Total confirmed cases (by week, 2015)

SUMMARY

There were 30 confirmed cases of Ebola virus disease (EVD) reported in the week to 5 July: 18 in Guinea, 3 in Liberia, and 9 in Sierra Leone. Although this is the highest weekly total since mid-May, improvements to case investigation and contact tracing, together with enhanced incentives to encourage case reporting and compliance with quarantine measures have led to a better understanding of chains of transmission than was the case a month ago. This, in turn, has resulted in a decreasing proportion of cases arising from as-yet unknown sources of infection (5 of 30 cases in the week to 5 July), particularly in previously problematic areas such as Boke and Forecariah in Guinea, and Kambia and Port Loko in Sierra Leone. However, significant challenges remain. A residual lack of trust in the response among some affected communities means that some cases still evade detection for too long, increasing the risk of further hidden transmission. The exportation of cases to densely populated urban areas such as Freetown and Conakry remains a risk, whilst the origin of the new cluster of cases in Liberia is not yet well understood.

In Guinea, cases were reported from the same 3 prefectures—Boke, Conakry, and Forecariah—that reported cases the previous week. The northern prefecture of Boke, which borders Guinea-Bissau, reported 6 cases, compared with 10 the previous week. All but one of these cases was a registered contact, with a single case reported to have arisen from an as-yet unknown source of infection. The single case reported from Conakry came from the Matam commune (municipal district) of the city, and was a known contact of a previous case from Benty sub-prefecture in Forecariah. The remaining 11 cases were reported from the prefecture of Forecariah, 9 of which were reported from the sub-prefecture of Benty. All but 2 of the 11 cases reported from Forecariah were known contacts of a previous case or have an established epidemiological link to one.

Liberia was declared free of Ebola transmission on 9 May 2015, after reporting no new cases for 42 consecutive days. The country subsequently entered a 3-month period of heightened surveillance, during which approximately 30 blood samples and oral swabs are collected each day from potential cases and tested for EVD. On 29 June, this routine surveillance detected a confirmed case of EVD in Margibi County, Liberia—the first new confirmed case reported from the country since 20 March. The case was a 17-year-old male who first became ill on 21 June, died on 28 June, and subsequently tested positive for EVD. Two contacts of the first-detected case have since been confirmed as EVD-positive. These additional cases are from the same small community as the first-detected case, and are now being treated in an Ebola Treatment Centre (ETC) in the capital, Monrovia. In addition, a probable case is in isolation at an ETC. The case has a strong epidemiological link to the first-detected case and is showing some symptoms of EVD, but has indeterminate test results for EVD. The origin of infection of the cluster of cases is currently under investigation. At present, these cases are considered to constitute a separate outbreak from that which was declared over on 9 May.

In Sierra Leone, 9 cases were reported from the same 3 districts as the previous weeks: Kambia, Port Loko, and the district that includes the capital, Freetown. One-third (3) of all cases reported from Sierra Leone arose in the densely populated Magazine Wharf area of Freetown. All 3 cases were registered contacts of a previous case. Four chiefdoms in Kambia each reported a single confirmed case of EVD, as did two chiefdoms in the neighbouring district of Port Loko. All but one of these cases were known contacts of a previous case or have an established epidemiological link to one.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 27 573 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1) up to 5 July, with 11 246 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 18 new confirmed cases were reported in Guinea, 3 in Liberia, and 9 in Sierra Leone in the week to 5 July.

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.

In the week to 5 July, one new health worker infection was reported from Kambia, Sierra Leone. A total of 875 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 509 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 3287 42 2049 Probable 450 * 450 Suspected 11 * ‡ Total 3748 42 2499 Liberia§ Confirmed 3151§ - ‡ Probable 1879 § - ‡ Suspected 5636 § - ‡ Total 10 666 § - 4806 § Liberia** Confirmed 3 3 1 Probable 1 1 ‡ Suspected ‡ * ‡ Total 4 4 1 Sierra Leone Confirmed 8674 25 3574 Probable 287 * 208 Suspected 4194 * 158 Total 13 155 25 3940 Total Confirmed 15 115 70 ‡ Probable 2617 1 ‡ Suspected 9841 * ‡ Total 27 573 71 11 246

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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 1571

(29) 1777

(31) 515

(11) 1869

(40) 853

(55) Liberia§ 1911

(96) 1838

(93) 561

(33) 2060

(121) 703

(132) Sierra Leone 4771

(167) 5071

(175) 1972

(81) 5571

(215) 2123

(287)

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Figure 2: Geographical distribution of confirmed cases reported in the week to 5 July 2015

Table 3: Cases and contacts by district/prefecture 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 5 July. ‡Includes Freetown.

Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 5 July 2015

Sub-prefectures/chiefdoms that reported one or more confirmed cases in the 7 days to 5 July 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. **Includes Freetown.

Figure 3: Geographical distribution of new and total confirmed cases

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

Country Cases Deaths Guinea 191 96 Liberia* 378 192 Sierra Leone 306 221‡ Total 875 509

GUINEA

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

Eighteen confirmed cases were reported from 3 prefectures—Boke, Conakry, and Forecariah—in the week to 5 July (table 3, table 4, figure 2, figure 3).

Five of 6 cases reported from the northwestern prefecture of Boke, which borders Guinea-Bissau, have come from the sub-prefecture of Boke Centre (table 3, table 4, figure 2). All 5 cases were registered contacts. By contrast, the remaining case, which was reported from the coastal sub-prefecture of Kamsar, arose from an as-yet unknown source of infection, and was identified after post-mortem testing of a community death.

The single case reported this week from Conakry came from the Matam commune (municipal district) of the city. The case was only identified after post-mortem testing despite being a registered contact of a previous case from Benty.

Most cases (11) were reported from the prefecture of Forecariah, which reported 1 case in the previous week. The sub-prefecture of Benty, which borders Sierra Leone, reported 9 cases, of which all but one was either a registered contact of a previous case, or otherwise had an epidemiological link to one. The remaining 2 cases in Forecariah were reported from the sub-prefectures of Farmoriah and Maferinyah. The case from Farmoriah was a registered contact, the case from Maferinyah arose from an unknown source of infection, and both cases were detected after post-mortem testing of community deaths.

Overall, 12 (67%) of the 18 cases reported from Guinea in the week to 5 July were registered contacts, compared with 10 (83%) of 12 cases reported the previous week. Three cases were not registered contacts but do have an established epidemiological link to a previous case, and 3 arose from an as-yet unknown source of infection. Four cases were identified after post-mortem testing of community deaths. On 5 July there were 2431 contacts being monitored across 5 Guinean prefectures (table 3).

The number of unsafe burials reported from Guinea remained stable at 7 (1%) unsafe burials of the 547 recorded community deaths in the week to 5 July, compared 7 (1%) unsafe burials of the 503 recorded community deaths in the previous week.

Including both initial and repeat testing, a total of 906 laboratory samples were tested in the week to 5 July: the fourth consecutive weekly increase in samples tested.

Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7. A new ETC in Boke opened in the week to July 5.

Locations of the 11 operational laboratories in Guinea are shown in figure 8. One new laboratory became operational in Conakry during the week to 5 July. After reporting health worker infections for 2 consecutive weeks, no health worker infections were reported from Guinea in the week to 5 July.

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. **Due to a policy change on 20 March affecting prefectures in Guinea in which there has been transmission within the past 21 days, unsafe burials now refer to any reported community death/burial that is not safe and carried out by a safe and dignified burial team.

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

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SIERRA LEONE

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

A total of 9 confirmed cases were reported from 3 districts (Kambia, Port Loko, and Western Area Urban) in the week to 5 July (table 3, figure 2, figure 3, figure 5, figure 6).

Four chiefdoms—Bramaia, Magbema, Samu and Tonko Limba—in the district of Kambia each reported a single confirmed case of EVD. All 4 cases were either registered contacts of a previous case or have an established epidemiological link to one.

Two cases were reported from two chiefdoms in Port Loko. The first, from Maforki chiefdom, was a registered contact of a previous case. The second, reported from the chiefdom of Masimera, arose from an unknown source of infection and was identified after post-mortem testing of a community death.

Three cases were reported from the Magazine Wharf area of the capital, Freetown. All three cases are registered contacts associated with previous cases in the cluster.

All but one of the 9 cases reported from Sierra Leone in the week to 5 July were either registered contacts of a previous case (5) or have an established epidemiological link to one (3). However, 3 cases were only identified as a result of post-mortem testing of community deaths. On 5 July, a total of 1521 contacts were being monitored in 3 districts: Kambia, Port Loko, and Western Area Urban (table 3).

In the week to 5 July, 98.1% of 480 credible reports of sick people with possible EVD-like symptoms were responded to within 24 hours. More than two-thirds (70%) of reports came from Freetown and the surrounding rural area. In addition, 1710 reports of deaths were received during the same period, 98.3% of which were responded to within 24 hours.

Locations of the 10 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7.

Laboratory indicators continue to reflect a heightened degree of vigilance, with 2012 new samples tested in the week to 5 July: the fifth consecutive weekly increase in new samples tested. Less than 1% tested positive for EVD.

Locations of the 9 operational laboratories in Sierra Leone are shown in figure 8. There was one health worker infection reported from Kambia in the week to 5 July.

