Total confirmed cases (by week, 2015)

SUMMARY

A total of 37 confirmed cases of Ebola virus disease (EVD) was reported in the week to 12 April, compared with 30 the previous week. Case incidence in Guinea increased to 28, compared with 21 confirmed cases the previous week. Sierra Leone reported 9 confirmed cases, the same total as in the previous week. Liberia reported no confirmed cases.

A total of 5 Guinean prefectures reported at least one confirmed case in the week to 12 April, compared with 6 the previous week. Transmission remains confined to the western area, and is primarily focused on the prefecture of Forecariah, which borders Sierra Leone. In total, 8 prefectures/districts in Guinea and Sierra Leone reported a confirmed case in the week to 12 April, compared with 10 the previous week. This is the lowest number of districts to report a confirmed case since the end of May 2014. Of 55 districts in Guinea, Liberia, and Sierra Leone that have reported at least one confirmed case of EVD since the start of the outbreak, 39 have not reported a case for over 6 weeks.

In the context of falling case incidence and a receding zone of transmission, treatment capacity exceeds demand in Liberia and Sierra Leone. Accordingly, and with technical guidance from WHO, national authorities in both countries have begun to implement plans for the phased safe decommissioning of surplus facilities. Each country will retain a core capacity of high-quality Ebola treatment centres, strategically located to ensure complete geographic coverage, with additional rapid-response capacity held in reserve.

In Sierra Leone, cases were reported from 3 western districts: Kambia (4 cases), Port Loko (1 case), and Western Area Urban (4 cases), which includes the capital, Freetown.

Response indicators from Sierra Leone continue to be encouraging. The number of EVD-positive deaths that were identified in the community after post-mortem testing was 3 in the week to 12 April. The low proportion of laboratory samples that tested EVD-positive (9 of 1338: <1%) and the increasing proportion of cases that arise among registered contacts (67% for the most recent reporting period) strengthen confidence that the downward trend in case incidence over the past 5 weeks will continue.

By contrast, response indicators for Guinea continue to present a mixed picture. A total of 8 confirmed deaths from EVD in the week to 12 April were identified post-mortem in the community. In addition, the proportion of confirmed cases that arose among registered contacts remained below 50% for the second consecutive week, at 44%. More positively, the number of laboratory samples tested increased for a fourth consecutive week to 518 in the week to 12 April: but 10% of samples tested positive for EVD.

A case-finding and community sensitization operation took place in the Guinean prefecture of Forecariah from 12 to 15 April. In the first 3 days over 29 000 households were visited, with 23 suspected cases identified and tested. Similar operations will take place in the prefectures of Boffa, Conakry, Coyah, Dubreka, and Kindia.

The last confirmed case in Liberia died on 27 March. Investigations are ongoing to establish the origin of infection. A total of 2 contacts associated with the case were being monitored as at 11 April. Heightened vigilance is being maintained throughout the country. In the 6 days to 11 April, 332 laboratory samples were tested for EVD, with no confirmed cases. 42 days will have elapsed since the last confirmed case on 8 May.

There was one new health worker infection in the week to 12 April, with the cumulative total increasing to 864 since the start of the outbreak.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 25 791 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with over 10 600 reported deaths (outcomes for many cases are unknown). A total of 28 new confirmed cases were reported in Guinea, 0 in Liberia, and 9 in Sierra Leone in the 7 days to 12 April.

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 three to five times more likely to be affected than are children.

