Corrigendum as of 6 March 2015

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SUMMARY

A total of 132 new confirmed cases of Ebola virus disease (EVD) were reported in the week to 1 March, an increase on the previous week (99 new cases). Liberia reported no new confirmed cases this week, the first time since the week of 26 May 2014. The weekly number of confirmed cases has increased in both Sierra Leone and Guinea. Transmission remains widespread in Sierra Leone, which reported new confirmed cases in 8 districts during the week to 1 March. In Guinea, Forecariah and Conakry reported a marked increase in case numbers compared with the previous week.

Guinea reported 51 new confirmed cases in the week to 1 March, compared with 35 cases the previous week. Cases continue to arise from unknown sources with only 49% of cases arising from registered contacts. Seven prefectures reported new cases, with the largest number of new confirmed cases reported from 3 neighbouring western prefectures: Conakry (17 cases), Coyah (5 cases), and Forecariah (23 cases). Macenta also reported 2 new confirmed cases, a district that has not reported a confirmed case for 4 weeks. Low levels of transmission continue in the eastern prefecture of Lola (1 new case), bordering Côte d’Ivoire.

Sierra Leone reported 81 new confirmed cases from 8 districts in the week to 1 March. A previously reported cluster of cases in the Aberdeen fishing community of the capital, Freetown, has seeded outbreaks in other districts, notably Bombali which reported 22 new confirmed cases. There were 26 new confirmed cases in Freetown and 16 new cases in Port Loko over the same period.

Liberia has reported no new confirmed cases this week. Contacts from the last known chain of transmission, in the St Paul’s Bridge district of Monrovia, are being monitored. In the week to 1 March, 277 samples were tested for EVD nationwide, no new test results were positive.

The number of confirmed EVD deaths occurring in the community in Guinea and Sierra Leone remains high, suggesting that the need for early isolation and treatment is not yet understood, accepted or acted upon. In Guinea in the week to 1 March over half (53%: 17 out of 32) of reported confirmed deaths occurred in the community, an increase from 42% the previous week (9 out of 21). In Sierra Leone, 16% of confirmed EVD deaths occurred in the community in the week to 1 March, compared with 21% the previous week.

Unsafe burials continue to occur, with 16 reports of unsafe burials in both Guinea and Sierra Leone, respectively, during the weeks to 1 March and to 22 February.

Laboratories in Guinea, Liberia and Sierra Leone processed 270, 277 and 1531 samples, respectively, in the week to 1 March.

Mindful of the risk of cross border transmission, delegations from Guinea, Mali and Senegal met on 25-26 February 2015 and agreed to strengthen cross-border cooperation in case management (including the sharing of laboratory resources), community-based surveillance, risk communication and information sharing, and screening at border crossings.

In the week to 1 March, 1 new health worker infection was reported Guinea, bringing the total of health worker infections reported across the three most-affected countries since the start of the outbreak to 839, with 491 deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been over 23 900 reported confirmed, probable, and suspected cases cases of EVD in Guinea, Liberia and Sierra Leone (table 1), with over 9800 reported deaths (outcomes for many cases are unknown). A total of 51 new confirmed cases were reported in Guinea, 0 in Liberia, and 81 in Sierra Leone in the 7 days to 1 March.

The total number of confirmed and probable cases is similar in males and females (table 2). Compared with children (people aged 14 years and under), people aged 15 to 44 are approximately three times more likely to be affected. People aged 45 and over are nearly four times more likely to be affected than children.

A total of 839 confirmed health worker infections have been reported in the 3 intense-transmission countries; there have been 491 reported deaths (table 4).

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

Country Case definition Cumulative cases Cases in past 21 days Cumulative deaths Guinea Confirmed 2813 138 1737 Probable 392 * 392 Suspected 14 * ‡ Total 3219 138 2129 Liberia Confirmed 3150** 6 ‡ Probable 1877 * ‡ Suspected 4222 * ‡ Total 9249 6 4117 Sierra Leone Confirmed 8370 240 3180 Probable 287 * 208 Suspected 2809 * 158 Total 11 466 240 3546 Total Confirmed 14 333 384 ‡ Probable 2556 * ‡ Suspected 7045 * ‡ Total 23 934 384 9792

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Table 2: Cumulative number of confirmed and probable 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 1532

(28) 1637

(30) 495

(11) 1776

(38) 878

(56) Liberia 2871

(144) 2828

(144) 964

(56) 3077

(180) 1180

(221) Sierra Leone 5289

(185) 5614

(194) 2262

(93) 6069

(234) 2369

(321)

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GUINEA

Key performance indicators for the EVD response in Guinea are shown in table 3.

