Ebola Situation Report - 30 March 2016

Total confirmed cases (by week, up to 27 March 2016)

 

 
 
 
 

SUMMARY

  • The International Health Regulations (2005) Emergency Committee regarding Ebola virus disease (EVD) in West Africa met for a ninth time on 29 March. On the basis of the Committee’s advice and her own assessment of the situation, the WHO Director-General declared the end of the Public Health Emergency of International Concern regarding the Ebola virus disease outbreak in West Africa. The Committee noted that since its last meeting Guinea, Liberia, and Sierra Leone have all met the criteria for confirming interruption of their original chains of Ebola virus transmission. The Committee also noted that, although new clusters of EVD cases continue to occur as expected, including a recent and ongoing cluster in Guinea, all clusters to date have been detected and responded to rapidly.
  • Guinea was declared free of Ebola transmission linked directly to the original outbreak on 29 December 2015. On 17 March 2016 a cluster of 2 confirmed and 3 probable cases of Ebola virus disease was reported from the prefecture of N’Zerekore in south-eastern Guinea. Three further confirmed cases were reported on 21, 26, and 28 March, respectively. All confirmed cases had symptom onset in the sub-prefecture of Koropara. Cases reported on 21 and 26 March were high-risk contacts of the initial case-cluster; the contact status of the case confirmed on 28 March has not yet been reported. All 5 confirmed cases are epidemiologically linked to a chain of 3 probable cases in the subprefecture of Koropara: two females in their late 30s, and one male in his late 50s. All 3 probable cases died between 27 February and 15 March, and were not buried safely. Investigations have determined that the first probable case (a female in her late 30s) had symptom onset on or around 15 February 2016. The source of her infection is being investigated. Viral sequencing data indicate that virus present in the blood of one of the confirmed cases is closely related to virus that circulated in south-eastern Guinea in November 2014. 1033 contacts linked to the cluster have been identified so far, 171 of whom are considered to be high risk. All but 10 contacts have been traced. Response efforts have been reinforced by the redeployment of over 30 epidemiologists from western prefectures including the capital, Conakry. In addition, four villages are subject to cerclage measures, whereby individuals must report for regular check-ups and are not permitted to leave the immediate area of the village. Vaccination teams began vaccination of contacts and contacts of contacts on 22 March. Additional cases are likely because of the large number of contacts. One suspect case (reported 30 March) is currently under observation in an Ebola treatment centre.
  • Not including individuals who have been tested as part of ongoing viral persistence studies, over 350 male survivors in Liberia have used semen screening and counselling services. In addition, over 2600 survivors in Sierra Leone have accessed a general health assessment and eye exam.
  • To manage the residual risks of Ebola reintroduction or re-emergence, WHO has supported the implementation of enhanced surveillance systems in Guinea, Liberia, and Sierra Leone to alert authorities to cases of febrile illness or death that may be related to EVD. In the week to 27 March, 1512 alerts were reported in Guinea from all of the country’s 34 prefectures. Over the same period, 9 operational laboratories in Guinea tested a total of 434 new and repeat samples from 19 of the country’s 34 prefectures. In Liberia, 861 alerts were reported from all of the country’s 15 counties. The country’s 5 operational laboratories tested 730 new and repeat samples for Ebola virus over the same period. In Sierra Leone 1220 alerts were reported from the country’s 14 districts in the week to 20 March. 911 new and repeat samples were tested for Ebola virus by the country’s 7 operational laboratories in the week to 27 March. 

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 3351 - 2083
Probable 453 - 453
Suspected 0 -
Total 3804 - 2536
Confirmed 4 4 4
Probable 3 3 3
Suspected * * *
Total 7 7 7
Liberia** Confirmed 3151 -
Probable 1879 -
Suspected 5636 -
Total 10 666 - 4806
Confirmed 9 0 3
Probable * *
Suspected * *
Total 9 0 3
Sierra Leone§ Confirmed 8704 - 3589
Probable 287 - 208
Suspected 5131 - 158
Total 14 122 - 3955
Confirmed 2 0 1
Probable * * *
Suspected * * *
Total 2 0 1
Total Confirmed 15 221 4
Probable 2622 3
Suspected 10 767 *
Total 28 610 7 11 308

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Table 2: Confirmed cases and contacts by prefecture over the past 3 weeks§§

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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 28 March 2016. §§One additional confirmed case was reported in Guinea on 28 March 2016.

Table 3: Location and epidemiological status of confirmed cases reported in 3 weeks to 27 March 2016§§

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*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. §§One additional confirmed case was reported in Guinea on 28 March 2016.

