Total confirmed cases (by week, 2015)

SUMMARY

There were 30 confirmed cases of Ebola virus disease (EVD) reported in the week to 12 July: 13 in Guinea, 3 in Liberia, and 14 in Sierra Leone. Although the total number of confirmed cases is the same as the previous week, there has been a shift in the foci of transmission. For the first time in several months, most cases were reported from Conakry and Freetown, the capitals of Guinea and Sierra Leone, respectively. All 9 of the cases reported from Conakry and all 10 of the cases reported from Freetown were either registered contacts of a previous case or have an established epidemiological link to a known chain of transmission. One of the 30 cases reported in the week to 12 July arose from a yet unknown source of infection. However, a substantial proportion of cases (7 of 30: 23%) continue to be identified as EVD-positive only after post-mortem testing. This suggests that although improvements to case investigation are increasing our understanding of chains of transmission, contact tracing, which aims to minimise transmission by identifying symptoms among contacts at the earliest stage of infection, is still a challenge in several areas.

In Guinea, cases were reported from the prefectures of Conakry, Forecariah, and Fria. The northern prefecture of Boke, which has been a focus of transmission for over a month, has not reported a case for 11 days. Nine cases were reported from Conakry, 7 of which are linked to a chain of transmission in the Ratoma area. Three cases, one of whom is a health worker, were reported from Forecariah. The source of exposure of the health worker is under investigation. The remaining case in Guinea was reported from the prefecture of Fria, which had not reported a case for over 40 days. The case is a contact from Boke who had been lost to follow-up.

Three new cases were reported from Liberia in the week to 12 July, taking the total number of cases since 29 June to 6. The country had not previously reported a case since 20 March. All 3 confirmed cases reported in the week to 12 July were registered contacts associated with the same chain of transmission as the 3 cases reported the previous week. One of the cases reported in the week to 12 July had symptom onset in a quarantined home in Montserrado County, near to the capital, Monrovia, before being transferred to an Ebola Treatment Centre. The origin of the cluster of cases remains under investigation. Preliminary evidence from genomic sequencing strongly suggests that the most likely origin of transmission is a re-emergence of the virus from a survivor within Liberia.

In Sierra Leone, 14 cases were reported from Freetown, Kambia, and Port Loko. Of the 10 cases reported from Freetown, 8 came from quarantined homes in the Magazine Wharf area of the city, which has been a focus of transmission for several weeks. The remaining 2 cases from Freetown were reported from other areas of the city but are associated with the Magazine Wharf chain of transmission. Two chiefdoms in Kambia reported cases this week, compared with 4 the previous week. Two cases were reported from the northwestern chiefdom of Samu, one of which was a community death. The remaining case from Kambia was reported from Tonko Limba chiefdom. In Port Loko, a single case was reported from the chiefdom of Marampa.

On 12 July there were 3552 contacts being monitored across 6 prefectures in Guinea, 2 counties in Liberia, and 3 districts in Sierra Leone.

One new health worker infection was reported from Forecariah, Guinea, in the week to 12 July. There have been a total of 876 confirmed health worker infections reported from Guinea, Liberia, and Sierra Leone since the start of the outbreak, with 509 reported deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 27 642 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1) up to 12 July, with 11 261 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 13 new confirmed cases were reported in Guinea, 3 in Liberia, and 14 in Sierra Leone in the week to 12 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.

One new health worker infection was reported in Forecariah, Guinea, in the week to 12 July. Since the start of the outbreak a total of 876 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 3300 43 2056 Probable 450 * 450 Suspected 10 * ‡ Total 3760 43 2506 Liberia§ Confirmed 3151 - ‡ Probable 1879 - ‡ Suspected 5636 - ‡ Total 10 666 - 4806 Liberia** Confirmed 6 6 2 Probable 1 1 ‡ Suspected ‡ * ‡ Total 7 7 2 Sierra Leone Confirmed 8688 31 3581 Probable 287 * 208 Suspected 4234 * 158 Total 13 209 31 3947 Total Confirmed 15 145 80 ‡ Probable 2617 1 ‡ Suspected 9880 * ‡ Total 27 642 81 11 261

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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 1574

(29) 1716

(32) 516

(11) 1874

(40) 855

(55) Liberia§ 1911

(96) 1838

(93) 561

(33) 2060

(121) 703

(132) Sierra Leone 4792

(168) 5081

(175) 1978

(82) 5592

(216) 2129

(288)

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Figure 2: Geographical distribution of confirmed cases reported in the week to 12 July 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 12 July. ‡Includes Freetown.

Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 12 July 2015

Sub-prefectures/chiefdoms/districts that reported one or more confirmed cases in the 7 days to 12 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 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 192 96 Liberia* 378 192 Sierra Leone 306 221‡ Total 876 509

GUINEA

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

Thirteen confirmed cases were reported from 3 prefectures—Conakry, Forecariah, and Fria—in the week to 12 July (table 3, table 4, figure 2, figure 3).