A total of 864 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 503 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 3117 106 1932 Probable 414 * 414 Suspected 17 * ‡ Total 3548 106 2346 Liberia** Confirmed 3151 1 ‡ Probable 1879 * ‡ Suspected 5012 * ‡ Total 10 042 0 4486 Sierra Leone Confirmed 8563 43 3491 Probable 287 * 208 Suspected 3351 * 158 Total 12 201 43 3857 Total Confirmed 14 831 149 ‡ Probable 2580 * ‡ Suspected 8380 * ‡ Total 25 791 149 10 689

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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 1673

(31) 1818

(33) 555

(12) 1954

(42) 960

(61) Liberia 2958

(149) 2891

(147) 993

(58) 3170

(186) 1208

(226) Sierra Leone 5433

(191) 5768

(199) 2330

(96) 6231

(241) 2427

(328)

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Figure 2: Geographical distribution of new and total confirmed cases

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GUINEA

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

A total of 28 confirmed cases were reported in the 7 days to 12 April (figure 3), compared with 21 cases the previous week.

A total of 5 prefectures reported at least one confirmed case, compared with 6 the previous week (figure 2; figure 6). Transmission remains centred in the west of the country, and particularly in the prefecture of Forecariah, which borders Sierra Leone. With 17 confirmed cases, Forecariah accounted for 61% of all cases reported from Guinea in the week to 12 April. The capital Conakry (6 cases) and the nearby prefectures of Boffa (1 case), Coyah (3 cases), and Kindia (1 case) also reported cases (figure 2, figure 6).

Response indicators for Guinea continue to present a mixed picture (table 3). Of 13 confirmed deaths from EVD in the week to 12 April, 8 were identified post-mortem in the community, whilst the proportion of confirmed cases that arose among registered contacts remained under 50% the second consecutive week, at 44% in the week to 5 April. However, there are encouraging signs that surveillance is improving. The number of laboratory samples tested increased for a fourth consecutive week to 518 in the week to 12 April: 10% of samples tested positive for EVD. In addition, a change to the way unsafe burials are defined in Conakry, Coyah, and Forecariah, with any reported burial that is not carried out by an authorized team now deemed unsafe, will strengthen surveillance efforts.

As part of the 45-day reinforcement of emergency measures in western Guinea, a 4-day door-to-door campaign to improve community participation in surveillance activities and identify suspected cases took place in the prefecture of Forecariah from 12 to 15 April. In the first 3 days over 29 000 households were visited, with 23 suspected cases identified and tested. A similar operation is scheduled to take place in the prefectures of Boffa, Conakry, Coyah, Dubreka, and Kindia from 18 to 21 April.

The security situation in Guinea continues to present challenges. A total of 5 prefectures reported instances of community resistance in the week to 12 April, whilst civil unrest in Conakry has affected field operations.

Locations of 8 operational Ebola treatment centres (ETCs) are shown in figure 7. One ETC opened Forecariah in the week to 12 April. One health worker infection was reported in the week to 12 April.

Locations of the 9 operational laboratories in Guinea are shown in figure 8. The Rospotrebnadzor Mobile Lab (Russian Lab) moved from Conakry to Kindia, and the EU Mobile Lab moved from Gueckedou to Coyah. Of 518 samples tested in the week to 12 April, 98% were processed within 1 day of arrival at a laboratory.

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

Figure 3: 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 4.

No new confirmed cases were reported from Liberia in the week to 12 April (figure 2; figure 4). The last confirmed case died on 27 March. A total of 2 contacts associated with the case were being monitored as at 11 April. Heightened vigilance is being maintained throughout the country. In the 6 days to 11 April, 332 new laboratory samples were tested for EVD, none of which tested positive. All counties, with the exception of Montserrado, have now not reported a new case for over 6 weeks.

Locations of the 16 operational Ebola treatment centres (ETCs) in Liberia are shown in figure 7. One ETC in Margibi county was decommissioned in the week to 12 April.

Locations of the 4 operational laboratories in Liberia are shown in figure 8. The Dutch Mobile Laboratory in Grand Cape Mount closed on 12 April. Of the 332 new samples that were tested in the 6 days to 11 April, 65% were processed within 1 day of arrival at a laboratory.

