Total confirmed cases (by week, 2015)

SUMMARY

There were 7 confirmed cases of Ebola virus disease (EVD) reported in the week to 26 July: 4 in Guinea and 3 in Sierra Leone. This is the lowest weekly total for over a year, and comes after 8 consecutive weeks during which case incidence had plateaued at between 20 and 30 cases per week. Although this decline in case incidence is welcome, it is too early to tell whether it will be sustained. There have been several high-risk events in both Guinea and Sierra Leone in the past 14 days, and past experience has shown that it can take a single high-risk case or missed contact to spark a new cluster of cases. In addition, there are over 2000 contacts still within their 21-day follow-up period in Guinea, Liberia, and Sierra Leone, representing a substantial residual risk of further cases. Refinements to the response continue to yield improvements, with recent weeks seeing a higher proportion of cases arising from contacts and a lower proportion of cases identified post-mortem than at any time previously, but the continued occurrence of high-risk transmission events means that an increase in case incidence in the near term is a strong possibility.

In Guinea, cases were restricted to a small geographical area in Conakry (3 cases) and the nearby prefecture Coyah (1 case). The large prefecture of Forecariah, which has seen widespread transmission since the start of the year, reported no cases for the first time since January 2015, although there are still over 700 contacts under follow-up in the prefecture. For the first time in the outbreak, all cases reported from Guinea were registered contacts. All 3 of the cases from Conakry were registered contacts associated with a chain of transmission that originated in the prefecture of Dubreka. The remaining case from Coyah was a registered contact associated with a chain of transmission that originated in Forecariah. For the first time since September 2014, no EVD-positive community deaths were reported from Guinea.

No new cases were reported from Liberia in the week to 26 July. Of the 6 confirmed cases reported since 29 June, 2 have died, and the remaining 4 have now all been discharged after treatment. There are currently 33 contacts under follow-up in Liberia, all of whom will have completed the 21-day follow-up period by 2 August.

The 3 confirmed cases in Sierra Leone were reported from Freetown (2 cases) and Tonkolili (1 case). Both cases from Freetown were registered contacts who were residing in a voluntary quarantine facility at the time of symptom onset, and were rapidly isolated. The remaining case from Tonkolili, a district east of Freetown in the centre of the country, is assessed as posing a substantial risk of further transmission. The case travelled to Tonkolili from an area near the Magazine Wharf neighbourhood of Freetown on 16 July, and died on 23 July in a community hospital, where he was confirmed EVD-positive after post-mortem testing. The case visited at least two health facilities between 19 and 21 July, and over 500 contacts have been identified so far. Investigations are ongoing to establish the source of infection and identify and trace all contacts.

One new health worker infection was reported from Conakry, Guinea, in the week to 26 July. Guinea has reported health worker infections in 5 of the past 6 weeks. No health worker infections were reported from Sierra Leone, but several health workers are listed as contacts of the case in Tonkolili. There have been a total of 880 confirmed health worker infections reported from Guinea, Liberia, and Sierra Leone since the start of the outbreak, with 510 reported deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 27 748 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1) up to 26 July, with 11 279 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 4 new confirmed cases were reported in Guinea and 3 in Sierra Leone in the week to 26 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 the week to 26 July, from Conakry in Guinea. Since the start of the outbreak a total of 880 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 510 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 3326 39 2069 Probable 451 * 451 Suspected 9 * ‡ Total 3786 39 2520 Liberia§ Confirmed 3151 - ‡ Probable 1879 - ‡ Suspected 5636 - ‡ Total 10 666 - 4806 Liberia** Confirmed 6 3 2 Probable 0 * ‡ Suspected ‡ * ‡ Total 6 3 2 Sierra Leone Confirmed 8694§ 20 3585 Probable 287 * 208 Suspected 4309 * 158 Total 13 290 20 3951 Total Confirmed 15 177 62 ‡ Probable 2617 * ‡ Suspected 9954 * ‡ Total 27 748 62 11 279

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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 1588

(29) 1732

(32) 527

(11) 1891

(41) 857

(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 26 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 26 July for Guinea and Sierra Leone (27 July for Tonkolili) and data as of 22 July for Liberia. ‡Includes Freetown. **On 23 July 2015, one case reported from Port Loko on 17 July 2015 was reclassified as a non-case following a review of epidemiological and laboratory data.

Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 26 July 2015

Sub-prefectures/chiefdoms/districts that reported one or more confirmed cases in the 7 days to 26 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. ¶On 23 July 2015, one case reported from Port Loko on 17 July 2015 was reclassified as a non-case following a review of epidemiological and laboratory data.

