Ebola Situation Report - 3 June 2015

Total confirmed cases (by week, 2015)

 

 
 
 

SUMMARY

  • Since the week ending 10 May, when a 10-month low of 9 cases of Ebola virus disease (EVD) were reported from 2 prefectures of Guinea and 1 district of Sierra Leone, both the intensity and geographical area of EVD transmission have increased. In the week ending 31 May, a total of 25 confirmed cases were reported from 4 prefectures of Guinea and 3 districts of Sierra Leone. Several cases in both Guinea and Sierra Leone arose from unknown sources of infection in areas that have not reported confirmed cases for several weeks, indicating that chains of transmission continue to go undetected. Rigorous contact tracing, active case finding, and infection prevention and control must be maintained at current intensive levels in order to uncover and break every chain of transmission. However, the onset of the rainy season will make field operations more difficult from now onwards.
  • A total of 13 cases were reported from 4 western prefectures of Guinea in the week to 31 May. Most cases (7) were reported from the prefecture of Forecariah, which borders Sierra Leone. Multiple chains of transmission gave rise to cases in 4 of Forecariah’s 10 sub-prefectures, although all cases were either registered contacts of a previous case or had an established epidemiological link to one. The remaining cases were reported from the north-western prefecture of Boke (1 case), which borders Guinea-Bissau; the west-coast prefecture of Dubreka (4 cases), which borders the capital, Conakry; and the western inland prefecture of Fria (1 case).
  • Community engagement has proved challenging in all 4 affected prefectures of Guinea, with several reported incidents of violence directed at field staff during the past week. In addition, 4 of the 13 nationally reported cases were identified only after post-mortem testing of community deaths. Of those 4 community deaths, 2 were registered contacts, suggesting that even when contacts can be traced, regular monitoring to ensure they receive prompt testing and treatment as soon as symptoms arise remains a challenge.
  • Sierra Leone reported a total of 12 cases from 3 districts in the week to 31 May. The majority of cases (8) were reported from a densely populated area of the Kaffu Bullom chiefdom in the district of Port Loko, just north of the capital, Freetown. All but one of the cases were registered contacts of previous cases within quarantined houses in the chiefdom. The additional case is from the same neighbourhood but was not on a contact list and was living in a non-quarantined home at the time of symptom onset. The district of Kambia reported its first case for over 2 weeks on 31 May. The case was identified after a post-mortem test of a community death and was not a known contact of a previous case. The remaining 3 cases were reported from the capital, Freetown. At this time, none of those 3 cases can be linked to previous chains of transmission, although investigations are at an early stage.
  • As at 31 May, a total of 1880 contacts associated with reported confirmed cases were under follow-up in 6 Guinean prefectures: Boke, Conakry, Dubreka, Forecariah, Fria, and Kindia. A total of 461 contacts were under follow-up in 3 districts of Sierra Leone: Kambia, Port Loko, and Western Area Urban (the area that includes the capital, Freetown).
  • Two response teams from Guinea-Bissau have been deployed to the border with Guinea to assess several points of entry and sensitize communities.  
  • 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 27 145 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11 147 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 13 new confirmed cases were reported in Guinea and 12 in Sierra Leone in the 7 days to 31 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 3223 49 2010
Probable 419 * 419
Suspected 10 *
Total 3652 49 2429
Liberia§ Confirmed 3151 0
Probable 1879 *
Suspected 5636 *
Total 10 666 0 4806
Sierra Leone Confirmed 8620 23 3546
Probable 287 * 208
Suspected 3920 * 158
Total 12 827 23 3912
Total Confirmed 14 994 72
Probable 2585 *
Suspected 9566 *
Total 27 145 72 11 147

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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 1549
(28)
1669
(31)
500
(11)
1841
(40)
832
(53)
Liberia§ 1911
(96)
1838
(93)
561
(33)
2060
(121)
703
(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 31 May 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 31 May 2015

 

