- Guinea reported its lowest weekly total of new confirmed Ebola virus disease (EVD) cases since the week ending 17 August 2014. Case numbers remain low in Liberia, with no confirmed cases nationally for the final 2 days of the week ending 11 January, and the lowest weekly total of confirmed cases since the first week of June 2014. Sierra Leone has now reported a decline in case incidence for the second week running, and recorded its lowest weekly total of new confirmed cases since the week ending 31 August 2014.
- Each of the intense-transmission countries has sufficient capacity to isolate and treat patients, with more than 2 treatment beds per reported confirmed and probable case. However, the uneven geographical distribution of beds and cases, and the under-reporting of cases, means that not all EVD cases are isolated in several areas.
- Similarly, each country has sufficient capacity to bury all people known to have died from EVD. However, the under-reporting of deaths means that not all burials are done safely.
- Guinea, Liberia and Sierra Leone report that between 84% and 99% of registered contacts are monitored, though the number of contacts traced per EVD case remains lower than expected in many districts. In areas where transmission has been driven down to low levels, rigorous contact tracing will be essential to break chains of transmission. In the week to January 11, 15% of new confirmed cases in Guinea arose from known contacts (equivalent information is not yet available for Liberia and Sierra Leone).
- There are currently 27 laboratories providing case-confirmation services in the 3 intense-transmission countries. Four more laboratories are planned in order to meet demand.
- Case fatality among hospitalized patients (calculated from all hospitalized patients with a reported definitive outcome) is between 57% and 60% in the 3 intense-transmission countries.
- A total of 825 health-care worker infections have been reported in the 3 intense-transmission countries; there have been 493 reported deaths.
- Many elements of the response to the Ebola outbreak, from safe burials to contact tracing, rely on actively engaging affected communities to take ownership of the response. At present, 33 of 38 (87%) of districts in Guinea, 100% of districts in Liberia, and 57% (8 of 14) of districts in Sierra Leone have systems in place to monitor community engagement activities.
1. COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
- There have been in excess of 21 000 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (table 1), with more than 8300 deaths (outcomes are under-reported)
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|
- A stratified analysis of cumulative confirmed and probable cases indicates that the number of cases in males and females is about the same (table 2). Compared with children (people aged 14 years and under), people aged 15 to 44 are three times more likely to be affected (35 reported cases per 100 000 population, compared with 101 per 100 000 population). People aged 45 and over (130 reported cases per 100 000 population) are almost four times more likely to be affected than are children.
- There have been 26 reported confirmed, probable and suspected cases per 100 000 population in Guinea, 210 cases per 100 000 population in Liberia, and 176 cases per 100 000 population in Sierra Leone.
Table 2: Cumulative number of confirmed and probable cases by sex and age group in Guinea, Liberia, and Sierra Leone
(per 100 000 population)
|By age group‡
(per 100 000 population)
|Male||Female||0-14 years||15-44 years||45+ years|
- 42 confirmed cases were reported in the 7 days to 11 January 2015 (figure 1). Case incidence declined for the second week in a row to the lowest level nationally since the week ending 17 August 2014, and in the capital Conakry since late November 2014. Eight districts reported a confirmed or probable case during the reporting period (figure 4).
- Forecariah, with 12 confirmed cases, was the worst-affected district, followed by Conakry with 9 confirmed cases. Fria reported no cases in the week to 11 January, having reported its first 2 confirmed cases the previous week.
- 4 districts that have previously reported Ebola cases, including the origin of the epidemic, Gueckedou, did not report any confirmed cases in the 21 days to 11 January (figure 4).
Figure 1: Confirmed Ebola virus disease cases reported each week from Guinea and Conakry
- Case incidence has declined from a peak of over 300 new confirmed cases per week in August and September 2014 to 8 confirmed cases in the 7 days to 11 January 2015 (figure 2).
- The district of Montserrado, which includes the capital Monrovia, continues to report cases. In the 7 days to 11 January, 4 cases were reported in Montserrado, with 4 in Grand Cape Mount. Lofa, which borders Gueckedou, has reported no cases for 78 days.
