Ebola Situation Report - 26 November 2014

 

HIGHLIGHTS

  • There have been 15 935 reported cases of Ebola virus disease (EVD), with 5689 reported deaths.
  • 600 cases were reported in the three most-affected countries in the past week.
  • Case incidence is stable in Guinea, stable or declining in Liberia, but may still be increasing in Sierra Leone.
  • Uncertainties in data preclude firm conclusions about progress towards UNMEER goals.
  • Over 70% of patients with EVD in Guinea are isolated, while over 80% of required safe and dignified burial teams are in place. Liberia and Sierra Leone report that fewer than 70% of patients are isolated, though there is wide variation among districts. Approximately 25% of the required safe burial teams are in place in both countries, though this does not include military burial teams.

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SUMMARY

A total of 15 935 confirmed, probable, and suspected cases of Ebola virus disease (EVD) have been reported in six affected countries (Guinea, Liberia, Mali, Sierra Leone, Spain and the United States of America) and two previously affected countries (Nigeria and Senegal) up to the end of 23 November. There have been 5689 reported deaths. Cases and deaths continue to be under-reported in this outbreak. Reported case incidence is stable in Guinea (148 confirmed cases reported in the week to 23 November), stable or declining in Liberia (67 new confirmed cases in the week to 23 November), and may still be rising in Sierra Leone (385 new confirmed cases in the week to 23 November). The total number of cases reported in Sierra Leone since the outbreak began will soon eclipse the number reported from Liberia. The case fatality rate across the three most-affected countries in patients with a recorded definitive outcome is approximately 60%. Three health-care workers were reported infected with EVD in Guinea in the week to 23 November.  

Response activities continue to intensify in line with the UNMEER aim to isolate 70% of EVD cases and safely bury 70% of EVD-related deaths by 1 December. Guinea isolates over 70% of all reported cases of EVD, and has more than 80% of required safe burial teams. Progress on isolation and safe burials has apparently been slower in parts of Liberia and Sierra Leone, although uncertainties in data preclude firm conclusions. At a national level, both countries are apparently unable to isolate 70% of patients, although data on isolation is up to 3 weeks out of date. Every EVD-affected district in the three intense-transmission countries has access to a laboratory for case confirmation within 24 hours of sample collection. All three countries report that more than 80% of registered contacts associated with known cases of EVD are traced, though the low mean number of contacts registered per case suggests that contact tracing is still a challenge in areas of intense transmission.  

 

OUTLINE

This situation report on the Ebola Response Roadmap contains a review of the epidemiological situation based on official information reported by ministries of health, and an assessment of the response measured against the core Roadmap indicators where available. Substantial efforts are ongoing to improve the availability and quality of information about both the epidemiological situation and the implementation of response measures.

Following the Roadmap structure, country reports fall into three categories: (1) those with widespread and intense transmission (Guinea, Liberia and Sierra Leone); (2) those with or that have had an initial case or cases, or with localized transmission (Mali, Nigeria, Senegal, Spain and the United States of America); and (3) those countries that neighbour or have strong trade ties with areas of active transmission. A separate, unrelated outbreak of EVD in the Democratic Republic of the Congo has now been declared over.

 

1.   COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

A total of 15 901 confirmed, probable, and suspected cases of EVD and 5674 deaths have been reported up to the end of 23 November 2014 by the Ministries of Health of Guinea and Sierra Leone, and 22 November by the Ministry of Health of Liberia (table 1). The data are reported through WHO country offices.

 

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

Country Case definition Cumulative cases Cases in past 21 days Cumulative deaths
Guinea Confirmed 1850 374 1050
Probable 210 * 210
Suspected 74 * 0
Total 2134 374 1260
Liberia Confirmed 2727 319**
Probable 1754 *
Suspected 2687 *
Total 7168 319** 3016
Sierra Leone Confirmed 5441 1339 1189
Probable 79 * 174
Suspected 1079 * 35
Total 6599 1339 1398
Total   15 901 2032 5674

Data are based on official information reported by ministries of health, through WHO country offices. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. *Not reported due to the high proportion of probable and suspected cases that are reclassified. **Data available for past 20 days only. ‡Data not available. §Data missing for 23 November.