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 13 confirmed cases were reported from 4 prefectures in the 7 days to 31 May (table 3, table 4, figure 2, figure 3), compared with 9 cases from 3 prefectures the previous week (table 3, figure 4).
  • Most cases (7) were reported from the prefecture of Forecariah, which borders Sierra Leone. A total of 4 of Forecariah’s 10 sub-prefectures reported confirmed cases, although most (5) cases were concentrated in a central area of the prefecture where the sub-prefectures of Farmoriah, Kaliah, and Moussayah intersect (figure 2). All cases reported from the prefecture were either registered contacts of a previous case or had an established epidemiological link to one.
  • The remaining cases were reported from the north-western prefecture of Boke (1 case), which borders Guinea-Bissau; the west-coast prefecture of Dubreka (4 cases), which borders the capital, Conakry; and the western inland prefecture of Fria (1 case; figure 2, table 3, table 4). The cases in Boke and Dubreka were all registered contacts of cases linked to localised chains of transmission (table 4). However, the case reported from Fria arose from an unknown source, and is suspected to have originated from an as-yet unidentified chain of transmission in the neighbouring prefecture of Telimele.
  • Investigations into the origin of the case in Fria have been complicated by active and passive resistance from communities in both Fria and Telimele. Community engagement has proved challenging in all 4 affected prefectures of Guinea, with several reported incidents of violence directed at field staff during the past week. In addition, 4 of the 13 nationally reported cases were identified only after post-mortem testing of community deaths. Of those 4 community deaths, 2 were registered contacts, suggesting that even when contacts can be traced, regular monitoring to ensure they receive prompt testing and treatment as soon as symptoms arise remains a challenge in many areas.
  • As at 31 May, a total of 1880 contacts associated with reported confirmed cases were under follow-up in 6 Guinean prefectures: Boke, Conakry, Dubreka, Forecariah, Fria, and Kindia (table 3).
  • 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. The investigation team were not able to locate the contact who had attended the funeral of a case in Boke, and who is thought to have returned to a fishing community in Guinea-Bissau.
  • The number of reported unsafe burials increased slightly compared with the previous week, from 13 to 16, although it remained stable as a proportion of all reported burials, at 4% of 384.
  • A total of 608 laboratory samples were tested in the week to 31 May, including both initial and repeat testing. Including repeat positive samples taken from patients undergoing treatment, 4% of samples tested positive for EVD, compared with 6% the previous week.
  • Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7. No health worker infections were reported in Guinea the week to 31 May.
  • Locations of the 9 operational laboratories in Guinea are shown in figure 8.

Table 6: Key performance indicators for Guinea

Figure 4: Confirmed weekly Ebola virus disease cases reported nationally and by district from 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 12 confirmed cases were reported from 3 districts in the week to 31 May, compared with 3 cases from 2 districts the previous week (table 3, figure 2, figure 3, figure 5, figure 6). The weekly total is the highest for over 1 month.
  • The majority (8) of cases were reported from a densely populated area of the Kaffu Bullom chiefdom in Port Loko. All but one of the cases were registered contacts of previous cases within quarantined houses in the chiefdom (table 4), and are the third generation of cases in the locale that can be linked back to a single case imported from the district of Kambia, which lies just to the north of Port Loko on the border with Guinea (figure 2, figure 3, figure 5, figure 6). The additional case is from the same neighbourhood but was not on a contact list, and was living in a non-quarantined home at the time of symptom onset.
  • Kambia reported its first case for over 2 weeks on 31 May (figure 6). The case was identified after a post-mortem test of a community death and was not a known contact of a previous case. Epidemiological investigations have so far not been able to establish an epidemiological link to a previous case, and it is suspected that an active chain of transmission may have gone undetected in the community for several weeks. Community engagement has continued to be challenging in several chiefdoms in Kambia, with UNICEF reporting a large number of incidents of resistance to response measures in the district.   
  • The remaining 3 cases were reported from the capital, Freetown. At this time, none of the 3 cases can be linked to previous chains of transmission, although investigations are at an early stage. One of the cases was a stillborn child who tested PCR-positive for EVD on delivery; the mother tested PCR-negative for EVD. Serological tests have detected antibodies against EVD in the mother, indicative of a prior infection or exposure. The case underlines the need for close monitoring of pregnancy and child birth among female EVD survivors.
  • A total of 461 contacts were under follow-up in 3 districts of Sierra Leone: Kambia, Port Loko, and Western Area Urban (the area that includes the capital, Freetown; table 4).
  • No health worker infections were reported in the week to 31 May.
  • Laboratory indicators continue to reflect a heightened degree of vigilance, with 1617 new samples tested in the week to 31 May. Less than 1% of samples tested positive.
  • Locations of the 10 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7. Two ETCs closed in the Western Area Rural district in the week to 31 May.
  • 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. A total of 19 contacts associated with the case were monitored for 21 days (table 8). Information regarding the number of contacts that have completed the 21-day follow-up period is pending.
  • 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 31 May, an average of 30 laboratory samples were tested per day.

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, 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, 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 has deployed a logistician to implement a basic stock-management system and to coordinate the receipt and distribution of 1500 sets of PPE to replace previously damaged stocks. In addition, WHO has deployed 2 epidemiologists in collaboration with the Portuguese Ministry of Health, and 2 social mobilisation experts to regions on the border with Guinea.
  • In Mali, WHO deployed a field coordinator on 24 May to prepare national simulation exercises and review the country’s national training plan.
  • In Côte d’Ivoire, WHO deployed a logistician to support the implementation of the correct waste-management systems at holding centres, and evaluate current PPE stocks, patient-transport procedures, communication capacity, and outbreak 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.

Training

  • 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 to 18 June in Ghana and Senegal, with dates to be confirmed for Burkina Faso, Cote d’Ivoire, Gambia, 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.

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.
  • A meeting of preparedness officers in priority countries is taking place in Brazzaville from 2 to 4 June 2015.

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