contact, or subsequently be found to have had contact with a known case (epi-link), or have no known link to a previous case. **Includes Freetown.

 

Figure 3: Geographical distribution of new and total confirmed cases in Guinea, Liberia and Sierra Leone

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 194 97
Liberia* 378 192
Sierra Leone 307 221
Total 879 510

GUINEA

  • Key performance indicators for the EVD response in Guinea are shown in table 6.
  • 22 confirmed cases were reported from 3 prefectures—Conakry, Coyah, and Forecariah—in the week to 19 July (table 3, table 4, figure 2, figure 3).
  • For the second consecutive week, the majority of cases (13) in Guinea were reported from the capital, Conakry. Twelve cases were reported from Ratoma commune (administrative district), and are registered contacts linked to a chain of transmission that originated in the Tanene sub-prefecture of Dubreka. Two of these cases are health workers. The first is a lab technician; the second is a doctor in training from a military hospital where a confirmed case was treated the previous week. The remaining case from Conakry came from the commune of Matam (table 3, table 4, figure 2), and is a registered contact from the Benty transmission chain in Forecariah.
  • In the prefecture of Coyah, just to the northeast of Conakry, 2 cases were reported from the sub-prefecture of Maneah. These are the first cases reported from Coyah since April. Both are registered contacts associated with a chain of transmission that stems from the sub-prefecture of Benty in Forecariah.
  • Six of the 7 cases reported from Forecariah were registered contacts associated with the same chain of transmission in Benty. The remaining case from Forecariah arose from an unknown source of infection in the sub-prefecture of Alassoyah.
  • Overall, 21 (95%) of 22 cases in Guinea were registered contacts: the highest reported proportion since the onset of the outbreak. However, 2 cases in Forecariah were only identified after post-mortem testing of community deaths.
  • On 19 July there were 2832 contacts being monitored across 7 Guinean prefectures (table 3). Forecariah accounts for the majority of contacts (2008), followed by Conakry (612).
  • There were 5 (1%) unsafe burials reported in Guinea out of 500 recorded community deaths in the week to 19 July, compared with 4 (0.7%) unsafe burials out of 558 recorded community deaths in the previous week.
  • Including both initial and repeat testing, a total of 744 laboratory samples were tested in the week to 19 July.
  • Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7. Two health worker infections were reported in the week to 19 July.
  • Locations of the 11 operational laboratories in Guinea are shown in figure 8. 

Table 6: Key performance indicators for Guinea

guinea_kpi_v2.png

For definitions of key performance indicators see Annex 2. Data are given for 7-day periods. *Includes repeat samples. Data missing for 0–3% of cases. #Outcome data missing for 0–1% of hospitalized confirmed cases. 

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 4 confirmed cases were reported from 2 districts (Freetown and Port Loko) in the week to 19 July (table 3, figure 2, figure 3, figure 5, figure 6).
  • Two cases were reported from the capital, Freetown. The first case from Freetown is a health worker who tested positive for EVD after the onset of symptoms in a voluntary quarantine facility. The second case was found with advanced disease including wet symptoms outside a community health facility near the Magazine Wharf neighbourhood of the city, which reported 8 cases last week. However, the case is not a registered contact of any case from the Magazine Wharf chain of transmission. Investigations are underway to determine the source of infection and any contacts of the case. Contact tracing is complicated by the fact that the case has no fixed address and was symptomatic for an unknown period prior to identification.
  • Two cases were reported from the chiefdom of Marampa in Port Loko. Both are registered contacts associated with a transmission chain linked to an EVD-positive mother who died during childbirth in mid-June.
  • Three of the 4 cases reported from Sierra Leone in the week to 19 July were registered contacts. No cases were identified as a result of post-mortem testing of community deaths.
  • On 19 July, a total of 618 contacts were being monitored in 4 districts: Kambia, Port Loko, Western Area Rural, and Western Area Urban (table 3).
  • Locations of the 10 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7.
  • Laboratory indicators continue to reflect a heightened degree of vigilance, with 1502 new samples tested in the 6 days to 19 July (data are missing for 14 July). Fewer than 1% of samples tested positive for EVD.
  • Locations of the 10 operational laboratories in Sierra Leone are shown in figure 8. 