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GUINEA

A total of 148 new confirmed cases were reported nationally during the week to 23 November (figure 1), compared with 81 cases the week before. The south-eastern districts of Macenta (26 new confirmed cases), N’Zerekore (29 new confirmed cases), and Kerouane (8 new confirmed cases) accounted for 43% of all new cases reported in the country during the past week (figure 4). However, the district at the outbreak’s epicentre, Gueckedou, which neighbours Macenta, reported only 2 new confirmed cases in the week to 23 November, and has reported no more than 3 confirmed cases in any one of the past 6 weeks. Similar to the districts of Kenema in Sierra Leone and Lofa in Liberia, Gueckedou, is one of several districts in the outbreak to date to have successfully brought down a very high case incidence to a level low enough to end local chains of transmission.

In the west of the country, the capital, Conakry, reported 6 new confirmed cases in the week to 23 November (figure 1). The neighbouring districts of Coyah (10 confirmed cases), Dubreka (6 confirmed cases), and Kindia (11 confirmed cases) all reported an increase in the number of new reported cases compared with each of the previous 2 weeks.

In the centre of the country, the district of Dabola reported its first confirmed case for 3 weeks, while the neighbouring district of Faranah, on the border with Sierra Leone, reported 16 new confirmed cases in the week to 23 November: more than the combined total of confirmed cases for the previous 6 weeks. The district of Siguiri, which borders Mali, reported 3 new confirmed cases, and has now reported between 1 and 3 cases for each of the past 6 weeks.

Of a total of 34 districts in Guinea, 10 are yet to report a case of EVD.

 

Figure 1: Confirmed Ebola virus disease cases reported each week from Guinea and Conakry

The graphs in figures 1-3 show the number of new cases reported each week in country situation reports (in dark blue; beginning from epidemiological week 38, 15-21 September) and from patient databases (light blue). The patient databases give the best representation of the history of the epidemic, and include confirmed and probable cases. However, data for the most recent weeks are sometimes less complete than in the weekly situation reports. Situation reports contain confirmed cases only. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results.

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LIBERIA

Case incidence has stabilized over the past 5 weeks, after declining from mid-September until mid-October. A total of 67 confirmed cases were reported in the week to 23 November.

The district of Montserrado, which includes the capital Monrovia, reported 40 confirmed cases: 60% of all cases reported in Liberia in the week to 23 November. Bomi (2 cases), Bong (10 cases), Grand Bassa (1 case), Grand Cape Mount (12 cases), and Margibi (2 cases) are the only other districts to report a case during the same period.

The district of Lofa, in the north of the country and on the border with Guinea and Sierra Leone, reported no cases for the fourth consecutive week.

 

Figure 2: Confirmed Ebola virus disease cases reported each week from Liberia and Monrovia

*Situation report data are laboratory confirmed cases only. Systematic data on laboratory confirmed cases have been available since 3 November nationally, and since 16 November for each district. Data missing for 23 November.

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SIERRA LEONE

EVD transmission remains intense in Sierra Leone, with 385 new confirmed cases reported in the week to 23 November, compared with 533 cases the previous week. Much of this was driven by intense transmission in the country’s west and north. The worst affected area remains the capital, Freetown, which reported 118 new confirmed cases (figure 3). Transmission remains persistent and intense across the country with the exception of the south east, with the districts of Bo (14 cases), Bombali (54 cases), Kono (16 cases), Moyamba (10 cases), Port Loko (72 cases), Tonkolili (31 cases), and Western Rural Area (55 cases) all reporting high numbers of new confirmed cases. By contrast, several districts in the south east have reported very few new cases in recent weeks. Kenema and Kailahun reported 1 and 2 cases, respectively. The single case in Kenema was its first since 1 November. Bonthe was the only district not to report a case in the week to 23 November.