A total of 51 confirmed cases were reported in the 7 days to 1 March (figure 1), compared with 35 cases the week before.

Seven prefectures reported new confirmed cases, most of which are concentrated in the west of the country, with the majority reported from Conakry (17 cases), Coyah (5 cases), and Forecariah (23 cases). The neighbouring prefectures of Dubreka (2 cases) and Boffa (1 case) also reported new confirmed cases during the reporting period (figure 1).

Macenta, which had not reported a confirmed case for 4 weeks, reported 2 new confirmed cases. The eastern prefecture Lola, which borders Côte d’Ivoire, reported 1 new confirmed case. Cross-border surveillance has been strengthened.

At least one security incident was reported in 4 of 34 prefectures in the week to 1 March.

Difficulty engaging with communities can make identifying contacts and tracing chains of transmission more challenging. As a result, some cases are only identified after post-mortem testing. Over half (16 out of 30) of the confirmed deaths from EVD in the week to 1 March occurred in the community. Over the same period, 12 unsafe burials were reported, compared with 19 the previous week.

Locations of 7 operational Ebola treatment centres (ETCs) are shown in figure 6. Two ETCs have been assessed and have met minimum standards for infection prevention and control (IPC). At present, 3 of 6 ETCs are occupied by patients with EVD. One new health worker infection and 1 new health worker deaths was reported in the week to 1 March in Forecariah and Boffa, respectively.

The case fatality rate (CFR) among people hospitalized with confirmed EVD for whom a definitive outcome was reported was 55%, 57% and 66% for November, December and January, respectively. On average, it took 3.3 days between the onset of EVD symptoms and isolation and treatment of a confirmed, probable or suspected case during January.

During the month of February, 98% of samples from suspected and probable cases were tested within 1 day of collection; 80% were tested on the same day as collection. 270 samples were tested for EVD in the week to 1 March, 114 of which were swabs from deceased individuals. Locations of the 7 operational laboratories in Guinea are shown in figure 7.

Figure 1: Confirmed weekly Ebola virus disease cases reported nationally and by district from Guinea

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LIBERIA

Key performance indicators for the EVD response in Liberia are shown in table 3.

No new confirmed cases have been reported in the week to 1 March, the first week with no new confirmed cases reported since the week of 26 May 2014.

Montserrado and Margibi are the only counties to have reported a confirmed case within the past 45 days (figure 5).

Locations of the 19 operational Ebola treatment centres (ETCs) in Liberia are shown in figure 6. All of the 12 that have been assessed met minimum infection prevention and control standards. No new health worker infections were reported in Liberia in the week to 1 March.

Case fatality rates for people hospitalized with confirmed EVD for whom a definitive outcome was reported were 53%, 52% and 50% for the months of October, November and December respectively. On average, it took 2.8 days between the onset of EVD symptoms and isolation and treatment of a confirmed, probable or suspected case during November.

During the month of February, 85% of samples from suspected and probable cases were tested within 1 day of collection compared with 95% during January. 40% of samples were tested on the same day as collection. During the week to 1 March, 277 samples were tested by the 5 operational laboratories in Liberia shown in figure 7.

Figure 2: Confirmed weekly Ebola virus disease cases reported nationally and by district from Liberia

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SIERRA LEONE

Key performance indicators for the EVD response in Sierra Leone are shown in table 3.

After a rapid decline, weekly case incidence has stabilized since the week ending 25 January, at between 60 and 100 confirmed cases per week. A total of 81 confirmed cases were reported in the week to 1 March, a rise on the previous week (to 22 February), but slightly less than the 96 confirmed cases reported in the week to 15 February.