Figure 2: Confirmed Ebola virus disease cases reported each week from Liberia and Monrovia
- Case incidence is decreasing in Sierra Leone, although with 184 new confirmed cases reported in the week to 11 January 2015, it remains the worst-affected country.
- The west of the country remains the area of most intense transmission. The capital, Freetown, reported 59 new confirmed cases, and the neighbouring districts of Port Loko and Western Rural reported 41 and 31 new confirmed cases, respectively, in the 7 days to 11 January. A total of 10 out of 14 districts reported new confirmed cases in the latest reporting period. Kailahun, which borders Gueckedou, has reported no cases for 30 days.
- Kambia, which borders Port Loko and the Guinean district of Forecariah (the worst affected Guinean district this reporting period), reported 17 confirmed cases.
- In the east of the country, on the border with Guinea, the district of Kono reported 14 confirmed cases during the reporting period.
Figure 3: Confirmed Ebola virus disease cases reported each week from Sierra Leone and Freetown
Figure 4: Geographical distribution of new and total confirmed and probable* cases in Guinea, Liberia, Mali and Sierra Leone
RESPONSE IN COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
As part of the international response to the EVD epidemic, the UN Mission for Ebola Emergency Response set the goal of putting capacity in place to treat and isolate 100% of EVD cases, and conduct 100% of EVD burials safely and with dignity at the end of a 90-day period to 1 January 2015 (Annex 2; the various agencies that coordinate each part of the response are shown in Annex 3). Though that deadline has now passed, efforts to attain each target will continue until the epidemic has been brought to an end. Tables 3 to 5 provide information on progress on the lines of action for which WHO is the lead agency: case management and case finding (laboratory confirmation and contact tracing). Information is also provided on social mobilization and the capacity to conduct safe burials.
Table 3: Key performance indicators for the Ebola response in Guinea
Table 4: Key performance indicators for the Ebola response in Liberia
Table 5: Key performance indicators for the Ebola response in Sierra Leone
- All three intense-transmission countries currently have the capacity to isolate all reported cases. In Guinea (table 3), in the 21 days to 11 January, there were 3.1 available beds per reported confirmed and probable EVD case. In Liberia (table 4) there were 13.9 beds for every confirmed and probable case, and in Sierra Leone there were 6.4 beds for every confirmed and probable case (table 5). Including suspected cases lowers the number of available beds per case to 2.3, 3.8 and 4.4 in Guinea, Liberia and Sierra Leone, respectively.
- Though capacity is sufficient at a national level, several districts remain remote from EVD treatment facilities, especially in Guinea (figure 5).
- As of 11 January 2015, 250 EVD-treatment and isolation beds were operational in Guinea, concentrated in 5 ETCs located in Conakry, and the south-eastern districts of Gueckedou, Macenta and N’Zerekore. One further ETC is planned in Conakry, with five ETCs in the eastern districts of Beyla (1), Faranah (1), and Kankan (2). A community transit centre (CTCom) is open in Kouremale in the Siguri prefecture.
- In Liberia, 510 beds are operational in 16 ETCs (figure 5). There are 93 beds operational in CCCs.
- In Sierra Leone, a total of 1207 ETC beds are operational in 23 ETCs, with 437 beds operational in 26 CCCs (figure 5).
Figure 5: Location of Ebola Treatment Centres and capacity to isolate probable and confirmed cases by district in Guinea, Liberia, and Sierra Leone
- The cumulative case fatality rate in the three intense-transmission countries among all probable and confirmed cases for whom a definitive outcome is recorded is 71%. For those patients recorded as hospitalized, the case fatality rate is 57% in Guinea, 58% in Liberia, and 60% in Sierra Leone (tables 3–5).
- Providing capacity for prompt and accurate diagnosis of EVD cases is an integral part of the response to the EVD outbreak.
- All 54 EVD-affected districts (those that have ever reported a probable or confirmed case) have access to laboratory support within 24 hours of sample collection (figure 6).
- As of 11 January 2015, 27 laboratories have the capacity to confirm EVD cases: 5 in Guinea, 9 in Liberia and 13 in Sierra Leone. Five labs are in the planning process for deployment in Guinea (3), Liberia (1) and Sierra Leone (1).