 

Figure 3: Confirmed Ebola virus disease cases reported each week from Sierra Leone and Freetown

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Figure 4: Geographical distribution of new and total confirmed and probable* cases in Guinea, Liberia, Mali and Sierra Leone

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Data are based on situation reports provided by countries. The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Data are missing from Liberia for 23 November. *Data for the past 21 days represent confirmed cases in Guinea, Sierra Leone, and Mali. Data for the past 21 days represent probable cases in Liberia due to the unavailability of systematic district-level data on laboratory confirmed cases before 16 November.

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RESPONSE IN COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

A comprehensive 90-day plan has been implemented to control and reverse the EVD outbreak in West Africa (see UN Mission for Ebola Emergency Response: Annex 2). Among the plan’s key objectives is to isolate at least 70% of EVD cases and bury at least 70% of patients who die from EVD in a safe and dignified manner by 1 December 2014 (the 60-day target). The ultimate goal is to have capacity to isolate 100% of EVD cases and safely bury 100% of patients who die from EVD by 1 January 2015 (the 90-day target). Tables 2 to 4 provide information on progress for each of the three countries with widespread and intense transmission.

Case management

Isolation of patients with EVD in Ebola Treatment Centres (ETCs) and Community Care Centres (CCCs) is necessary to prevent further transmission of the disease. CCCs provide an alternative to care in ETCs in areas where there is insufficient ETC capacity, and remote areas that are not yet served by an ETC. Compared with ETCs, CCCs are smaller, with 8 to 15 beds per facility. This means they are easier to set up, which enables response coordinators to provide more rapid, flexible coverage dispersed over a wider geographical area.

Table 2: Key performance indicators for the Ebola response in Guinea

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*Priority indicator. Targets are as per original UNMEER planning figures. Definitions for each indicator are found in Annex 2.

In Guinea, 253 of 256 (99%) probable and confirmed EVD cases reported during the 21 days to 16 November, and whose hospitalization status is known, were hospitalized and isolated (table 2). This equates to 75% of all 336 EVD cases reported in Guinea during the same period, including those cases whose records do not contain data on isolation or hospitalization. Approximately 78% of all cases reported during the same period are recorded as hospitalized.

In Liberia, 57 of 245 (23%) probable and confirmed EVD cases reported during the 21 days to 9 November, and whose hospitalization status is known, were hospitalized and isolated (table 3). This equates to 20% all 282 EVD cases reported in Liberia during the same period, including those cases whose records do not contain data on isolation or hospitalization. Just under 30% of all cases reported during the same period are recorded as hospitalized.

In Sierra Leone, 308 of 773 (40%) probable and confirmed EVD cases reported during the 21 days to 2 November, and whose hospitalization status is known, were hospitalized and isolated (table 4). This equates to 19% of all 1582 EVD cases reported in Sierra Leone during the same period, including those cases whose records do not contain data on isolation or hospitalization. Approximately 27% of all cases reported during the same period are recorded as hospitalized.

As of 26 November, 1188 ETC beds were operational and able to receive patients (160 in Guinea, 672 in Liberia, and 356 in Sierra Leone; figure 5) across the three intense-transmission countries. According to recent data there are around 600 new reported cases of EVD every week across the three countries with widespread and intense transmission.

As at 5 November, 60 CCC beds were operational in Liberia and Sierra Leone. This number is likely to have increased, but more current data is not available. WHO is working with key partners, including the US Centers for Disease Control and Prevention, UNICEF, Médecins Sans Frontières, and others, to establish additional CCCs. Guidelines on the implementation of CCCs are being finalized.

 

Figure 5: Ebola Treatment Centres in Guinea, Liberia and Sierra Leone

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Case fatality

As at 23 November, the case fatality rate among all patients recorded as hospitalized in the three intense-transmission countries since the outbreak began, and for whom there is a definitive outcome recorded, is 60% in Guinea, 61% in Liberia, and 60% in Sierra Leone. In a subset of 282 HCWs for whom a definitive outcome has been reported, the case fatality rate is 63%.

 

Safe and dignified burials

The bodies of patients who have died from EVD are extremely infectious. Therefore, conducting burials in a safe and dignified manner is a crucial component of efforts to halt the transmission of the disease.