Both Freetown and Western Rural district reported a rise in new confirmed cases compared to the previous week: Freetown reported 26 cases compared with 14 the previous week, and Western Rural reported 8 cases compared with 3 the previous week. The increase in reported confirmed cases in the northern district of Bombali has continued with 22 confirmed cases reported in the week to 1 March. The neighbouring districts of Kambia (6 confirmed cases) and Port Loko (16 confirmed cases) also report persistent transmission. The outbreak in Bombali is reportedly linked to the cluster of cases in the fishing community in the Aberdeen area of Freetown. A response team continues to trace and monitor over 2000 contacts associated with the Aberdeen cluster.

Although most cases are reported from western districts, transmission is also reported in several other regions of the country, including Koinadugu, Kono, and Tonkolili, which each reported 1 confirmed case in the week to 1 March.

Community engagement remains a challenge in several areas of Sierra Leone. A total of 16 unsafe burials were reported in the week to 25 February. In the week to 1 March, a total of 14 confirmed cases were identified after post-mortem testing of dead bodies found in the community. Four incidents of community resistance were reported in the week to 25 February.

Locations of the 22 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 6. Two ETCs closed during the past week, one in Kailahun and the other in Freetown. No health worker infections were reported in the week to 1 March.

There are 13 operational laboratories in Sierra Leone (figure 7). In the month of February, 88% of samples from suspected and probable cases were tested within 1 day of collection. 50% of samples were tested on the same day they were collected. 1531 samples were tested for EVD in the week to 1 March, 953 of which were collected post mortem. This large number of samples indicates a high level of surveillance.

Figure 3: Confirmed weekly Ebola virus disease cases reported nationally and by district from Sierra Leone

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Figure 4: Geographical distribution of new and total confirmed cases

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Table 3: Key performance indicators for Phase 2 of the Ebola response

For definitions of key performance indicators see Annex 2. Data are given for complete months unless otherwise specified. *These numbers are subject to change due to ongoing reclassification, retrospective investigation and the availability of laboratory results. §Laboratory data has been retrospectively corrected (6 March 2015). #Data from Guinea includes new confirmed and probable cases from registered contacts.

For definitions of key performance indicators see Annex 2.

For definitions of key performance indicators see Annex 2. ‡Isolation for confirmed, probable and suspected cases is not recorded for 4-8% of cases in Guinea, 62-65% in Liberia and 50-61% in Sierra Leone. ##No final outcome is recorded in 3-19% of confirmed and probable cases in Guinea, 2-41% in Liberia, and 68-76% in Sierra Leone. §IPC assessment results are available periodically. This data reflects IPC assessments of ETCs and not Community Care Centres (CCCs) or other Ebola facilities. **Does not include foreign medical teams.

For definitions of key performance indicators see Annex 2. †Please note the different time period used.

Table 4: Ebola virus disease infections in health workers in the three countries with intense transmission

Country Cases Deaths Guinea 172 89 Liberia 372 180 Sierra Leone* 295 221 Total 839 491

Figure 5: Days since last confirmed case by district in Guinea, Liberia, and Sierra Leone

1 March is counted as day 0.

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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 5). The case was a health worker who returned from volunteering at an ETC in Sierra Leone. The patient was isolated on 29 December and received treatment in London. On 23 January the patient tested negative twice for EVD, and on 24 January the patient was discharged. All contacts have completed 21-day follow-up.

Table 5: Ebola virus disease cases and deaths in 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 United Kingdom 1 0 0 0 100% 0 55 23/01/2015 39

Figure 6: 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 for as long as cases are reported in any country. 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.

Figure 7: 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 – 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, preparedness-strengthening teams (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.

Follow-up visits to support priority needs in EVD Preparedness have now completed their activities in the four Member States (Côte d’Ivoire, Senegal, Mali, and Guinea Bissau) immediately surrounding countries experiencing widespread and intense EVD transmission. In addition to supporting priority areas in each of these countries, the visits were able to strengthen cross-border surveillance and the sharing of outbreak data under the framework of the International Health Regulations.

A high level meeting held in Labe, Guinea, attended by delegations from Guinea, Mali and Senegal on 25-26 February 2014 issued a final communiqué strengthening cooperation between the three countries in case management (including the sharing of laboratory resources), community-based surveillance, risk communication and information sharing, and screening at border crossings. The meeting also established a 12 month calendar of activities to maintain collaboration at the operational and policy levels.

