- Reported case incidence continues to fluctuate in Guinea, with no identifiable downward trend. Ebola virus disease (EVD) continues to spread geographically within the country, with the prefecture of Fria reporting 2 confirmed cases for the first time. Case incidence has declined to low levels in Liberia. There are signs that incidence has levelled off in Sierra Leone, although transmission remains intense in the west of the country.
- The UN Mission for Ebola Emergency Response (UNMEER) set twin targets of isolating and treating 100% of EVD cases, and conducting 100% of burials safely and with dignity by 1 January, 2015, in Guinea, Liberia, and Sierra Leone.
- 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 the UNMEER target of isolating and treating 100% of EVD cases is still not met in some areas. An increasing emphasis will be put on the rapid deployment of smaller treatment facilities to ensure that capacity is matched with demand in each area.
- Similarly, each country has sufficient capacity to bury all people known to have died from EVD, though the under-reporting of deaths means that the UNMEER target of 100% safe burial was not met.
- In addition to the two UNMMER targets, there are several other crucial aspects of the response, including rigorous contact tracing, access to laboratory services, and community engagement.
- Guinea, Liberia and Sierra Leone report that more than 90% 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.
- There are currently 23 laboratories providing case-confirmation services in the three intense-transmission countries. Five 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 approximately 60% in the three intense-transmission countries.
- A total of 820 health-care worker infections have been reported in the intense-transmission countries; there have been 488 deaths.
- Many elements of the response to the EVD outbreak, from safe burials to contact tracing, rely on actively engaging affected communities to take ownership of the response. UNICEF leads the community engagement arm of the EVD 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 20 000 confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (table 1), with more than 8000 deaths (deaths are under-reported).
- 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 (33 reported cases per 100 000 population, compared with 98 per 100 000 population). People aged 45 and over (125 reported cases per 100 000 population) are almost four times more likely to be affected than are children.
- There have been 26 reported confirmed and probable cases per 100 000 population in Guinea, 206 cases per 100 000 population in Liberia, and 170 cases per 100 000 population in Sierra Leone.
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|
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|
- 74 confirmed cases were reported in the 7 days to 4 January 2015 (figure 1). There is no discernible upward or downward trend. However, EVD continues to spread geographically, with the western prefecture of Fria reporting confirmed cases for the first time (figure 4). 19 districts have reported a confirmed or probable case in the 21 days to 4 January.
- Conakry is the worst-affected district, followed by the nearby district of Dubreka, with 24 and 16 new confirmed cases, respectively, in the week to 4 January. The eastern district of Lola, which borders Côte d’Ivoire, reported 12 new confirmed cases.
- Six districts that have previously reported Ebola cases did not report any confirmed or probable cases in the 21 days to 4 January.
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 to 8 new confirmed cases and 40 probable cases in the 5 days to 2 January, 2015 (figure 2).
- The district of Montserrado, which includes the capital Monrovia, continues to account for most cases in the country, with 6 confirmed and 33 probable cases reported in the 5 days to 2 January.
- Twelve of 15 districts in Liberia did not report any confirmed cases during the 5 days to 2 January.
Figure 2: Confirmed Ebola virus disease cases reported each week from Liberia and Monrovia
- There are signs that case incidence may have levelled off in Sierra Leone, although with 248 new confirmed cases reported in the week to 4 January 2015, it remains by far the worst-affected country at present.
- The west of the country remains the area of most intense transmission. The capital, Freetown, reported 93 new confirmed cases, and the neighbouring districts of Port Loko and Western Rural reported 41 and 50 new confirmed cases, respectively, in the 7 days to 4 January. A total of 11 out of 14 districts reported new confirmed cases in the latest reporting period.
- In the east of the country, on the border with Guinea, the district of Kono reported 32 confirmed cases during the reporting period, and has reported 84 confirmed cases in the past 21 days.
Figure 3: Confirmed Ebola virus disease cases reported each week from Sierra Leone and Freetown
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 in the domains 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.
Figure 4: Geographical distribution of new and total confirmed and probable* cases in Guinea, Liberia, Mali and Sierra Leone
- Providing the capacity to isolate and treat patients with EVD is central to the EVD response.
- All three intense-transmission countries currently have the capacity to isolate all reported cases. In Guinea (table 3), in the 21 days to 4 January, there were 2.1 available beds per reported confirmed and probable EVD case. In Liberia (table 4) there were 15.1 beds for every confirmed and probable case, and in Sierra Leone there were 4.6 beds for every confirmed and probable case (table 5). This represents a significant increase in capacity compared with October 1, which was the beginning of the 90-day UNMEER target period (figure 5). Including suspected cases lowers the number of available beds per case to 1.5, 4.7 and 3.3 in Guinea, Liberia and Sierra Leone, respectively.
