Total confirmed cases (by week, 2015)

SUMMARY

There were 24 confirmed cases of Ebola virus disease (EVD) reported in the week to 14 June, compared with 27 cases the previous week. In Guinea, 10 cases were reported from 4 prefectures (Boke, Conakry, Dubreka, and Forecariah). A total of 14 cases were reported from 2 districts (Kambia and Port Loko) in Sierra Leone.

Of 76 confirmed cases reported from Guinea and Sierra Leone in the 21 days to 14 June, 69 (91%) have come from 3 prefectures in Guinea (Boke, Dubreka, and Forecariah) and 2 districts in Sierra Leone (Kambia and Port Loko). Most (55) of these 69 cases came from well-characterised chains of transmission, and arose among registered, monitored contacts of previous cases. Each of these cases presents a risk of further transmission, but in most instances that risk is well understood and can be planned for accordingly. However, 14 of those 69 cases, and 5 of the 7 cases that were reported from other prefectures and districts during the same period, arose from unknown sources of infection, and/or are associated with a large number of high-risk contacts, some of whom it was not possible to trace. Effectively managing the risks associated with cases such as these will be crucial to getting to zero. To that end, a package of enhanced surveillance and response measures has been introduced in both Guinea and Sierra Leone: In Guinea, health checkpoints have been established in the western prefectures of Boke and Coyah. A 6-day door-to-door case-finding and sensitization campaign was carried out in Dubreka from 7 June, leading to the detection of 1 confirmed case. In addition, intensive investigations are underway to trace a number of high-risk contacts associated with 3 cases reported from the Guinean capital, Conakry, over the past 2 weeks. All of the 3 cases acquired infection outside the capital. In Sierra Leone, a large-scale operation is planned in the districts of Kambia and Port Loko, aimed at ending the secret movement of cases, contacts, and dead bodies that has propagated transmission over the past 2 months. Measures include broadened criteria for identifying and tracing contacts, improved incentives to increase compliance with quarantine measures and encourage the timely reporting and isolation of cases, and expanded use of rapid diagnostic tests.

As at 14 June, there were 1927 contacts being monitored across 8 prefectures in Guinea. In Sierra Leone, 443 contacts were under follow-up in 3 districts. A total of 660 laboratory samples were tested in Guinea in the week to 14 June: 4% tested positive. Over the same period, 1787 new samples were tested in Sierra Leone, with less than 1% testing positive.

In Guinea there were a total of 15 unsafe burials in the week to 14 June, representing 4% of 357 community deaths. In the week to 7 June, 1 unsafe burial was reported in Sierra Leone.

The last health worker infections in Guinea and Sierra Leone were reported on 6 April and 14 May, respectively. However, a case reported this week from the Targrin area of Port Loko, Sierra Leone, acquired infection after being treated in the same private healthcare facility as another confirmed case. There is an extremely high likelihood that this case will lead to further transmission, with 20 health workers who came into direct or indirect contact with the case defined as medium or high-risk contacts, along with many patients who were treated at the same facility. There have been a total of 869 confirmed health worker infections reported from Guinea, Liberia, and Sierra Leone since the start of the outbreak, with 507 reported deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 27 305 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11 169 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 10 new confirmed cases were reported in Guinea and 14 in Sierra Leone in the 7 days to 14 June. The outbreak in Liberia was declared over on 9 May.

The total number of confirmed 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 3 to 4 times more likely to be affected. People aged 45 and over are 4 to 5 times more likely to be affected than children.

A total of 869 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 507 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 3245** 35 2025 Probable 419 * 419 Suspected 12 * ‡ Total 3674** 35 2444 Liberia§ Confirmed 3151 0 ‡ Probable 1879 * ‡ Suspected 5636 * ‡ Total 10 666 0 4806 Sierra Leone Confirmed 8649 41 3553 Probable 287 * 208 Suspected 4029 * 158 Total 12 965 41 3919 Total Confirmed 15 045 76 ‡ Probable 2585 * ‡ Suspected 9675 * ‡ Total 27 305 76 11 169

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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 1559

(29) 1685

(31) 505

(11) 1854

(40) 840

(54) Liberia§ 1911

(96) 1838

(93) 561

(33) 2060

(121) 703

(132) Sierra Leone 4742

(166) 5026

(173) 1954

(81) 5535

(214) 2105

(285)

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Figure 2: Geographical distribution of confirmed cases reported in the week to 14 June 2015

Table 3: Cases and contacts by district/prefecture over the past 4 weeks

Table 4: Location and epidemiological status of confirmed cases reported in the week to 14 June 2015

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 187 94 Liberia* 378 192 Sierra Leone 304 221‡ Total 869 507

GUINEA

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

A total of 10 confirmed cases were reported from 4 prefectures in the 7 days to 14 June (table 3, table 4, figure 2, figure 3), compared with 12 cases from 4 prefectures the previous week (1 case from Forecariah and 3 cases from Kindia were determined to have been false positives, and have been discarded from the previous week’s total).