For the first time in several months, the majority of cases (9) in Guinea were reported from the capital, Conakry. Seven of the 9 cases were reported from Ratoma commune (administrative district), with the remaining 2 reported from the neighbouring commune of Matam (table 3, table 4, figure 2). All 9 cases are either registered contacts or have an epidemiological link to a known chain of transmission.

The northern prefecture of Boke, which had been a focus of transmission for several weeks and borders Guinea-Bissau, has not reported a case for 11 consecutive days. However, 125 contacts associated with previous cases are still being monitored.

The small western prefecture of Fria reported a confirmed case for the first time in over 40 days. The case is a contact of a previous case in the northern prefecture of Boke, and had been lost to follow-up.

Overall, 9 (69%) of 13 cases in Guinea were registered contacts, compared with 12 (67%) of 18 cases reported the previous week. All remaining cases had an epidemiological link to a previous case, with no cases arising from an unknown source of infection. However, 3 cases—2 in Conakry and 1 in Forecariah—were only identified after post-mortem testing of community deaths.

On 12 July there were 2472 contacts being monitored across 6 Guinean prefectures (table 3). Forecariah accounts for the majority of contacts (1900), followed by Conakry (374).

The number of unsafe burials reported from Guinea decreased to 4 (0.7%) unsafe burials of the 558 recorded community deaths in the week to 12 July, compared with 7 (1%) unsafe burials of the 547 recorded community deaths in the previous week.

Including both initial and repeat testing, a total of 785 laboratory samples were tested in the week to 12 July: a slight decrease compared with the previous week.

Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7. One health worker, from an ETC in Forecariah Centre, tested positive for EVD in the week to 12 July.

Locations of the 11 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. **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 prefecture 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 14 confirmed cases were reported from 3 districts (Freetown, Kambia, and Port Loko) in the week to 12 July (table 3, figure 2, figure 3, figure 5, figure 6). This is the highest total since the second week in June.

For the first time in several months the majority of cases in Sierra Leone were reported from the capital, Freetown. Eight of the 10 cases reported from the capital were registered contacts residing in quarantined homes in the Magazine Wharf area of the city, which has been a focus of transmission for several weeks. The remaining 2 cases both have an epidemiological link to the Magazine Wharf chain of transmission, but were identified after post-mortem testing of community deaths, and represent a high risk of further transmission.

In Kambia, 2 cases were reported from Samu chiefdom on the northern border with Forecariah, Guinea. Both were known contacts of a previous case. The remaining case was reported from a quarantined home in Tonko Limba chiefdom, and was also a registered contact of a previous case.

The single case reported from Port Loko was reported from the chiefdom of Marampa, and the source of infection is still under investigation.

All but 1 of the 14 cases reported from Sierra Leone in the week to 12 July were either registered contacts of a previous case (11) or have an established epidemiological link to a case (2), although 4 cases were only identified as a result of post-mortem testing of community deaths.

On 12 July, a total of 940 contacts were being monitored in 3 districts: Kambia, Port Loko, and Western Area Urban (table 3).

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 1813 new samples tested in the week to 12 July: a slight decrease compared with 2012 samples tested the previous week. Less than 1% of samples tested positive for EVD.

Locations of the 10 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. ‡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 heightened surveillance detected an EVD-positive community death 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. As at 12 July, 5 contacts associated with the first-detected case have since been confirmed as EVD-positive. One of the 3 cases reported in the week to 12 July had symptom onset in a quarantined home in Montserrado County, near to the capital, Monrovia, before being transferred to an ETC. The origin of the cluster of cases remains under investigation. Preliminary evidence from genomic sequencing suggests that the most likely origin of transmission is a re-emergence of the virus from a survivor within Liberia, rather than an importation from Guinea or Sierra Leone.

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 case 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 33

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 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 are in transit to Algeria, Gabon, Kenya, Lesotho, Libya, Mozambique, South Sudan, and Sudan. 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. Two epidemiologists are currently deployed in Gabu and Tombali. An additional two epidemiologists will be deployed to support the sub-offices until the end of August. Daily communication and reporting between the border locations and EOC are taking place to ensure a heightened state of alertness and updates. Swabbing of dead bodies is being implemented to rule out EVD as the cause of death. WHO is also increasing staff levels in the country to support national and regional emergency coordination. Logistics support will be provided through the activation of the WHO/WFP logistics framework agreement.

In Côte D’Ivoire, a workshop will be held between 20 and 25 July to harmonize and finalize various standard operating procedures related to IPC, epidemiology and training.

In Mali, a simulation exercise will run between 25 July and 1 August. Experts in coordination, epidemiology, logistics, and simulations will support and facilitate the exercise.

A joint border mission in Mali, Sierra Leone, and Liberia is taking place from 7 to 16 July to assess capacities, processes, and procedures for the detection of and response to EVD cases.

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