Ebola Situation Report - 9 December 2015

Total confirmed cases (by week, 2015)

 

 
 
 

SUMMARY

  • No confirmed cases of Ebola virus disease (EVD) were reported in the week to 6 December. Investigations into the origin of infection of the cluster of 3 confirmed cases of EVD reported from Liberia in the week to 22 November are continuing, with a working assumption that the cluster arose as a result of a rare re-emergence of persistent virus from a survivor. The first-reported case in that cluster was a 15-year-old boy who tested positive for EVD after admission to a health facility in the Greater Monrovia area on 19 November. He was then transferred to an Ebola treatment centre along with the 5 other members of his family. Two other members of the family – the boy’s 8-year old brother and his 40-year-old father – subsequently tested positive for EVD whilst in isolation. Both tested negative twice for Ebola virus on 3 December. The 15-year-old boy died on 23 November. In addition to the family of the first-reported case, 165 contacts have been identified, including 15 high-risk contacts. Contacts are now in the third week of their 21-day follow-up period.
  • On 7 November WHO declared that Sierra Leone had achieved objective 1 of the phase 3 framework, and the country has now entered a 90-day period of enhanced surveillance scheduled to conclude on 5 February 2016. As of 6 December it had been 20 days since the last EVD patient in Guinea received a second consecutive EVD-negative blood test. The last case in Guinea was reported on 29 October 2015.
  • The recent cases in Liberia underscore the importance of robust surveillance measures to ensure the rapid detection of any reintroduction or re-emergence of EVD in currently unaffected areas. In order to achieve objective 2 of the phase 3 response framework – 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 illness or death that they suspect may be related to EVD to the relevant authorities. In the week to 6 December, 19 864 such alerts were reported in Guinea, with alerts reported from all of the country’s 34 prefectures. Equivalent data are not currently available for Liberia. In Sierra Leone, 1420 alerts were reported from all 14 districts in the week ending 15 November (the most recent week for which data are available).
  • 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 6 December 8 operational laboratories in Guinea tested a total of 582 new and repeat samples from 12 of the country’s 34 prefectures. 84% of all samples tested in Guinea were swabs collected from dead bodies. By contrast, 82% of the 1020 new and repeat samples tested in Liberia over the same period were blood samples collected from live patients. In addition, all 15 counties in Liberia submitted samples for testing by the country’s 5 operational laboratories. 1363 new samples were collected from all 14 districts in Sierra Leone and tested by 8 operational laboratories. 95% of samples in Sierra Leone were swabs collected from dead bodies.
  • 964 deaths in the community were reported from Guinea in the week to 6 December through the country’s alert system. This represents approximately 43% 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. Equivalent data are not yet available for Liberia. In Sierra Leone, 1282 reports of community deaths were received through the alert system during the week ending 15 November (the most recent week for which data are available), representing approximately 62% of the 2075 deaths expected each week based on estimates of the population and a crude mortality rate of 17 deaths per 1000 people per year.

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 0 2083
Probable 453 * 453
Suspected 0 *
Total 3804 0 2536
Liberia Confirmed 3151 -
Probable 1879 -
Suspected 5636 -
Total 10 666 - 4806
Liberia** Confirmed 9 3 3
Probable * *
Suspected *
Total 9 3 3
Sierra Leone§ Confirmed 8704 0 3589
Probable 287 * 208
Suspected 5131 * 158
Total 14 122 0 3955
Total Confirmed 15 215 3
Probable 2619 *
Suspected 10 767 *
Total 28 601 3 11 300

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PHASE 3 RESPONSE FRAMEWORK

  • 28 601 confirmed, probable, and suspected cases have been reported in Guinea, Liberia, and Sierra Leone, with 11 300 deaths (table 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, termed phase 2, succeeded in driving case incidence to 5 cases or fewer per week by the end of July. 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. The indicators below detail progress made towards attaining the two primary objectives of the phase 3 framework.