An estimated 370 trained burial teams are needed to provide adequate coverage across the three countries with widespread and intense transmission. As of 9 November, 131 trained teams were operational: 50 teams in Guinea, 57 teams in Liberia, and 24 teams in Sierra Leone. All reported burial teams in Guinea are organized by the International Federation of Red Cross and Red Crescent Societies (IFRC). Burial teams in Sierra Leone and Liberia are coordinated by multiple organizations, including the IFRC, the ministries of health and international non-governmental organizations.

During the week to 18 November, there were 151 safe and dignified burials in Guinea, 40 in Liberia, and 365 in Sierra Leone reported by IFRC. Data is not reported on how many of these burials were of patients who did not die from EVD, and the number includes some EVD-suspected deaths that were later laboratory-confirmed as negative for the disease. The figures do not exclude burials carried out by military teams.

Table 3: Key performance indicators for the Ebola response in Liberia

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*Priority indicator. Due to a lack of available data, isolation is reported for the 21 days to 9 November for Liberia, and should not therefore be taken as an indication of the current isolation rate. 

During the week to 18 November, there were 151 safe and dignified burials in Guinea, 40 in Liberia, and 365 in Sierra Leone reported by IFRC. Data is not reported on how many of these burials were of patients who did not die from EVD, and the number includes some EVD-suspected deaths that were later laboratory-confirmed as negative for the disease. The figures do not exclude burials carried out by military teams.

 

Case confirmation and surveillance

Providing capacity for prompt and accurate diagnosis of cases of EVD is an integral part of the response to the EVD outbreak. All 53 EVD-affected districts (those that have ever reported a probable or confirmed case) have access to laboratory support (figure 6). Access is defined as having the logistical capacity to transport a sample to a laboratory by road within 24 h of sample collection.

Fourteen laboratories have the capacity to confirm EVD cases – 3 in Guinea, 6 in Liberia, and 5 Sierra Leone. These laboratories currently serve 24 affected districts in Guinea, 15 in Liberia and 14 in Sierra Leone.

Between 1150 and 1170 samples are tested daily in laboratories in the three countries. The maximum testing capacity for each laboratory ranges from 50 to 100 samples per day.

Effective contact tracing ensures that the reported and registered contacts of confirmed EVD cases are visited daily to monitor the onset of symptoms during the 21-day incubation period of the Ebola virus. Contacts presenting symptoms should be promptly isolated, tested for EVD, and if necessary treated, to prevent further disease transmission.

During the week to 23 November, 4559 new contacts were identified and traced in Guinea, Liberia and Sierra Leone, compared with 5301 new contacts in the previous week. Overall, 89% of all registered contacts were visited on a daily basis between 17 and 23 November. In Guinea, 96% (25 926 of 26 963) of registered contacts were reached on a daily basis. In Liberia, 94% (35 183 of 37 539) of registered contacts were reached on a daily basis. 86% of contacts (104 454 of 122 108) were reached daily in Sierra Leone. However, the proportion of contacts reached was lower in many districts. Each district is reported to have at least one contact-tracing team in place.

On average, 6 contacts were listed per new case in Guinea during the past week, 21 in Liberia, and 6 in Sierra Leone. These numbers are relatively low, and suggest that in districts with high case incidence fewer contacts are currently registered in connection with each new case than is necessary to accurately monitor chains of transmission. Active case finding teams are being mobilized as a complementary case-detection strategy in several areas.

 

Figure 6: Status of laboratories deployed in the affected countries to support the Ebola outbreak response​

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Health-care workers

A total of 592 health-care workers (HCWs) are known to have been infected with EVD up to the end of 23 November, 340 of whom have died (table 5). The total case count includes 2 HCWs in Mali, 11 HCWs infected in Nigeria, 1 HCW infected in Spain while treating an EVD-positive patient, and 3 HCWs in the US (including a HCW infected in Guinea, and 2 HCWs infected during the care of a patient in Texas).

