Total confirmed cases (by week, 2015)

SUMMARY

There were 5 confirmed cases of Ebola virus disease (EVD) reported in the week to 13 September, all of which were in Sierra Leone. Guinea recorded its first EVD-free week in over 12 months. All but one of the cases in Sierra Leone were registered contacts associated with the Kambia chain of transmission. A new confirmed case was also reported from the central Sierra Leonean district of Bombali, which has not reported a case for over 5 months. The case, a 16-year-old girl, had severe symptoms in the community for several days before being admitted to an Ebola treatment centre (ETC). There is considered to be a high-risk of further transmission associated with this case, and over 600 contacts have been identified so far. A rapid-response team has been deployed in order to minimise the risk of further transmission and establish the origin of infection. The total number of contacts under observation in Guinea and Sierra Leone has increased from approximately 1300 on 6 September to 1800 on 13 September. The vast majority of these contacts are located in the Sierra Leonean districts of Bombali and Kambia. Approximately 60 contacts are considered to be high-risk.

Guinea recorded a twelfth consecutive day without a confirmed case on 13 September. The last confirmed case was reported on 1 September from the Ratoma area of the capital, Conakry. However, over 200 contacts remain under follow-up in Conakry and the nearby prefecture of Dubreka; the majority of contacts in Conakry are approximately halfway through their 21-day follow-up period, with those in Dubreka due to complete follow-up on 16 September. A total of 23 contacts have been lost to follow-up during the past 42 days, at least one of whom was considered a high-risk contact. Rapid-response teams remain on alert and ready to deploy should any further cases be reported.

Of the 5 new confirmed cases reported from Sierra Leone in the week to 13 September, 4 were high-risk contacts associated with the Kambia transmission chain centred on several homes in the village of Sella Kafta, Tonko Limba chiefdom. All 4 cases are close relatives of the initial case in the cluster: an approximately 60-year-old woman identified as a community death during the week to 30 August. Over 840 contacts have been identified in association with the chain of transmission, although the majority of these contacts have been defined by geographical proximity rather than by history of possible exposure, and are therefore considered to be at low risk. Approximately 40 high-risk contacts have been identified in association with the Kambia chain of transmission; one high-risk contact has been lost to follow-up and is being traced. In addition, a case was reported from Bombali Sebora chiefdom in the district of Bombali on 13 September. The case, a 16-year-old girl, was symptomatic in the community for several days before her death shortly after admission to an ETC. The origin of infection is currently under investigation. Bombali had not reported a case for over 5 months. A rapid response team has been deployed to coordinate case investigation and contact tracing. Over 600 contacts in a community of approximately 800 people have been identified so far, of whom 18 are considered to be high-risk contacts; one high-risk contact has not yet been traced.

No new health worker infections were reported in the week to 13 September. There have been a total of 881 confirmed health worker infections reported from Guinea, Liberia, and Sierra Leone since the start of the outbreak, with 513 reported deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 28 220 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia, and Sierra Leone (figure 1, table 1) up to 13 September, with 11 291 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). Five new cases were reported in the week to 13 September, all of which were in Sierra Leone.

The total number of confirmed cases is similar in males and females (table 2). Compared with children (people aged 14 years and under), adults aged 15 to 44 are approximately four times more likely to be affected in Guinea and Liberia, and three times more likely to be affected in Sierra Leone.

No new health worker infections were reported in the week to 13 September. Since the start of the outbreak a total of 881 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 513 reported deaths (table 5).

Figure 1: Confirmed, probable, and suspected EVD cases worldwide

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

Country Case definition Cumulative cases Cases in past 21 days Cumulative deaths Guinea Confirmed 3338 3 2078 Probable 452 * 452 Suspected 2 * ‡ Total 3792 3 2530 Liberia§ Confirmed 3151 - ‡ Probable 1879 - ‡ Suspected 5636 - ‡ Total 10 666 - 4806 Liberia** Confirmed 6 0 2 Probable * * ‡ Suspected ‡ * ‡ Total 6 0 2 Sierra Leone Confirmed 8704 7 3587 Probable 287 * 208 Suspected 4765 * 158 Total 13 756 7 3953 Total Confirmed 15 199 10 ‡ Probable 2618 * ‡ Suspected 10 403 * ‡ Total 28 220 10 11 291

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Table 2: Cumulative number of confirmed 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 1594

(29) 1739

(32) 531

(11) 1898

(41) 860

(55) Liberia§ 1911

(96) 1838

(93) 561

(33) 2060

(121) 703

(132) Sierra Leone 4823

(169) 5118

(176) 1992

(82) 5636

(218) 2140

(290)

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Figure 2: Geographical distribution of confirmed cases reported in the week to 13 September 2015

Table 3: Cases and contacts by district/prefecture/county over the past 3 weeks

Data are based on official information reported by ministries of health. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. *Data as of 13 September 2015 for Guinea and Sierra Leone.

Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 13 September 2015

Sub-prefectures/chiefdoms/districts that reported one or more confirmed cases in the 7 days to 13 September are highlighted. *Epi-link refers to cases who were not registered as contacts of a previous case (possibly because they refused to cooperate or were untraceable), but who, after further epidemiological investigation, were found to have had contact with a previous case, OR refers to cases who are resident or are from a community with active transmission in the past 21 days. ‡Includes cases under epidemiological investigation. §A case that is identified as a community death can also be registered as a contact, or subsequently be found to have had contact with a known case (epi-link), or have no known link to a previous case.

Figure 3: Geographical distribution of new and total confirmed cases in Guinea, Liberia, and Sierra Leone

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Table 5: Ebola virus disease infections in health workers in Guinea, Liberia and Sierra Leone

Country Cases Deaths Guinea 196 100 Liberia* 378 192 Sierra Leone 307 221‡ Total 881 513

GUINEA

Key performance indicators for the EVD response in Guinea are shown in table 6.

No cases were reported from Guinea the week to 13 September (table 3, table 4, figure 2, figure 3). This is the first time Guinea has completed a full epidemiological week without a case for over a year. As at 13 September the country had gone 12 consecutive days without reporting a case. However, 23 contacts have been lost to follow-up during the past 42 days, at least one of whom was considered a high-risk contact.

The last case was a 13-year-old girl and registered contact associated with the Ratoma chain of transmission, and was considered to present a high-risk of further transmission. That case was reported on 1 September.

The Ebola ça suffit! ring vaccination trial is continuing in Guinea. All rings comprised of contacts and contacts of contacts associated with confirmed cases now receive immediate vaccination with the rVSV-ZEBOV Ebola vaccine. Previously, rings were randomly allocated to receive either immediate vaccination or vaccination 21 days after the confirmation of a case.

241 contacts were under follow-up on 13 September in Guinea in 2 adjacent prefectures, Conakry (223 contacts) and Dubreka (18 contacts), compared with 292 contacts in the same 2 prefectures the previous week.

There was 1 (0.2%) unsafe burial reported in Guinea out of 587 community deaths during the week to 13 September, compared with 9 (2%) unsafe burials out of 542 community deaths during the previous week.

Including both initial and repeat testing, a total of 765 laboratory samples were tested in the week to 13 September. Most tests (93% in the week to 13 September) are of post-mortem swabs taken to rule out EVD as the cause of death. In the week to 6 September, 11 (32%) of 34 prefectures in Guinea submitted samples for laboratory testing.

Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7. No health worker infections were reported in the week to 13 September.

Locations of the 8 operational laboratories in Guinea are shown in figure 8.

Table 6: Key performance indicators for Guinea

For definitions of key performance indicators see Annex 2. Data are given for 7-day periods. *Includes repeat samples. ‡Data missing for 0–3% of cases. #Outcome data missing for 0–1% of hospitalized confirmed cases.

Figure 4: Confirmed weekly Ebola virus disease cases reported nationally and by prefecture from Guinea

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SIERRA LEONE

Key performance indicators for the EVD response in Sierra Leone are shown in table 7.

Five new confirmed cases were reported from Sierra Leone in the week to 13 September (table 3, table 4, figure 2, figure 3). Four cases were high-risk contacts associated with the Kambia transmission chain centred on several homes in the village of Sella Kafta, Tonko Limba chiefdom. All 4 cases are close relatives of the initial case in the cluster: an approximately 60-year-old woman identified as a community death during the week to 30 August. In addition, a case was reported from Bombali Sebora chiefdom in the district of Bombali on 13 September. The case, a 16-year-old girl, was symptomatic in the community for several days before her death shortly after admission to an ETC. The origin of infection is currently under investigation. Bombali has not reported a case for over 5 months. A rapid response team has been deployed to coordinate case investigation and contact tracing.

The Ebola ça suffit! ring vaccination Phase 3 efficacy trial of the rVSV-ZEBOV vaccine has now been extended from Guinea to Sierra Leone. Contacts and contacts of contacts associated with new confirmed cases and who meet the trial’s eligibility criteria will therefore be offered the vaccine.

As at 13 September a total of 844 contacts had been identified in association with the Kambia chain of transmission, although the majority of these contacts have been defined by geographical proximity rather than by history of possible exposure, and are therefore considered to be at very low risk. Approximately 40 high-risk contacts have been identified and are being monitored closely. One high-risk contact has been lost to follow-up and is being traced. Over 600 contacts from a community of approximately 800 people have been identified so far in association with the case reported from Bombali. Eighteen of those contacts are deemed to have a high risk of developing EVD. One high-risk contact has not yet been traced.

Locations of the 10 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7. No health worker infections were reported in the week to 13 September.

Laboratory indicators continue to reflect a heightened degree of vigilance, with 1778 new samples tested in the week to 6 September. Five new samples tested positive for EVD. Most tests (81% in the week to 13 September) are of post-mortem swabs taken to rule out EVD as the cause of death. In the week to 6 September, all 14 districts in Sierra Leone submitted samples for laboratory testing.