OBJECTIVE 1: RAPIDLY INTERRUPT ALL REMAINING CHAINS OF EBOLA TRANSMISSION

  • As of 7 November objective 1 of the phase 3 response framework was achieved in Sierra Leone.
  • As of 6 December it had been 20 days since the last EVD patient in Guinea received a second consecutive negative test for Ebola virus. Key performance indicators for objective 1 of the phase 3 response framework in Guinea are shown in table 4.
  • The Ebola ça suffit! ring vaccination trial is continuing in Guinea and Sierra Leone, and has now been extended to Liberia following the country’s recent cluster of cases. All rings comprised of contacts and contacts of contacts associated with confirmed cases now receive immediate vaccination with the rVSV-ZEBOV Ebola vaccine. On 1 September, the eligibility criteria for the trial were amended to allow the vaccination of children aged 6 years and above.
  • Investigations into the origin of infection of the cluster of 3 confirmed cases of Ebola virus disease (EVD) reported from Liberia in the week to 22 November are continuing, with a working assumption that the cluster arose as a result of a rare re-emergence of persistent virus from a survivor. The first-reported case in that cluster was a 15-year-old boy who tested positive for Ebola virus after admission to a health facility in the Greater Monrovia area on 19 November. He was then transferred to an Ebola treatment centre along with the 5 other members of his family. Two other members of the family – the boy’s 8-year old brother and his 40-year-old father – subsequently tested positive for EVD whilst in isolation. Both tested negative twice for Ebola virus on 3 December. The 15-year-old boy died on 23 November.
  • In addition to the family of the first-reported case, 165 contacts have been identified, including 15 high-risk contacts. Contacts are now in the third week of their 21-day follow-up period.

Table 2: Cases and contacts by prefecture/county 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 6 December 2015.

Table 3: Location and epidemiological status of confirmed cases reported in the 3 weeks to 6 December 2015

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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.

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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Figure 3: Confirmed weekly Ebola virus disease cases reported nationally and by prefecture from Guinea

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Table 4: Key performance indicators for phase 3 objective 1 in Guinea

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For definitions of key performance indicators see Annex 1. Week 40 commenced 28 September. Week 49 ended 6 December.

Table 5: Key performance indicators for phase 3 objective 1 in Liberia

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For definitions of key performance indicators see Annex 1. Week 40 commenced 28 September. Week 49 ended 6 December.

OBJECTIVE 2: MANAGE AND RESPOND TO THE CONSEQUENCES OF RESIDUAL RISKS​​

  • Key performance indicators for the surveillance component of objective 2 of the phase 3 response framework are shown for Guinea, Liberia, and Sierra Leone (table 6). Data for phase 3 indicators pertaining to service provision for survivors and rapid response capacity (annex 1 and annex 2) are being collected and will be included in subsequent situation reports.
  • The recent cases in Liberia underscore the importance of robust surveillance measures to ensure the rapid detection of any reintroduction or re-emergence of EVD in currently unaffected areas. In order to achieve objective 2 of the phase 3 response framework – 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 6 December, 19 864 such alerts were reported in Guinea, with alerts reported from all of the country’s 34 prefectures. Equivalent data are not currently available for Liberia. In Sierra Leone, 1420 alerts were reported from all 14 districts in the week ending 15 November (the most recent week for which data are available; table 6).
  • 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 6 December, 8 operational laboratories in Guinea tested a total of 582 new and repeat samples from 12 of the country’s 34 prefectures (table 6; figures 4 and 5). This represents a small decrease compared with the previous week, though the trend in the number of samples tested each week has remained flat for the past two months. 84% of all samples tested in Guinea were swabs collected from dead bodies. By contrast, 82% of the 1020 new and repeat samples tested in Liberia over the same period were blood samples collected from live patients. This is the fourth consecutive weekly increase in samples tested for Ebola virus in Liberia. In addition, all 15 counties in Liberia submitted samples for testing by the country’s 5 operational laboratories. 1363 new samples were collected from all 14 districts in Sierra Leone and tested by 8 operational laboratories. This is a marginal increase compared with the previous week. 95% of samples in Sierra Leone were swabs collected from dead bodies (table 6; figures 4 and 5).
  • 964 deaths in the community were reported from Guinea in the week to 6 December through the country’s alert system (table 6). This represents approximately 43% 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. Equivalent data are not yet available for Liberia. In Sierra Leone, 1282 reports of community deaths were received through the alert system during the week ending 15 November (the most recent week for which data are available), representing approximately 62% of the 2075 deaths expected each week based on estimates of the population and a crude mortality rate of 17 deaths per 1000 people per year.
  • The unprecedented scale of the EVD outbreak in Guinea, Liberia, and Sierra Leone means there are estimated to be several thousands of survivors throughout the three countries. Survivors have contributed enormously to many aspects of response, but they face many challenges. In addition to the stigmatization they frequently experience when they return to their own communities, survivors also face myriad health issues, from joint pains and headaches to problems with vision and poor mental health. Although there is a vibrant self-organised survivor-support community, survivors require specialized medical support as well as access to routine health care services such as ante-natal care and vaccinations and screening. With guidance from WHO and other partners, ministries of health in the three most-affected countries have plans in place to deliver a comprehensive package of services to ensure the welfare of survivors and mitigate risks posed by viral persistence.