Figure 2: 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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PHASE 3 RESPONSE FRAMEWORK

  • 28 610 confirmed, probable, and suspected cases have been reported in Guinea, Liberia, and Sierra Leone, with 11 308 deaths (table 1; figure 1; figure 2) since the onset of the Ebola outbreak. The majority of these cases and deaths were reported between August and December 2014, after which case incidence began to decline as a result of the rapid scale-up of treatment, isolation, and safe burial capacity in the three countries. This rapid scale-up operation was known as phase 1 of the response, and was built on in the first half of 2015 during a period of continuous refinement to surveillance, contact tracing, and community engagement interventions. This period was termed phase 2, and succeeded in driving case incidence to 5 cases or fewer per week by the end of July 2015. This marked fall in case incidence signalled a transition to a distinct third phase of the epidemic, characterised by limited transmission across small geographical areas, combined with a low probability of high-consequence incidents of re-emergence of EVD from reservoirs of viral persistence. In order to effectively interrupt remaining transmission chains and manage the residual risks posed by viral persistence, WHO, as lead agency within the Interagency Collaboration on Ebola and in coordination with national and international partners, designed the phase 3 Ebola response framework. The phase 3 response framework builds on the foundations of phase 1 and phase 2 to incorporate new developments in Ebola control, from vaccines and rapid-response teams to counselling and welfare services for survivors. 

PHASE 3 RESPONSE INDICATORS

  • Key performance indicators for the phase 3 response framework are shown for Guinea, Liberia, and Sierra Leone (table 4). A full list of phase 3 response indicators can be found in annex 2.
  • Human-to-human transmission linked to the primary outbreak in Guinea was declared to have ended on 29 December 2015. On 17 March 2016 a cluster of 2 confirmed and 3 probable cases of Ebola virus disease (EVD) was reported from the prefecture of N’Zerekore in south-eastern Guinea. Three further confirmed cases were reported on 21, 26, and 28 March respectively. All confirmed cases had symptom onset in the sub-prefecture of Koropara. Cases reported on 21 and 26 March were high-risk contacts of the initial case-cluster. The case reported on 21 March was identified as EVD-positive by post-mortem swab after dying in a health facility in the neighbouring prefecture of Macenta, after travelling to seek treatment. Community resistance in Macenta has made contact tracing problematic. The contact status of the case confirmed on 28 March has not yet been reported. All 5 confirmed cases are epidemiologically linked to a chain of 3 probable cases in the subprefecture of Koropara: two females in their late 30s, and one male in his late 50s. All 3 probable cases died between 27 February and 15 March, and were not buried safely. Investigations have determined that the first probable case (a female in her late 30s) had symptom onset on or around 15 February 2016. The source of her infection is not known and is under investigation. Viral sequencing data indicate that virus present in the blood of one of the confirmed cases is closely related to virus that circulated in south-eastern Guinea in November 2014. 1033 contacts linked to the cluster have been identified so far, 171 of whom are considered to be high risk. All but 10 contacts have been traced. Response efforts have been reinforced by the redeployment of over 30 epidemiologists from western prefectures including the capital, Conakry. In addition, four villages are subject to cerclage measures, whereby individuals must report for regular check-ups and are not permitted to leave the immediate area of the village. Vaccination teams began vaccination of contacts and contacts of contacts on 22 March. Additional cases are likely because of the large number of contacts. One suspect case (reported 30 March) is currently under observation in an Ebola treatment centre.
  • Human-to-human transmission linked to the most recent cluster of cases in Liberia was declared to have ended on 14 January 2016, 42 days after the second and last case in the cluster provided a second consecutive negative blood sample. Human-to-human transmission linked to the cluster of 2 cases of Ebola virus disease first reported from Sierra Leone on 14 January 2016 was declared to have ended on 17 March, 42 days after the second and last case in the cluster provided a second consecutive negative blood sample.
  • With guidance from WHO and other partners, ministries of health in Guinea, Liberia, and Sierra Leone have plans in place to deliver a package of essential services to safeguard the health of the more than 10 000 individuals who have survived an Ebola infection. Not including individuals who have been tested as part of ongoing viral persistence studies, over 350 male survivors in Liberia have used semen screening and counselling services (table 4), enabling them to understand and, if appropriate, take precautions to protect their close contacts. 125 men have accessed screening services in Guinea (105 in a research setting). In addition, over 2600 survivors in Sierra Leone have accessed a general health assessment and specialised eye exam (visual problems are commonly reported complications in individuals who have survived an Ebola infection).
  • To manage and respond to the consequences of residual Ebola risks, Guinea, Liberia, and Sierra Leone have each put surveillance systems in place to enable health workers and members of the public to report any case of febrile illness or death that they suspect may be related to EVD to the relevant authorities. In the week to 27 March, 1512 alerts were reported in Guinea from all of the country’s 34 prefectures (table 4). All but 10 were reports of community deaths. In Liberia, 861 alerts were reported from all of the country’s 15 counties, most of which (742) were related to live patients. In Sierra Leone 1220 alerts were reported from all of the country’s 14 districts in the week to 20 March. The majority of alerts (1016) were for community deaths.
  • As part of each country’s EVD surveillance strategy, blood samples or oral swabs should be collected from any live or deceased individuals who have or had clinical symptoms compatible with EVD. In the week to 27 March, 9 operational laboratories in Guinea tested a total of 434 new and repeat samples from 19 of the country’s 34 prefectures. 91% of all samples tested in Guinea were swabs collected from dead bodies. By contrast, 77% of the 861 new and repeat samples tested in Liberia over the same period were blood samples collected from live patients. In addition, 14 of the 15 counties in Liberia submitted samples for testing by the country’s 5 operational laboratories. 930 new and repeat samples were collected from all 14 districts in Sierra Leone and tested by 7 operational laboratories. 98% of samples in Sierra Leone were swabs collected from dead bodies (table 4; figures 3 and 4).
  • 1502 deaths in the community were reported from Guinea in the week to 27 March through the country’s alert system (table 2). This equates to 67% of the 2248 community deaths expected based on estimates of the population and a crude mortality rate of 11 deaths per 1000 people per year. 119 deaths in the community were reported from Liberia over the same period, representing approximately 12% of the 982 community deaths expected per week. 1016 deaths in the community were reported from Sierra Leone, representing approximately 49% of the 2075 community deaths expected per week.
  • The capacity to deploy rapid-response teams following the detection of a new confirmed case continues to be a cornerstone of the national response strategy in Guinea, Liberia, and Sierra Leone. Each country reports to have at least 1 national rapid-response team (table 4). Strengthening of national and subnational rapid-response capacity and validation of incident-response plans will continue throughout 2016.

