Ebola Situation Report - 11 February 2015

 

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SUMMARY

  • Total weekly case incidence increased for the second consecutive week, with 144 new confirmed cases reported in the week to 8 February. Guinea reported a sharp increase in incidence, with 65 new confirmed cases compared with 39 the week before. Transmission remains widespread in Sierra Leone, which reported 76 new confirmed cases, while the resurgence in cases in the western district of Port Loko continued for a second week. Liberia continues to report a low number of new confirmed cases.
  • Despite improvements in case finding and management, burial practices, and community engagement, the decline in case incidence has stalled. The spike in cases in Guinea and continued widespread transmission in Sierra Leone underline the considerable challenges that must still be overcome to get to zero cases. The infrastructure, systems, and people needed to end the epidemic are now in place; response measures must now be fully implemented.
  • The surge of new confirmed cases reported by Guinea was driven primarily by transmission in the capital, Conakry (21 confirmed cases) and the western prefecture of Forecariah (26 confirmed cases). Community engagement continues to be a challenge in Conakry and Forecariah, and in Guinea more widely. Almost one-third of the country’s EVD-affected prefectures reported at least one security incident in the week to 8 February. Effective contact tracing, which relies on the cooperation of communities, has also proved challenging. In the week to 1 February, just 7 of 42 cases arose among registered contacts. A total of 34 unsafe burials were reported, with 21 EVD-positive deaths reported in the community.
  • Seven new confirmed cases were reported in the east-Guinean prefecture of Lola. A field team is currently deployed to Côte d’Ivoire to assess the state of preparedness in western areas of the country that border Lola.
  • Follow-up preparedness missions are planned for Mali and Senegal later this month, culminating in a tri-partite meeting between Guinea, Mali, and Senegal to strengthen cross-border surveillance.
  • A total of 3 confirmed cases was reported from Liberia. All of the cases originated from the same area of Montserrado county, linked to a single chain of transmission.
  • Following the steep decline in case incidence in Sierra Leone from December until the end of January, incidence has now stabilized. A total of 76 cases were reported in the week to 8 February, a decrease from the 80 confirmed cases reported in the week to 1 February, but higher than the 65 confirmed cases reported in the week to 25 January. Transmission remains widespread, with 7 districts reporting new confirmed cases. A total of 41 unsafe burials were reported in the week to 8 February.
  • The case fatality rate among hospitalized cases (calculated from all confirmed and probable hospitalized cases with a reported definitive outcome) remains high, between 53% and 60%.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

  • There have been almost 23 000 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (table 1), with almost 9000 reported deaths (outcomes for many cases are unknown). A total of 65 new confirmed cases were reported in Guinea, 3 in Liberia, and 76 in Sierra Leone in the 7 days to 8 February (data missing for 8 February in Liberia). At the start of the epidemic many reported suspected cases were genuine cases of EVD. At this stage, with improved surveillance systems in place, a far smaller proportion of suspected cases are confirmed to have EVD. Consequently, the incidence of new confirmed cases gives a more accurate picture of the epidemic.
  • A stratified analysis of cumulative confirmed and probable cases indicates that the number of cases in males and females is similar (table 2). Compared with children (people aged 14 years and under), people aged 15 to 44 are approximately three times more likely to be affected. People aged 45 and over are almost four times more likely to be affected than are children.
  • A total of 830 confirmed health worker infections have been reported in the 3 intense-transmission countries; there have been 488 reported deaths (table 3).

Table 1: Confirmed, probable, and suspected cases reported by Guinea, Liberia, and Sierra Leone

Country Case definition Cumulative cases Cases in past 21 days Cumulative deaths
Guinea Confirmed 2674 134 1643
Probable 352 * 352
Suspected 18 *
Total 3044 134 1995
Liberia Confirmed 3146 12 3826
Probable 1873 *
Suspected 3862 *
Total 8881 12 3826
Sierra Leone Confirmed 8135 221 2975
Probable 287 * 208
Suspected 2512 * 158
Total 10 934 221 3341
Total   22 859 367 9162

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Table 2: Cumulative number of confirmed and probable 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 1413
(26)
1508
(28)
460
(10)
1648
(35)
791
(51)
Liberia 2801
(141)
2746
(140)
943
(55)
2981
(175)
1145
(214)
Sierra Leone 5037
(177)
5400
(186)
2201
(91)
5751
(222)
2298
(311)

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Table 3: Ebola virus disease infections in health workers in the three countries with intense transmission

Country Cases Deaths
Guinea 166 88
Liberia 371 179
Sierra Leone 293 221
Total 830 488

 