Locations of the 8 operational laboratories in Sierra Leone are shown in figure 8.

Table 7: Key performance indicators for Sierra Leone

For definitions of key performance indicators see Annex 2. Data are for 7-day periods. §Laboratory data missing for 14 July. ‡Data missing for 7–14% of cases. #Outcome data missing for 0–79% of hospitalized confirmed cases.

Figure 5: Confirmed weekly Ebola virus disease cases reported nationally and by district from Sierra Leone

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Figure 6: Days since last confirmed case by district in Guinea, Liberia, and Sierra Leone

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OTHER AFFECTED AND PREVIOUSLY AFFECTED COUNTRIES

Liberia was declared free of Ebola virus transmission in the human population on 3 September 2015, 42 days after the country’s last laboratory-confirmed case completed treatment and was confirmed as EVD-negative. It is now 64 days since symptom onset of the last reported confirmed case (figure 6). The country has now entered a 90-day period of heightened surveillance. Laboratory capacity is being increased to speed up the processing of samples.

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

Figure 7: 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 an EVD case into unaffected countries remains a risk as long as cases exist in any country. With adequate preparation, however, such an introduction can be contained through a timely and effective response.

WHO’s preparedness activities aim to ensure all countries are ready to effectively and safely detect, investigate, and report potential EVD cases, and to mount an effective response. WHO provides this support through country support visits by preparedness-strengthening teams (PSTs) to help identify and prioritize gaps and needs, direct technical assistance, and provide technical guidance and tools.

Figure 8: Location of laboratories in Guinea, Liberia, and Sierra Leone

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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—Benin, Burkina Faso, Cameroon, Central African Republic, Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Mauritania, Niger, Nigeria, South Sudan, and Togo. The criteria used to prioritize countries include the geographical proximity to affected countries, the magnitude of trade and migration links, and the relative strength of their health systems.

Since 20 October 2014, PSTs have provided technical support in Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Ghana, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, South Sudan, and Togo. Technical working group meetings, field visits, high-level table-top exercises, and field simulations have helped to identify key areas for improvement. Each country has a tailored plan to strengthen operational readiness.

From October 2014 to September 2015 WHO has undertaken over 285 field deployments to priority countries to assist with the implementation of national plans.

WHO provides personal protective equipment (PPE) modules containing minimum stocks to cover staff protection and other equipment needs to support 10 patient-beds for 10 days for all staff with essential functions. PPE modules have been delivered or are in the process of being delivered to all countries on the African continent. In addition, all countries have received a PPE training module.

Contingency stockpiles of PPE are in place in the United Nations Humanitarian Response Depots (UNHRD) in Accra and Dubai, and are available to any country in the event that they experience a shortage.

Follow-up support to priority countries

Following initial PST assessment missions to the 14 priority countries in 2014, a second phase of preparedness-strengthening activities have provided support on a country-by-country basis. Activities in the week to 16 September are highlighted below.

Following initial PST assessment missions to the 14 priority countries in 2014, a second phase of preparedness-strengthening activities have provided support on a country-by-country basis. Activities in the week to 16 September are highlighted below. In Guinea-Bissau, preparedness support continues to be provided at the central level, and in two priority regions (Tombali and Gabu) through WHO sub-offices.

EVD preparedness officers

Dedicated EVD preparedness officers have been deployed to support the implementation of country preparedness plans, coordinate partners, provide a focal point for inter-agency collaboration, offer specific technical support in their respective areas of expertise, and develop capacity of national WHO staff. Preparedness officers are currently deployed to Benin, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Ghana, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, and Togo.

Training, exercises, and simulations

Priority countries that have achieved a minimum of 50% implementation of preparedness checklist activities are encouraged to undertake a series of drills on elements of an EVD response and a functional exercise to test the coordination of the Ebola operations centre.

Simulation exercises aimed at testing preparedness capabilities are being planned and will start in the coming weeks in Burkina Faso, Ethiopia, Ghana, and Guinea-Bissau.

Training in public health functions at points-of-entry is planned for the end of September in Mauritania. At the beginning of October a facilitation team will be deployed to plan a simulation exercise.

Logistics support will be provided in the Central African Republic from 28 September to 2 October.

An infection prevention and control (IPC) specialist will be deployed to Togo at the beginning of October to follow-up on activities performed during a previous visit to the country.

Training in clinical management and IPC will be take place from 4 to 10 October in Côte d’Ivoire.

A team has been deployed to Benin to plan simulation exercises, and an IPC expert will support the country from the beginning of November.

Surveillance and preparedness indicators

Indicators based on surveillance data, case-management capacity, laboratory testing, and equipment stocks continue to be collected on a weekly basis from the four countries that share a border with affected countries: Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal.

An interactive preparedness dashboard based on the WHO EVD checklist is now available online.

ANNEX 1: 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, and technical institutions and networks in the Global Outbreak Alert and Response Network (GOARN). 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, laboratory services 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 PHASE 2 KEY PERFORMANCE INDICATORS