 

Table 5: Ebola virus disease infections in health-care workers in the three countries with intense transmission

Country Cases Deaths
Guinea 97 56
Liberia 342 172
Sierra Leone 136 105
Total 575 333

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.

 
Extensive investigations to determine the source of exposure in each case are being undertaken. Early indications are that a substantial proportion of infections occurred outside the context of Ebola treatment and care centres. This reinforces the need to adhere to infection prevention and control measures at all health-care facilities, not just EVD-related facilities. WHO has conducted a review of personal protective equipment (PPE) guidelines for HCWs who provide direct care to patients, and has updated its guidelines in the context of the current EVD outbreak. Comprehensive mandatory training in the use of PPE, and mentoring for all users before engaging in clinical care, is considered fundamental for the protection of HCWs and patients.  

 

Social mobilization and community engagement

UNICEF is the lead agency in social mobilization during this outbreak. A joint WHO-UNICEF team has visited the three intense-transmission countries to review and assist them with their social mobilization plans.

Budget

As at 24 November, WHO had received US$162 million, with a further $35 million pledged.

 

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

Five countries (Mali, Nigeria, Senegal, Spain and the United States of America) have reported a case or cases imported from a country with widespread and intense transmission (table 6).

A total of 8 cases (7 confirmed and 1 probable), including 6 deaths (5 confirmed, 1 probable), have now been reported in Mali (figure 1). The most recent cases are in the Malian capital Bamako, and are not related to the country’s first EVD case, who died in Kayes on 24 October. All identified contacts connected with the initial case have now completed 21 day follow-up. On 24 November 2014, 285 of 288 current contacts linked with the outbreak in Bamako were followed-up.

 

Table 6: Ebola virus disease cases and deaths in Mali, Spain and the United States of America

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
Mali 7 1 0 6 25% 288 118 N/A N/A
Spain 1 0 0 0 100% 0 83 21/10/2004 36
United States of America 4 0 0 1 75% 0 177 11/11/2014* 16

*Includes two HCWs infected in the USA while treating a patient with EVD from Liberia, and a HCW infected in Guinea. 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.

 

In Spain, 36 days have passed since the HCW infected while caring for a patient with EVD in Madrid tested negative twice and was discharged from hospital. Spain will therefore be declared free of EVD 42 days (double the 21-day incubation period of the Ebola virus) after the date of the second negative test if no new cases are reported. All 83 contacts of the HCW have completed 21-day follow-up.

In the United States of America, there have been 4 cases of EVD and 1 death. One HCW in New York and 2 HCWs in Texas have tested negative for EVD twice and have been released from hospital. All contacts in the country have completed the 21-day follow-up period.

In Nigeria, there were 20 cases and 8 deaths. In Senegal, there was 1 case and no deaths. However, following a successful response in both countries, the outbreaks of EVD in Senegal and Nigeria were declared over on 17 October and 19 October 2014, respectively.

 

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

The evolving EVD outbreak highlights the considerable risk of cases being imported into unaffected countries. With adequate levels of preparation, however, such introductions of the disease can be contained before they develop into large outbreaks.

The success of Nigeria and Senegal in halting the transmission of EVD highlights the critical importance of preparedness. Key factors in preventing the spread of EVD in both countries included strong political leadership, early detection and response, public awareness campaigns, and strong support from partner organizations.

 

Fifteen countries that neighbour countries with widespread and intense transmission, or that otherwise have strong trade and travel ties with countries with widespread and intense transmission, have been prioritized for technical assistance on preparedness from specialist WHO teams and partners. These countries are: Benin, Burkina Faso, Cameroon, Central African Republic, Cote D’Ivoire, Democratic Republic of Congo, Gambia, Ghana, Guinea Bissau, Mali, Mauritania, Nigeria, Senegal, South Sudan, and Togo.

 

WHO and partners are supporting these countries to help increase their level of preparedness. A team was deployed to Mali and Cote d’Ivoire in October. As of 26 November teams have visited Benin, Burkina Faso, Cameroon, Gambia, Ghana, Guinea Bissau, Senegal, Mauritania, and Togo. Visits to the Central African Republic, Niger, and Ethiopia are planned for the week beginning 1 December.