Figure 1: Geographical distribution of new and total confirmed cases

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GUINEA

  • Key performance indicators for the EVD response in Guinea are shown in table 4.
  • A total of 65 confirmed cases were reported in the 7 days to 8 February 2015 (figure 2), compared with 39 the week before. This is the third week in a row that case incidence has increased in Guinea, and the highest weekly total since the first week of 2015.
  • The recent surge in cases is driven primarily by the western district of Forecariah (26 confirmed cases) and the capital, Conakry (21 confirmed cases).
  • The 26 confirmed cases reported from Forecariah represent the highest ever weekly total reported from the prefecture. To the immediate south, the Sierra Leonean district of Kambia reported 11 confirmed cases in the week to 8 February, highlighting the need for close cross-border cooperation in order to stymie transmission.
  • Community engagement continues to be a challenge in many areas of Guinea, with approximately one-third of EVD-affected prefectures reporting at least one security incident in the week to 8 February.
  • A total of 8 prefectures reported a confirmed or probable case during the reporting period (figure 2).
  • Seven new confirmed cases were reported from the eastern prefecture of Lola, on the border with Côte d’Ivoire. A team is currently deployed to Cote d’Ivoire to assess the state of preparations in western areas.
  • The north Guinean prefecture Mali, which borders Senegal, has reported its second confirmed case. The case is the aunt of the first case reported in the prefecture: a man who travelled from Monrovia. Three prefectures along Guinea’s northern border have reported confirmed cases in the past 21 days (figure 1).
  • Twelve districts that have previously reported confirmed cases did not report any confirmed cases in the 21 days to 8 February; 9 have reported no cases for over 42 days (figure 1, figure 5).
  • Locations of 6 operational Ebola treatment centres (ETCs) are shown in figure 6. 100% (2/2) of ETCs assessed met minimum standards for infection prevention and control (IPC). No new health worker infections were reported in the week to 8 February.
  • The case fatality rate (CFR) during the month of December was 55% among hospitalized confirmed cases for whom a definitive outcome was reported. Western districts reported a lower CFR from October to December 2014 (43% in Conakry, 45% in Coyah) compared with eastern districts (66% in Kerouane, 65% in Macenta, and 61% in N’Zerekore). Possible explanations for this variation include differences in treatment, and distance required to travel to a treatment facility.
  • Locations of the 5 operational and 4 planned laboratories in Guinea are shown in figure 7.
  • In the week to 1 February, 17% of new confirmed and probable cases arose among registered contacts; a drop from 55% the previous week. During the week to 8 February, 89% of all registered contacts were seen on a daily basis.
  • A total of 21 EVD-positive deaths were reported in the community in the week to 8 February. Ideally all cases should be identified and treated in an Ebola-specific facility; there should be no EVD-related deaths in the community. A total of 34 unsafe burials were reported in the same period.
  • The high number of community deaths and reported unsafe burials combined with widespread reports of security incidents related to the EVD response, underscore the need to improve community engagement strategies in many areas of the country.

Figure 2: Confirmed weekly Ebola virus disease cases reported nationally and by district from Guinea

 

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

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LIBERIA

  • Key performance indicators for the EVD response in Liberia are shown in table 4.
  • A total of 3 confirmed cases were reported in the 7 days to 8 February (figure 3).
  • All confirmed cases were reported from Montserrado, the district that includes the capital, Monrovia (figure 1 and figure 3). All cases are reported to be linked to the same chain of transmission.
  • Eleven districts in Liberia have not reported a confirmed case for over 42 days (figure 5).
  • Locations of the 18 operational Ebola treatment centres (ETCs) in Liberia are shown in figure 6.
  • Locations of the 8 operational laboratories in Liberia are shown in figure 7.
  • In the 7 days to 8 February, 1 of 3 (33%) new confirmed cases arose among registered contacts; down from 100% of cases during the previous 9-day period. During the week to 8 February 2015, all registered contacts were seen on a daily basis.
  • Two counties in Liberia reported an instance of community resistance in the week to 4 January.

Figure 3: Confirmed weekly Ebola virus disease cases reported nationally and by district from Liberia

 