Table 7: Key performance indicators for Sierra Leone

For definitions of key performance indicators see Annex 2. Data are for 7-day periods. ‡Data missing for 4–12% of cases. #Outcome data missing for 25–75% of hospitalized confirmed cases. An outcome is known for only 6 hospitalized, confirmed cases in April. *Use of a new rapid-reporting system from 26 April onwards means that data for the most recent 11 weeks cannot be directly compared with previous weeks.

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 transmission on 9 May 2015, after reporting no new cases for 42 consecutive days. The country subsequently entered a 3-month period of heightened surveillance, during which approximately 30 blood samples and oral swabs are collected each day from potential cases and tested for EVD. On 29 June, this routine surveillance detected a confirmed case of EVD in Margibi County, Liberia—the first new confirmed case reported from the country since 20 March. The case was a 17-year-old male who first became ill on 21 June, died on 28 June, and subsequently tested positive for EVD. Two contacts of the first-detected case have since been confirmed as EVD-positive. These additional cases are from the same small community as the first-detected case, and are now being treated in an ETC in the capital, Monrovia. In addition, a probable case is in isolation at an ETC. The case has a strong epidemiological link to the first-detected case and is showing some symptoms of EVD, but has indeterminate test results for EVD. The origin of infection of the cluster of cases is currently under investigation. At present, these cases are considered to constitute a separate outbreak from that which was declared over on 9 May.

Six countries (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.

On 12 May, WHO was notified of a laboratory confirmed EVD case in Italy in a health worker who returned to Italy from Sierra Leone on 7 May, 2015 (table 7). The patient was discharged on 10 June 2015 after having tested negative for Ebola virus on 9 June 2015. All 19 contacts associated with the case completed the 21-day follow-up period (table 8).

Table 8: Ebola virus disease cases in Italy

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 Italy 1 0 0 0 100% - 19 09/06/2015 26

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 relative 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 exercises, and field simulations have helped to identify key areas for improvement. Each country has a tailored plan to strengthen operational readiness. WHO and partners are deploying staff to the priority countries to assist with the implementation of national plans.

Follow-up missions in the four highest priority countries (Côte d’Ivoire, Senegal, Mali, and Guinea-Bissau) were able to strengthen cross-border surveillance and the sharing of outbreak data under the framework of the International Health Regulations (2005), as well as support other technical areas.

From October 2014 to June 2015 the WHO has undertaken over 251 field deployments to priority countries.

WHO provides personal protective equipment (PPE) modules containing minimum stocks to cover staff protection and other equipment needs to support 10 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. PPE modules sent to Algeria, Gabon, Kenya, Lesotho, Libya, Mozambique, South Sudan, and Sudan are in transit.

In addition, all countries have received one PPE training module.

Contingency stockpiles of PPE are in place 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 the initial PST assessment missions to the 14 priority countries undertaken in 2014, a second phase of preparedness strengthening activities has been initiated to achieve the following goals: Provide leadership and coordinate partners to support each national plan fully; Contribute to the International Health Regulations (2005) strengthening of national core capacities and the resilience of health systems.

In Guinea-Bissau, two WHO sub-offices have been established in the regions of Gabu and Buba. A multi-disciplinary team of experts is in country to assist in the implementation of heightened surveillance and early response activities. Activities include the implementation of an active surveillance protocol and capacity to strengthen the country’s ability to detect cases, and the establishment of one national and two regional coordination structures with Emergency Operations Centres (EOCs) and rapid response teams. WHO is also increasing staff levels in the country to support national and regional emergency coordination. Logistics support will also be provided for through the activation of the WHO/WFP logistics framework agreement.

In Cote d’Ivoire, a simulation exercise is taking place until 12 July to test triage, case detection, rapid response team function, case transport, ETC infection prevention and control, and safe and dignified burials. A logistician and an exercise consultant are deployed to support the simulation. Clinical management training is planned for August 2015.

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, provide specific technical support in their respective areas of expertise, and provide capacity development to national WHO staff. Preparedness officers are currently deployed to Benin, Cameroon, Cote d’Ivoire, Ethiopia, The Gambia, Ghana, Guinea-Bissau, Mali, Mauritania, Senegal, and Togo.

Training, exercises and simulations

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

Exercises in Côte d’Ivoire, Mali, and The Gambia are currently planned for July 2015.

The dates for training in Burkina Faso and Guinea-Bissau are to be confirmed.

International meetings on Ebola preparedness

A high-level partner meeting will take place from 13 to 15 July in South Africa. The goal of the meeting is to bring together key national, regional, and international stakeholders to establish a common framework of action to support, coordinate, and intensify the strategic development and maintenance of health security preparedness over the long term.

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 neighbouring 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. Agencies responsible for coordinating four 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