Table 4: Key performance indicators for phase 3 in Guinea, Liberia, and Sierra Leone in the 3 weeks to 27 March 2016

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All data provided by WHO country offices. For definitions of key performance indicators see Annex 1. **Number of estimated survivors not yet confirmed by Liberia WHO country office. #Reported services accessed in Liberia currently include semen screening and counselling for male survivors; reported services accessed in Sierra Leone currently include a general health assessment and eye exam. *Data correspond to the three weeks ending 20 December 2015.

Figure 3: Location of laboratories and geographical distribution of samples from live patients in Guinea, Liberia, and Sierra Leone in the week to 27 March 2016

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

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Figure 4: Location of laboratories and geographical distribution of samples from dead bodies in Guinea, Liberia, and Sierra Leone in the week to 27 March 2016Location of Ebola treatment centres in Guinea, Liberia and Sierra Leone

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Figure 5: Time since last confirmed case in Guinea, Liberia,and Sierra Leone§§

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

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PREVIOUSLY AFFECTED COUNTRIES

  • 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. 

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

  • WHO’s preparedness activities have aimed to ensure all countries are operationally ready to effectively and safely detect, investigate, and report potential EVD cases, and to mount an effective response. WHO has provided 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.

Priority countries in Africa

  • The initial focus of support by WHO and partners was on highest priority countries – Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal—followed by high priority countries—Benin, Burkina Faso, Cameroon, Central African Republic, Ethiopia, Islamic Republic of The Gambia, Ghana, Mauritania, Niger, South Sudan, and Togo. The criteria used to prioritize countries include the geographical proximity to affected countries, the magnitude of trade and migration links, and the relative strength of their health systems.
  • From October 2014 to 29 March 2016, WHO has undertaken 396 field deployments to work with ministries of health to address gaps or as part of multi-partner teams to support preparedness efforts and to assist with the implementation of national plans.
  • Over the past 12 months, technical assistance in priority countries has led to significant progress in Ebola preparedness. The Preparedness Dashboard demonstrates an increase in overall preparedness at the country-level.  As of January 2016, 86% of priority countries for Ebola preparedness have achieved over half of the tasks on WHO’s Ebola preparedness checklist. This compares to only 7% in December 2014. 
  • Contingency stockpiles of PPE are in place in all countries on the African continent and at the United Nations Humanitarian Response Depots in Accra and Dubai where they are available to any country in the event that they experience a shortage.

Ongoing follow-up support to priority countries

  • After a phase of targeted activities to strengthen Ebola preparedness, WHO has now transitioned its emergency preparedness support to a broader range of risks, and extending activities to other countries, including Guinea, Liberia, Sierra Leone, Chad, Democratic Republic of Congo, Malawi, Tanzania, and Uganda.
  • Technical support is provided at the request of the respective ministries of health in several interlinked technical areas at the country level: planning and resources for health emergencies; coordination; accelerated health system and capacity strengthening; improving outbreak operations through stronger logistical systems; and system monitoring, evaluation and testing. 

Increased WHO capacity for emergency preparedness

  • Dedicated health security and emergency (HSE) officers have been recruited to support the implementation of WHO’s broader emergency preparedness work. These staff support country preparedness plans, coordinate partners, provide a focal point for inter-agency collaboration, offer specific technical support in their respective areas of expertise, and develop the capacity of national WHO staff. HSE officers are currently deployed to Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Ethiopia, Ghana, Islamic Republic of The Gambia, Guinea-Bissau, Mauritania, Niger, Senegal, and Tanzania, Togo, and Uganda. 

Training, exercises, and simulations

  • Priority countries that have implemented a minimum of 50% of Ebola preparedness checklist activities are encouraged to test outbreak preparedness and response by undertaking a series of skill drills and simulations on elements of an EVD response. 

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 that share a border with affected countries: Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal.
  • An interactive preparedness dashboard based on the WHO EVD checklist is available online.

 

ANNEX 1: EBOLA RESPONSE PHASE 3 KEY PERFORMANCE INDICATORS

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ANNEX 2: KEY EBOLA RESPONSE PHASE 3 PERFORMANCE INDICATORS

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