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SIERRA LEONE

  • Key performance indicators for the EVD response in Sierra Leone are shown in table 4.
  • Following a steep decline from December to late January, weekly case incidence now seems to have flattened out. A total of 76 cases were reported in the week to 8 February, a decrease from the 80 confirmed cases reported in the week to 1 February, but higher than the 65 confirmed cases reported in the week to 25 January.
  • The west of the country remains the area of most intense transmission. The capital, Freetown, reported 19 new confirmed cases, compared with 22 the previous week. The neighbouring district of Port Loko saw a continuation of its recent resurgence of cases, with 28 new confirmed cases compared with 36 the previous week (figure 1, figure 4).
  • The district of Kambia, which borders the Guinean prefecture of Forecariah, reported 11 new confirmed cases.
  • Transmission remains widespread throughout the country. A total of 7 out of 14 districts reported at least one new confirmed case in the week to 8 February. In the south, Bo, Bonthe, Kailahun, and Pujehun have all reported no cases for more than 21 days (figure 5).
  • Locations of the 24 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 6. A total of 43 of 50 (86%) of assessed Ebola health facilities met minimum standards for infection prevention and control.
  • There are 12 operational laboratories and 1 pending in Sierra Leone (figure 7).
  • During the week to 8 February 2015, 98% of all registered contacts were visited on a daily basis.
  • In the week to 8 February 10 deaths from EVD were reported to have occurred in the community, and 41 unsafe burials were reported.
  • Two districts in Sierra Leone reported an instance of community resistance in the week to 4 February.

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

 

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

 

Figure 5: Days since last reported confirmed case by district in Guinea, Liberia, and Sierra Leone

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

February 8 is counted as day 0. 

 

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COUNTRIES WITH AN INITIAL CASE OR CASES, OR WITH LOCALIZED TRANSMISSION

  • Six countries (Mali, Nigeria, Senegal, Spain, the United Kingdom and the United States of America) have reported a case or cases imported from a country with widespread and intense transmission.
  • In the United Kingdom, public health authorities confirmed a case of EVD in Glasgow, Scotland, on 29 December 2014 (table 5). The case was a health worker who returned from volunteering at an ETC in Sierra Leone. The patient was isolated on 29 December and received treatment in London. On 23 January the patient tested negative twice for EVD, and on 24 January the patient was discharged. All contacts have completed 21-day follow-up.

Table 5: Ebola virus disease cases and deaths in the United Kingdom

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
United Kingdom 1 0 0 0 100% 0 55 23/01/2015 18

Figure 6: 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 a case into unaffected countries remains a risk for as long as cases are reported in any country. With adequate 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 support teams (PSTs), direct technical assistance to countries, and the provision of technical guidance and tools.

Figure 7: Location of laboratories in Guinea, Liberia, and Sierra Leone

Location of laboratories in Guinea, Liberia, and Sierra Leone

Location of one pending laboratory in Freetown, Sierra Leone, is not shown.

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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 – 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 14 countries: Benin, Burkina Faso, Cameroon, Central African Republic, Côte d'Ivoire, Ethiopia, Gambia, Ghana, Guinea Bissau, Mali, Mauritania, Niger, Senegal 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 90-day plan to strengthen operational readiness. WHO and partners are deploying staff to the 14 countries to assist with the implementation of 90-day plans.
  • A rapid response assessment team has been deployed to the western border area of Côte d'Ivoire to evaluate levels of preparedness for an imported case of EVD. The neighboring Guinean district of Lola has recently reported a cluster of cases. A technical support team has also been deployed to Côte d'Ivoire, and is focusing on cross-border collaboration with Guinea, response coordination, surveillance, and resource mobilisation. A training plan is being accelerated to strengthen capacity in these areas.
  • Follow-up PSTs are planned in February for Guinea-Bissau, Mali, and Senegal.

 

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 4 key lines of action in the response are given below.

Lines of action Lead agency
Case management WHO
Case finding, lab 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 KEY PERFORMANCE INDICATORS

Response monitoring indicators are calculated using the following numerators and denominators:

Indicator Numerator Numerator source Denominator Denominator source
Cases and deaths
Number of confirmed cases # of confirmed cases Daily WHO country situation reports N/A N/A
Number of confirmed deaths # of confirmed deaths Daily WHO country situation reports N/A N/A
Number of confirmed deaths that occurred in the community # of deaths in the community with positive EVD swab results

Guinea: Weekly country situation reports

Liberia: Ministry of Health report

Sierra Leone: Ministry of Health report

N/A N/A
Contact tracing
Percent of new confirmed cases from registered contacts # of new confirmed cases registered as a contact (includes probable cases in Guinea)

Guinea: Weekly country situation reports

Liberia: Incident Management System

Sierra Leone: WHO Country Office

Number of new confirmed cases (includes probable cases in Guinea) Daily WHO country situation reports
Isolation
Time between symptom onset and case isolation (days) Time between symptom onset and isolation of confirmed or probable cases (geometric mean number 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
Percent of IPC-assessed Ebola treatment centres (ETCs) # of IPC-assessed Ebola treatment centres IPC Reports # of operational Ebola treatment centres WHO field coordinators
Number of newly infected health workers # of newly infected health workers (does not include foreign medical teams) Daily country 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 country situation reports

Liberia: Ministry of Health

Sierra Leone: Ministry of Health report

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 country situation reports

Liberia: WHO Country Office

Sierra Leone: UNICEF

N/A N/A