Figure 6: Location of Ebola Treatment Centres and capacity to isolate probable and confirmed cases by district in Guinea, Liberia, and Sierra Leone
Contact tracing and case finding
- 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.
- During the week to 11 January 2015, 92% of all registered contacts were visited on a daily basis in Guinea, 99% in Liberia and 84% in Sierra Leone. However, the proportion of contacts reached was lower in several districts.
- Each district is reported to have at least one contact-tracing team in place. On average, during the past 21 days, 14 contacts were listed per new confirmed case in Guinea, 43 in Liberia, and 11 in Sierra Leone. There is a high degree of variation among districts. Active case-finding teams are being mobilized as a complementary case-detection strategy in several areas. In the week to January 11, 15% of new confirmed cases in Guinea arose from known contacts (equivalent information is not yet available for Liberia and Sierra Leone).
- A total of 843 health-care workers (HCWs) are known to have been infected with EVD up to the end of 11 January 2015 in all affected and previously affected countries. 500 HCWs have died. Figures for the 3 intense-transmission countries are shown in table 6.
Table 6: Ebola virus disease infections in health-care workers in the three countries with intense transmission
Safe and dignified burials
- As of 11 January 2015, there were 224 safe burial teams trained and in place: 61 teams in Guinea, 64 teams in Liberia and 92 teams in Sierra Leone.
Community engagement and social mobilization
- Community engagement and social mobilization promotes the adoption of strategies to prevent EVD infection, helps communities to gain a better understanding of EVD, and dispels misconceptions about the disease. UNICEF is the lead agency in social mobilization during this Ebola outbreak, supported by partners and WHO.
- Social mobilization taskforces have been established to develop activities promoting safe and culturally acceptable burial practices, and to engage communities about the need to isolate and appropriately treat those with clinical symptoms of EVD. As of 4 January 2015, all 14 districts in Sierra Leone have a list of identified key religious leaders or community groups promoting such burial practices. In Guinea, 71% (27 of 38) of districts have such a list. Data are not available for Liberia.
- A total of 33 of 38 (87%) of districts in Guinea are monitoring the status and progress of community sensitization activities, 100% (15 of 15) of districts in Liberia, and 57% (8 of 14) of districts in Sierra Leone.
- In Guinea, social mobilization activities in the country include the establishment of Community Watch Committees (CWCs). As at 31 December 2014, 1399 of 2950 planned CWCs had been set up.
- In Liberia, 12 425 households were reached through door-to-door campaigns across all 15 counties in the week to 7 January. Community meetings and group discussions reached 14 567 women, 12 429 men, and 8237 children.
- In Sierra Leone, reporting from districts continues to remain a challenge, with 7 out of 14 districts reporting in the week to 7 January. Based on these reports, 2974 social mobilizers were trained in Bo, Bombali, Kailahun, Kambia, Kono, and Tonkolili. In these districts, social mobilizers reached 13 373 households through inter-personal communication, and engaged 457 religious leaders and 67 paramount chiefs and other community leaders in supporting intensified social mobilization efforts.
2. 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 7). The case is a HCW who returned from volunteering at an ETC in Sierra Leone. The patient has been isolated and is receiving treatment in London. As a precautionary measure, Public health authorities have investigated all possible contacts of the case. No high-risk contacts have been identified.
- A total of 8 cases, including 6 deaths, have been reported in Mali (table 7). The most recent 7 cases were in the Malian capital Bamako, and not related to the country’s first EVD case, who died in Kayes on 24 October 2014. The last confirmed case tested negative for the second time on 6 December 2014, and was discharged from hospital on 11 December 2014. All identified contacts connected with both the initial case in Kayes and the outbreak in Bamako have completed the 21 day follow-up period.
Table 7: Ebola virus disease cases and deaths in Mali and 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|
|Mali||7||1||0||6||25%||0||433||6 December 2014||38|
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 with a rapid and adequate response.