Table 6: Key surveillance indicators for phase 3 objective 2 in Guinea, Liberia, and Sierra Leone

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For definitions of key performance indicators see Annex 1. Week 40 commenced 28 September. Week 49 ended 6 December.

Figure 4: Location of laboratories and geographical distribution of samples from live patients in Guinea, Liberia, and Sierra Leone in the week to 6 December 2015

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

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Figure 5: Location of laboratories and geographical distribution of samples from dead bodies in Guinea, Liberia, and Sierra Leone in the week to 6 December 2015Location of Ebola treatment centres in Guinea, Liberia and Sierra Leone

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Figure 6: 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

  • 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.

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 magnitude of trade and migration links, and the relative strength of their health systems.
  • Since October 2014, technical support has been provided Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Ghana, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, South Sudan, and Togo through team missions and targeted technical support. 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.
  • From October 2014 to November 2015, WHO has undertaken over 336 field deployments to priority countries to assist with the implementation of national plans.
  • WHO provides personal protective equipment (PPE) modules containing minimum stocks to cover staff protection and other equipment needs to support 10 patient-beds for 10 days for all staff with essential functions. PPE modules have been delivered to all countries on the African continent. In addition, all countries have received a 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.

Ongoing follow-up support to priority countries

  • Following initial PST assessment missions to the priority countries in 2014, a second phase of preparedness-strengthening activities have provided support on a country-by-country basis.
  • Technical support is provided at the request of the respective ministries of health to strengthen EVD preparedness by operationalizing plans, testing systems, building capacity, and providing technical guidance.

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, offer specific technical support in their respective areas of expertise, and develop capacity of national WHO staff. Preparedness officers are currently deployed to Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Guinea-Bissau, Mauritania, Niger, Senegal, and Togo. 

Training, exercises, and simulations

  • Priority countries that have achieved a minimum of 50% implementation of preparedness checklist activities are encouraged to test outbreak preparedness and response by undertaking a series of skill drills on elements of an EVD response.
  • In Mauritania, from 30 November to 4 December 2015, WHO supported the Ministry of Health with a simulation exercise that focused on the coordination and operations of an Ebola treatment centre. Following the simulation exercise, WHO supported the Ministry of Health with risk mapping.
  • In Togo, rapid-response training for national and regional teams took place from 30 November to 5 December. WHO is also supporting the Ministry of Health with risk mapping from 8 to 15 December.
  • In Niger, from 14 to 15 December, WHO will support the Ministry of Health with an exercise to simulate the coordination and operations of an Ebola treatment centre, and subsequent risk mapping.
  • In Central African Republic, from 7 to 12 December, WHO is supporting the Ministry of Health with a logistics capacity assessment and simulation exercise planning.
  • In Uganda, from 7 to 16 December, WHO is supporting the training of national logisticians in stock management and emergency preparedness and 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 now available online.

 

ANNEX 1: EBOLA RESPONSE PHASE 3 KEY PERFORMANCE INDICATORS

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ANNEX 2: ALL EBOLA RESPONSE PHASE 3 KEY PERFORMANCE INDICATORS

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