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 195 97 Liberia* 378 192 Sierra Leone 307 221‡ Total 880 510

GUINEA

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

4 confirmed cases were reported from 2 adjacent prefectures—Conakry and Coyah—in the week to 26 July (table 3, table 4, figure 2, figure 3).

Most cases were reported from Conakry for the third successive week. All 3 cases from Conakry are registered contacts linked to a chain of transmission that originated in the Tanene sub-prefecture of Dubreka. However, one of the cases is a health worker, and is associated with a large number of contacts.

One case was reported from the prefecture of Coyah, just to the northeast of Conakry. The case is a registered contact associated with a chain of transmission that originated from the sub-prefecture of Benty in Forecariah.

For the first time in 27 weeks, no cases were reported from the prefecture of Forecariah.

All cases in Guinea were registered contacts: the highest reported proportion since the onset of the outbreak. In addition, no EVD-positive community deaths were reported in Guinea for the first time since September 2014.

On 26 July there were 1540 contacts being monitored across 6 Guinean prefectures (table 3). The majority of contacts (715) are now associated with the chains of transmission active in Conakry. 701 contacts are under follow-up in Forecariah.

There were 9 (2%) unsafe burials reported in Guinea out of 484 recorded community deaths in the week to 26 July, compared with 5 (1%) unsafe burials out of 500 recorded community deaths in the previous week.

Including both initial and repeat testing, a total of 868 laboratory samples were tested in the week to 26 July. This is the second highest reported number of samples tested in a week in Guinea since the outbreak began.

Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7. One health worker infection was reported from Conakry in the week to 26 July. Guinea has reported health worker infections in 5 out of the past 6 weeks.

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.

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 3 confirmed cases were reported from 2 districts (Freetown and Tonkolili) in the week to 26 July (table 3, figure 2, figure 3, figure 5, figure 6).

Two cases were reported from the capital, Freetown. Both cases from Freetown were registered contacts who were residing in a voluntary quarantine facility at the time of symptom onset, and were rapidly isolated.

The remaining case from Tonkolili is assessed as posing a substantial risk of further transmission. The case travelled to Tonkolili from an area close to the Magazine Wharf neighbourhood of Freetown on 16 July, but was not a registered contact of any case from the Magazine Wharf transmission chain. On 19 July the case attended a community hospital complaining of a headache, and was treated as an outpatient and discharged. Two days later on 21 July the case presented to a different hospital and was isolated on admission. The patient died on 23 July and was confirmed EVD-positive after post-mortem testing. Over 500 contacts have been listed so far, several of whom are deemed to be high risk. Investigations are ongoing to establish the source of infection and identify and trace all contacts.

On 26 July, a total of 279 contacts were being monitored in 4 districts: Kambia, Port Loko, Western Area Rural, and Western Area Urban (table 3). On 27 July, 537 contacts were reported in the district of Tonkolili, in relation to the newly confirmed case.

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 1918 new samples tested in the 7 days to 26 July. Fewer 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. §Laboratory data missing for 14 July. ‡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. As of 23 July 2015, one case reported from Port Loko on 17 July 2015 was reclassified as a non-case following a review of epidemiological and laboratory data.

Figure 5: Confirmed weekly Ebola virus disease cases reported nationally and by district from Sierra Leone

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 45 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. Of the 6 confirmed cases reported since 29 June, 2 have died, and the remaining 4 have now all been discharged after treatment. There are currently 33 contacts under follow-up: 16 contacts in Margibi, all of whom will have completed 21-day follow-up on 1 August; and 17 contacts in Montserrado, all of whom will have completed follow-up on 2 August. 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.

Seven countries (Italy, 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 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 table-top 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 July 2015 WHO has undertaken over 266 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. In addition, all countries have received one PPE training module.

Contingency stockpiles of PPE are in place in the United Nations Humanitarian Response Depots (UNHRD) 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 that share a border with Guinea to enhance event-based surveillance and to support two 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 reporting between the border locations and EOCs are taking place to ensure a heightened state of alertness and timely information sharing. A weekly progress update to identify and address any issues has been established. Regular meetings for infection prevention and control (IPC), social mobilization, and rapid-response team technical subgroups have also been established. Community-level activities (surveillance, social mobilization, and safe and effective triage of suspected cases) have been reinforced. The practice of swabbing 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 of WHO/WFP logistics framework agreement.

In Côte d’Ivoire, training in Ebola clinical care and IPC in Guiglo and Toulepleu is planned for September 2015.

In Mali, an EVD EOC functional exercise is taking place from 27 July to 1 August. A team of three facilitators has been deployed to support the exercise.

In Cameroon, there is a planned country follow-up mission from 11 to 14 August with an emphasis on surveillance, logistics and points of entry.

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 are 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.

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, and technical institutions and networks in the Global Outbreak Alert and Response Network (GOARN). 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, 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