Table 7: Key performance indicators for Sierra Leone

sierraleone_kpi_v5.png

For definitions of key performance indicators see Annex 2. Data are for 7-day periods. Data missing for 4–12% of cases. #Outcome data missing for 25–75% of hospitalized confirmed cases. An outcome is known for only 6 hospitalized, confirmed cases in April. 

 

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

  • Liberia was declared free of Ebola transmission on 9 May 2015, after reporting no new cases for 42 consecutive days. The country subsequently entered a 3-month period of heightened surveillance, during which approximately 30 blood samples and oral swabs are collected each day from potential cases and tested for EVD. On 29 June, this heightened surveillance detected an EVD-positive community death in Margibi County, Liberia—the first new confirmed case reported from the country since 20 March. The case was a 17-year-old male who first became ill on 21 June, died on 28 June, and subsequently tested positive for EVD. As at 12 July, 5 contacts associated with the first-detected case have since been confirmed as EVD-positive. Of the 6 confirmed cases reported since 29 June, 2 have died, 2 have been discharged after treatment, and 2 remain under observation in an Ebola Treatment Centre. As of 21 July, 56 contacts associated with the chain of transmission are under follow-up. A total of 18 contacts have completed the 21 day follow up period. If there are no further cases all contacts will have completed follow-up on 2 August. The origin of the cluster of cases remains under investigation. Preliminary evidence from genomic sequencing suggests that the most likely origin of transmission is a re-emergence of the virus from a survivor within Liberia, rather than an importation from Guinea or Sierra Leone.
  • Seven countries (Italy, 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 20 July, Italy was declared free of EVD transmission after the completion of 42 days without a case since the country’s first and only case of EVD to date was confirmed EVD-negative and discharged from hospital.

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 as long as cases exist in any country. With adequate preparation, however, such an introduction can be contained through a timely and effective 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 support visits by preparedness-strengthening teams (PSTs) to help identify and prioritize gaps and needs, direct technical assistance, and provide 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

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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—Benin, Burkina Faso, Cameroon, Central African Republic, Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Mauritania, Niger, Nigeria, South Sudan, and Togo. The criteria used to prioritize countries include the geographical proximity to affected countries, the relative magnitude of trade and migration links, and the relative strength of their 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 table-top 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 (2005), as well as support other technical areas.
  • From October 2014 to July 2015 WHO has undertaken over 266 field deployments to priority countries.
  • WHO provides personal protective equipment (PPE) modules containing 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 or are in the process of being delivered to all countries on the African continent. In addition, all countries have received one PPE training module.
  • Contingency stockpiles of PPE are in place in the United Nations Humanitarian Response Depots (UNHRD) in Accra and Dubai, and are 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 leadership and coordinate partners to support each national plan fully;
    • Contribute to the International Health Regulations (2005) strengthening of national core capacities and the resilience of health systems.
  • In Guinea-Bissau, two WHO sub-offices have been established in the regions of Gabu and Buba that share a border with Guinea to enhance event-based surveillance and support two Emergency Operations Centres (EOCs) and rapid response teams. Two epidemiologists are currently deployed in Gabu and Tombali. An additional two epidemiologists will be deployed to support the sub-offices until the end of August. Daily reporting between the border locations and EOC are taking place to ensure a heightened state of alertness and timely information sharing. Community-level activities (surveillance, social mobilization, and safe and effective triage of suspected cases) have been reinforced. The practice of swabbing dead bodies is being implemented to rule out EVD as the cause of death. WHO is also increasing staff levels in the country to support national and regional emergency coordination. Logistics support will be provided through the activation of the WHO/WFP logistics framework agreement.
  • In Côte d’Ivoire, a workshop is being held from 20 to 25 July to harmonize and finalize various standard operating procedures related to IPC and epidemiology.
  • In Mali, a simulation exercise will run from 25 July to 1 August with experts in coordination, epidemiology, logistics, and simulations facilitating the exercise.

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 are encouraged to undertake an outbreak response exercise. This exercise involves a series of drills on elements of an EVD response, and a functional exercise to test the coordination of the Ebola operations centre.
  • Exercises in Côte d’Ivoire, Mali, and The Gambia are currently planned for July 2015.
  • The dates for training in Burkina Faso and Guinea-Bissau are to be confirmed.

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