- WHO’s preparedness activities aim to ensure all countries are ready to effectively and safely detect, investigate and report potential EVD cases, and to mount an effective response. WHO provides this support through country visits by preparedness strengthening teams (PSTs), direct technical assistance to countries, and the provision of technical guidance and tools.
Tools and resources for preparedness
- Building on existing national and international preparedness efforts, a set of tools has been developed to support any country to identify opportunities for improvements to intensify and accelerate their readiness. The WHO EVD Preparedness Checklist identifies 10 key components and tasks for countries preparing their health systems to identify, detect and respond to EVD. The 10 components include: overall coordination, rapid response, public awareness and community engagement, infection prevention and control, case management, safe burials, epidemiological surveillance, contact tracing, laboratory capacity, and capacity building for points of entry. A revised list of technical guidelines and related training materials by preparedness component has been finalized and can be found on the revised WHO preparedness website.
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, 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. Budgeted operational preparedness and response plans in priority countries have been presented to technical and financial partners for support at the national level.
- Following PST missions, countries that share borders with the countries with intense transmission have taken additional action to prepare for an imported case. In Senegal, an Emergency Operation Centre (EOC) has been formalized by decree, and the coordinator nominated. The EOC is the main mechanism for coordinating the EVD preparedness and response in country. The WHO Country Team has been involved in assessing the needs for isolation units and treatment centres. There is currently one functional ETC, located in the capital, Dakar.
- Cote d’Ivoire is accelerating the establishment of treatment centres in the regions, and training has been planned for HCWs. There are currently 3 ETCs in Cote d’Ivoire, located in the capital, in Abidjan, Biankouma, and Bouaké. The country is also working actively on the other components of the checklist, with a strong emphasis on epidemiological surveillance, infection prevention and control, and communication and social mobilisation.
- Since its first PST mission, Guinea Bissau has been working across all the components of the checklist. An inter-ministerial task force led by the Minister of Health has been established and a High Commissioner for Ebola Response appointed. More than 400 health personnel have been trained by WHO. EVD communication materials have been developed and disseminated, including in schools, with the support of UNICEF. A treatment centre supported by MSF has been established in the capital, Bissau, and health personnel have been trained on how to identify cases, and how best to raise the alert if a case is suspected.
- A PST composed of experts from WHO, US CDC, UNICEF, and France is visited Equatorial Guinea. The mission implemented critical recommendations from a preliminary mission in late November, in advance of the Africa Cup of Nations football international tournament starting on 17 January.
- A consultative meeting between WHO and partners on EVD preparedness and readiness will take place in Geneva from 14 to 16 January. The meeting will bring together international technical and financial partners to take stock of the outcomes of the EVD PST Missions, present a revised checklist and a dashboard to help countries monitor their progress, and reach consensus on a multi-partner plan of action.
Preparedness in the rest of the world
- Beyond the focus on priority countries in Africa, significant efforts have been made in all WHO Regions to strengthen Ebola preparedness. Assessments in several countries in all Regions found that there are still significant gaps and needs related, for example, to building more capacity in risk communication, infection prevention and control, in-country testing for EVD, specimen dispatch internationally, case management and points of entry. There is also a need for standard operating procedures for rapid response teams. Globally, more than 110 countries have been supported to strengthen their public health response capacities in relation to EVD. Regional Offices have or are in the process of conducting regional/subregional training workshops on risk communication, laboratory testing and biosafety, infection prevention and control, and case management. WHO at country levels has also supported the organization of national workshops and simulation exercises to continue to address these gaps.
- A global strategy for personal protection equipment and infection control supplies has been developed and supplies have been or are being procured and strategically deployed/stockpiled to ensure their availability in the event of importation in any country of the world.
ANNEX 1: CATEGORIES USED TO CLASSIFY EBOLA CASES
EVD cases are classified as suspected, probable, or confirmed.
Ebola virus disease case-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:
ANNEX 3: COORDINATION OF THE EBOLA RESPONSE
|Lines of action||Lead agency|
|Case finding, lab and contact tracing||WHO|
|Safe and dignified burials||International Federation of Red Cross and Red Crescent Societies|
|Community engagement and social mobilization||UNICEF|