Cases were reported from 4 prefectures: Boke (2 cases), Conakry (1 case), Dubreka (4 cases), and Forecariah (3 cases; table 3, table 4, figure 2). Of those 10 cases, 5 were registered contacts, including all 4 cases reported from Dubreka (table 4). Of the remaining 5 cases, 4 arose from an unknown source of infection, including both cases from Boke prefecture and 2 of the 3 cases reported from Forecariah.

In Boke, a case was confirmed after post-mortem testing of a community death in the sub-prefecture of Kamsar. In addition, a case was reported from Boke Centre. This is the first time since the current cluster of cases in Boke was reported in the week ending 17 May that a case has been seen outside Kamsar sub-prefecture.

A 6-day door-to-door case-finding and sensitization campaign was carried out in Dubreka from 7 June, leading to the detection of 1 confirmed case.

The remaining 4 cases were reported from the capital, Conakry (1 case), and Forecariah (3 cases; figure 2, table 3, table 4). The case in Conakry has an epidemiological link to a previous case in Dubreka, and was in an advanced, infectious stage of disease at the time of discovery. High-risk contacts from this case and from 2 cases reported from Matoto, a different area of Conakry, during the previous week present a substantial risk of further transmission. All 3 cases acquired infection outside the capital. In Forecariah, 2 cases identified after post-mortem testing in the sub-prefecture of Sikhourou have not yet been linked to any known chain of transmission. The remaining case, reported from the sub-prefecture of Moussayah, was a registered contact of a previous case.

Investigations into the origin of a confirmed case reported 2 weeks ago in the prefecture of Fria have been inconclusive. No cases have been reported since, but difficulties engaging with local communities during the initial case investigation led field teams to conclude that there is a substantial risk of hidden transmission.

Community engagement remains challenging in most affected prefectures of Guinea, but has improved with the increased integration of anthropologists into case investigation teams. Three of the 10 nationally reported cases were identified only after post-mortem testing of community deaths in the week to 14 June. In addition, a total of 15 unsafe burials were reported over the same period, representing 4% of 357 community deaths; 19 unsafe burials were reported the previous week, representing 5% of 355 recorded community deaths.

As at 14 June, there were 1927 contacts being monitored across 8 Guinean prefectures (table 3).

Including both initial and repeat testing, a total of 660 laboratory samples were tested in the week to 14 June, compared with 602 the previous week. Including repeat positive samples taken from patients undergoing treatment, 4% of samples tested positive for EVD, compared with 6% the previous week.

Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7; 1 new ETC is under construction in Boke. No health worker infections were reported in Guinea in the week to 14 June.

Locations of the 9 operational laboratories in Guinea are shown in figure 8.

Table 6: Key performance indicators for 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 2 districts (Kambia and Port Loko) in the week to 14 June, compared with 15 cases from the same 2 districts the previous week (table 3, figure 2, figure 3, figure 5, figure 6).

For the third consecutive week, Kaffu Bullom in Port Loko reported the most cases (6) of any single chiefdom. Five of the 6 cases from Kaffu Bullom were contacts of previous cases in quarantined homes located in a small, densely populated area near the international airport. However, one case was reported from a new area of the chiefdom, Targrin, and on further investigation was determined to have acquired infection after sharing a ward with a confirmed case in a privately run health facility. A total of 20 health workers are registered as medium/high-risk contacts of the case, and are being monitored. All of the remaining 8 cases reported from Sierra Leone were registered contacts of known cases, and were reported from quarantined homes in 4 chiefdoms: Magbema (1 case), Samu (1 case) and Tonko Limba (4 cases) in Kambia, and Bureh Kasseh Ma (2 cases) in Port Loko.

As of 14 June, the Western Urban Area of Sierra Leone, which includes the capital Freetown, has reported no cases for over 16 consecutive days.