During the week to 1 March, five cross-border meetings took place, including a coordination meeting in Kambia/Forécariah. This meeting was held on both sides of the border to facilitate communication, to share best practices, and to align strategies.

A country visit to Mauritania is currently underway (25 February to 4 March) where support is being provided in the areas of community engagement and social mobilisation, case management, logistics, and points of entry.

Follow-up PST support is planned for all priority countries with a focus on the following: Provision of tailored, targeted technical guidance tools and support to strengthen EVD preparedness capacities; operationalize plans; test and improve procedures through field exercises and drills; and support the implementation of preparedness plans , including logistics support; Foster inter-country collaboration and networking, including cross-border communication, cooperation, and exchanges; Provide leadership and coordinate partners to fully support one national plan and the steering role of national authorities; Coordinate global advocacy and support to EVD preparedness, document and disseminate experiences, lessons learnt and good practices, monitor progress, and evaluate outcomes; Strengthen the implementation of the International Health Regulations, and ensure that the core capacities to manage health emergencies are at the heart of resilient health systems.



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 4 key lines of action in the response are given below.

Lines of action Lead agency Case management WHO Case finding, lab 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

Indicator Numerator Numerator source Denominator Denominator source Cases and deaths Number of confirmed cases # of confirmed cases Guinea: Daily WHO situation reports Liberia / Sierra Leone: Ministry of Health Ebola Situation Reports N/A N/A Number of confirmed deaths # of confirmed deaths Guinea: Daily WHO situation reports Liberia / Sierra Leone: Ministry of Health Ebola Situation Reports N/A N/A Number of confirmed deaths that occurred in the community # of deaths in the community with positive EVD swab results Guinea: Weekly WHO situation reports Liberia / Sierra Leone: Ministry of Health N/A N/A Diagnostic services Percent of samples tested within one day of collection # of samples for which the difference between date of sample testing and date of sample collection is less than or equal to one day* Laboratory Database # of samples that have date of test and date of collection recorded* Laboratory Database Number of samples tested and percentage with positive EVD results # of samples tested # of samples tested with a positive EVD result Laboratory Database N/A # of samples tested Laboratory Database Contact tracing Percent of new confirmed cases from registered contacts # of new confirmed cases registered as a contact Guinea: Weekly WHO situation reports Liberia: Ministry of Health Ebola Situation Reports Sierra Leone: Weekly Ministry of Health Surveillance Report Number of new confirmed cases Guinea: Daily WHO situation reports Liberia / Sierra Leone: Ministry of Health Ebola Situation Reports Isolation Time between symptom onset and case isolation (days) Time between symptom onset and isolation of confirmed, probable or suspected case (geometric mean # of days) Clinical investigation records N/A N/A Outcome of treatment Case fatality rate (among hospitalized cases) # of deaths among hospitalized cases (confirmed) Clinical investigation records # of hospitalized cases (confirmed) with a definitive survival outcome recorded Clinical investigation records Infection Prevention and Control (IPC) and Safety Percent of IPC-assessed Ebola treatment centres (ETCs) # of IPC-assessed Ebola treatment centres that met minimum IPC standards** IPC Reports # of IPC-assessed Ebola treatment centres IPC Reports Number of newly infected health workers # of newly infected health workers Guinea / Sierra Leone: Daily WHO situation reports Liberia: Ministry of Health Ebola Situation Reports N/A N/A Safe and dignified burials Number of unsafe burials reported # of reports/alerts of burials that were not known to be safe Guinea: Weekly WHO situation reports Liberia / Sierra Leone: Ministry of Health N/A N/A Social mobilization Number of districts with at least one security incident or other form of refusal to cooperate # of districts with at least one security incident or other form of refusal to cooperate in the past week Guinea: Daily WHO situation reports Liberia / Sierra Leone: UNICEF N/A N/A

*For samples that do not have a date of testing recorded, the date of receipt at a laboratory is used as a proxy. **A facility meets minimum standards when the average score for a selected list of IPC criteria is ≥ 80%.