Table 4: Key performance indicators for Liberia for Phase 2 of the Ebola Response

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

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Table 5: Ebola virus disease infections in health workers in the three countries with intense transmission

Country Cases Deaths Guinea 187 94 Liberia* 374 188 Sierra Leone 303 221** Total 864 503

SIERRA LEONE

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

A total of 9 confirmed cases were reported in the week to 12 April, the same total as in the previous week.

Cases were reported from 3 western districts: Kambia (4 cases), Port Loko (1 case), and Western Area Urban (4 cases), which includes the capital, Freetown. (figure 2; figure 5; figure 6).

Response indicators from Sierra Leone continue to be encouraging. The number of EVD-positive deaths that were identified in the community after post-mortem testing remained at 3 in the week to 12 April. The low proportion of laboratory samples that tested EVD-positive (9 of 1338: <1%) and the increase in the proportion of cases that arise among registered contacts (67%) strengthen confidence that the downward trend in case incidence over the past 5 weeks will continue.

Locations of the 15 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7. No new health worker infections were reported in the week to 12 April.

Locations of the 13 operational laboratories in Sierra Leone are shown in figure 8. The Nigeria Mobile Lab moved from Freetown to Kambia. A total of 83% of samples were tested within 1 day of arrival at a laboratory in the week to 12 April.

Table 6: Key performance indicators for Sierra Leone for Phase 2 of the Ebola Response

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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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 previously reported a case or cases imported from a country with widespread and intense transmission.

Figure 7: Location of Ebola treatment centres in Guinea, Liberia, and Sierra Leone

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PREPAREDNESS OF COUNTRIES TO RAPIDLY DETECT AND RESPOND TO AN EBOLA EXPOSURE

The introduction of an EVD case into unaffected countries remains a risk 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 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. Other countries of focus include Nigeria and South Sudan.

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 missions to support priority needs in EVD preparedness have implemented immediate 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 missions were able to strengthen cross-border surveillance and the sharing of outbreak data under the framework of the International Health Regulations.

A program to roll-out longer term support is currently under development, with staff levels being increased in WHO country offices to coordinate preparedness activities. EVD Preparedness Officers are currently deployed to Côte d’Ivoire, Guinea Bissau, The Gambia, and Ethiopia. Deployments to Benin, Mauritania, Senegal, and Togo are being finalized.

Standard viral haemorrhagic fever PPE modules have been delivered to Mali, Guinea Bissau, Côte d’Ivoire, Senegal, and Mauritania. The PPE modules contain minimum stocks to cover staff protection needs to support 10 beds for 10 days for all staff with essential functions.

Follow-up PST support to priority countries

Following the initial PST assessment missions to the 14 high-priority countries undertaken in 2014, a second phase of preparedness strengthening has been initiated to achieve the following goals: Provide tailored, targeted technical support to strengthen EVD capacities in human resources; operationalise plans; test and improve procedures through field exercises and drills; and support the implementation of preparedness plans with financial and logistics support; 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 preparedness strengthening mission is currently in South Sudan to assess the state of EVD readiness in the country. The mission will review the preparedness status across the 11 components of the EVD preparedness checklist. Due to the current security situation in South Sudan, it is not possible for the team to examine all points of entry, so they will focus only on capacities at the Juba International airport, and the Nimule land crossing with Uganda.

In addition to the PST missions and follow-up technical support missions, targeted technical support is also being provided to the 14 priority countries. At the request of the respective ministries of health, specialist technical staff in the areas of logistics, infection prevention and control, epidemiological surveillance, and emergency operations have been, or are in the process of being, deployed for periods of up to one month.

Training

A clinical case management training of trainers took place in Kampala, Uganda, from 23 to the 27 March, with participants from Ethiopia and Ghana.

A second training for francophone countries will take place in Senegal in the week of 27 April. Participants from Cameroon, Mauritania, Benin, Togo, Niger, Cote D’Ivoire, and Burkina Faso will attend this training. The PST will continue to support training at country level following the training of trainers.

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 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