All 14 cases reported from Sierra Leone in the week to 14 June can be traced back to the secret movement of cases, contacts, and the secret burials of EVD-related deaths during April. To prevent further clandestine movement from prolonging current chains of transmission, a package of enhanced surveillance and response measures will be introduced in Kambia and Port Loko over the coming days. Measures include broadened criteria for the identification and tracing contacts, improved incentives to increase compliance with quarantine measures and encourage the timely reporting and isolation of new cases, and expanded use of rapid diagnostic tests.

As at 14 June, a total of 443 contacts were being monitored in 3 districts: Kambia, Port Loko, and Western Area Urban (table 3).

One unsafe burial was reported in Sierra Leone in the week to 7 June.

No health worker infections were reported in the week to 14 June. Locations of the 9 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7.

Laboratory indicators continue to reflect a heightened degree of vigilance, with 1787 new samples tested in the week to 14 June.

Locations of the 11 operational laboratories in Sierra Leone are shown in figure 8.

Table 7: Key performance indicators for Sierra Leone

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

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 received notification of a laboratory confirmed EVD case in Italy (table 7). The case is a volunteer health worker who returned to Italy from Sierra Leone on 7 May. The patient developed symptoms on 10 May, and was transported on 11 May to the infectious diseases ward of the Hospital of Sassari, Sardinia. Clinical samples were confirmed as EVD positive on 12 May, and the patient was securely transferred to the National Institute for Infectious Diseases in Rome. All 19 contacts associated with the case have now completed 21-day follow-up, and the patient was confirmed EVD negative on 9 June (table 8).

The EVD outbreak in Liberia was declared over on 9 May. The country, which had previously experienced widespread and intense transmission, completed 42 days without any new confirmed cases since the burial of the last confirmed case on 28 March. The country has now entered a 3-month period of heightened vigilance. In the week to 14 June, an average of 31 laboratory samples were tested per day.

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 - 4

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 for as long as cases are reported in any country. With sufficient 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 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 – 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 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 (IHR: 2005), as well as support other technical areas.

A programme to roll-out longer term support to countries is ongoing, with staff levels being increased in WHO country offices to coordinate preparedness activities. EVD preparedness officers have been recruited to WHO country offices in Benin, Côte d’Ivoire, Ethiopia, Guinea-Bissau, Ghana, Gambia, Mali, Senegal, and Togo. Deployments to all other priority countries are being finalized, and three subject-matter experts are also providing dedicated support to countries in the areas of infection prevention and control, outbreak logistics, and coordination.

WHO personal protective equipment (PPE) modules contain 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 and forwarded to strategic locations in Senegal, Mauritania, Mali, Guinea-Bissau, Cote d’Ivoire, Ghana, Togo, Niger, and Cameroon. PPE modules are currently in country and awaiting delivery to strategic locations in Benin, Gambia, and Burkina Faso. PPE modules have been dispatched to both Central African Republic and Ethiopia.

Further modules are being dispatched to all other unaffected countries in the WHO African Region and seven countries on the African continent in the WHO Eastern Mediterranean Region. Contingency stockpiles of PPE are in place in Accra and Dubai, and are made 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 fully support one national plan; Contribute to the International Health Regulations (2005) strengthening of national core capacities and the resilience of health systems.

A follow-up mission to Ghana took place from 8 to 13 June. The objective of the mission was to assess the capacity of the Ebola Treatment Centre (ETC), discuss rapid-response team needs, and conduct a logistics capacity assessment. Recommendations included the need for additional training in infection prevention and control, regular skills drills and simulations, including a national level rapid-response team simulation with regional participation, and clarification of the roles of the various emergency committees. Logistics capacity was assessed at the Tema ETC, with recommendations made to strengthen several areas.

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.

In Senegal, a series of skill drills have been scheduled in Tambacounda for 8 to 18 June, as well as a functional emergency operations centre exercise in Dakar. These drills consist of testing capacity for contact tracing, safe and dignified burials, case management, and coordination through the Emergency Operations Centre. In Togo, WHO is supporting the regional training of trainers on EVD infection prevention and control from 5 to 22 June. In Gambia, a training of regional preparedness and response teams is taking place from 15 to 19 June, as well as a stepdown training in the regions from 22 to 26 June. In Mali, a simulation exercise for an emergency operations centre took place from 10 to 17 June. The dates for training in Burkina Faso, Cote d’Ivoire 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