- Though capacity is sufficient at a national level, several districts remain remote from EVD treatment facilities (figure 5). For example, in Guinea cases are spread throughout the country, whereas the country’s ETCs are concentrated in the capital, Conakry, and several districts in the east of the country (figure 6). By contrast, some areas with low case incidence such as southern Sierra Leone have spare treatment and isolation capacity (figure 6). This uneven distribution of treatment facilities, along with the underreporting of cases in some areas, meant the target of treating and isolating 100% of cases by January 1 was missed in some areas.
- As of 4 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 Guéckédou, Macenta and N’Zérékoré. ETCs in the eastern districts of Beyla, Faranah, Kankan, and Kérouané are planned. A new community transit centre (CTCom) has been constructed in Kourémalé in the Siguri préfecture. There are plans to construct 62 such facilities in the country.
- In Liberia, 546 beds are operational in 17 ETCs and 6 CCCs spread throughout the country (figure 6).
- In Sierra Leone, a total of 1046 ETC beds are operational in 19 ETCs and 26 CCCs (figure 6). In addition, Sierra Leone has 49 isolation units with 998 operational beds.
- 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 58% in Guinea and 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 53 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 7).
- As of 4 January 2015, 23 laboratories have the capacity to confirm EVD cases: 4 in Guinea, 8 in Liberia and 11 in Sierra Leone. It is anticipated that in coming weeks, 5 additional laboratories will become operational.
Figure 5: Capacity for isolation and treatment, and capacity for safe and dignified burials throughout the UNMEER 90-day target period in Guinea, Liberia, and Sierra Leone
Table 3: Key performance indicators for the Ebola response in Guinea
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 4 January 2015, 96% of all registered contacts were visited on a daily basis in Guinea, 98% in Liberia and 90% 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, during the past 21 days, 12 contacts were listed per new confirmed case in Guinea, 32 in Liberia, and 8 in Sierra Leone. Active case-finding teams are being mobilized as a complementary case-detection strategy in several areas.
- A total of 838 health-care workers (HCWs) are known to have been infected with EVD up to the end of 4 January 2015, 495 of whom have died (table 6).
- The marked increase from the total of 678 HCW infections reported last week is due to additional cases reported from Sierra Leone that have occurred since the onset of the epidemic. These are not infections that have occurred between the two most recent reporting periods.
Figure 6: Location of Ebola Treatment Centres and capacity to isolate probable and confirmed cases by district in Guinea, Liberia, and Sierra Leone
* Reported cases as of 03/01/15. Definitions for each indicator are found in Annex 2.
Safe and dignified burials
- As of 4 January 2015, there were 229 safe burial teams trained and in place: 61 teams in Guinea, 70 teams in Liberia and 98 teams in Sierra Leone. All countries are at or near their planned targets, and have rapidly increased capacity compared with 90 days ago (figure 5).
- At a national level, all three countries have sufficient capacity to safely bury all reported deaths. However, the under-reporting of deaths during the outbreak means that the UNMEER target of 100% safe burials was not met. Improved engagement with communities will help overcome some of the cultural barriers that have until now prevented some deaths from being reported to safe burial teams.
Table 4: Key performance indicators for the Ebola response in Liberia
Table 5: Key performance indicators for the Ebola response in Sierra Leone
Figure 7: Status of laboratories deployed in the affected countries to support the Ebola outbreak response
Table 6: Ebola virus disease infections in health-care workers in the three countries with intense transmission
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 have been set up.
- In Liberia, in 86 District Mobilization Coordinators across 15 counties were trained in the week to 31 December 2014.
- In Sierra Leone, UNICEF and the District Health Management Team (DHMT) trained and deployed 400 social mobilizers (SMs) in the two Western Area districts in the week to 31 December as part of the Western Area Surge.
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
|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||31|
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 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.
- A PST composed of experts from WHO, US CDC, UNICEF and France is visiting Equatorial Guinea from 7 to 15 January. The aim of this mission is to implement critical recommendations from a preliminary mission in late November, in advance of the Africa Cup of Nations football international tournament starting on 17 January.
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. Training courses, workshops and simulation exercises have been provided for groups of countries, and visits have been made to certain countries in all regions to review capacity and provide direct support. Regional offices also have EVD response plans with emergency operating centres and rapid-response teams in place or planned. Personal protective equipment kits are being stockpiled at strategic locations.
- All regions have established regional Ebola Task Forces, developed regional response plans, and regularly briefed the health ministries in their countries.
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|
|Logistics||UNMEER and World Food Programme|
|Cash payments coordination||United Nations Development Programme|
|Training||WHO and US Centers for Disease Control and Prevention|