 

WHO has developed the Consolidated Ebola Virus Disease Preparedness Checklist to help countries ensure they are ready to respond, should there be a case or cases of EVD. The checklist, along with other tools such as simulation exercises, help countries to assess and test their level of readiness. They can be used as the basis to identify action to be taken by countries and the international community to close potential gaps. The consolidated checklist identifies 10 key components and tasks for countries and the international community that should be completed within 30, 60 and 90 days from the date of issuing the list. Components include overall coordination, rapid response, public awareness and community engagement, infection prevention and control, case management of ETCs, safe burials, epidemiological surveillance, contact tracing, laboratory capacity, and capacity building for points of entry.

 

WHO, the UN and other partners are accelerating the deployment of international preparedness strengthening teams to help countries build upon their existing work and planning. At the end of each mission, technical experts remain in country to support and maximize capacity-building efforts to prepare for public health emergencies, including EVD.

 

ANNEX 1: CATEGORIES USED TO CLASSIFY EBOLA CASES

EVD cases are classified as suspected, probable, or confirmed depending on whether they meet certain criteria (table 7).

Table 7: Ebola virus disease case-classification criteria

Classification Criteria
Suspected Any person, alive or dead, who has (or had) sudden onset of high fever and had contact with a suspected, probable or confirmed Ebola virus disease (EVD) case, or a dead or sick animal OR any person with sudden onset of high fever and at least three of the following symptoms: headache, vomiting, anorexia/ loss of appetite, diarrhoea, lethargy, stomach pain, aching muscles or joints, difficulty swallowing, breathing difficulties, or hiccup; or any person with unexplained bleeding OR any sudden, unexplained death.
Probable Any suspected case evaluated by a clinician OR any person who died from ‘suspected’ EVD and had an epidemiological link to a confirmed case but was not tested and did not have laboratory confirmation of the disease.
Confirmed A probable or suspected case is classified as confirmed when a sample from that person tests positive for EVD in the laboratory.

ANNEX 2: UN MISSION FOR EBOLA EMERGENCY RESPONSE: DEFINITIONS OF KEY PERFORMANCE INDICATORS

The first-ever UN mission for a public health emergency, the UN Mission for Ebola Emergency Response (UNMEER), has been established to address the unprecedented EVD outbreak. WHO is a partner in the mission. Its strategic priorities are to stop the spread of the disease, treat infected patients, ensure essential services, preserve stability, and prevent the spread of EVD to unaffected countries. Response monitoring indicators are calculated using the following numerators and denominators:

 

Indicator

Numerator

Numerator source

Denominator

Denominator source

% of districts with laboratory services accessible within 24h

# of EVD-affected districts able to send samples to a laboratory within 24h

National laboratories

# of EVD-affected districts: reported a probable or confirmed EVD case

Clinical investigation records

% of ETC beds operational

# of ETC beds operational

WHO

# of ETC beds planned

UNMEER

% of CCC beds operational

# of CCC beds operational

UNMEER

# of CCC beds planned

UNMEER

% of cases isolated*

# of cases hospitalized and isolated

Clinical investigation records

# of patients with probable or confirmed EVD whose hospitalization status is recorded, excluding hospitalized patients with no data about isolation

Clinical investigation records

Case fatality rate (%) among hospitalized patients

# of deaths among hospitalized patients

Clinical investigation records

# of hospitalized patients with probable or confirmed EVD for whom a definitive survival outcome is reported

Clinical investigation records

% of registered contacts to be traced who were reached daily

# of registered contacts to be traced who were reached daily

Country situation reports

# of contacts currently registered

Country situation reports

# of newly infected HCWs**

# of newly infected HCWs

Country situation reports

N/A

N/A

% of burial teams trained and

in place

# of burial teams trained and in place

IFRC

# of burial teams planned

UNMEER

# of safe and dignified burials*

# of safe and dignified burials

IFRC

N/A

N/A

*Priority indictor. **Number of HCWs infected is reported as a measure of the effectiveness of infection prevention and control.