Total confirmed cases (by week, 2015)

SUMMARY

There were 4 confirmed cases of Ebola virus disease (EVD) reported in the week to 27 September, all in Guinea. Case incidence has remained below 10 cases per week since the end of July this year. Over the same period, transmission of the virus has been geographically confined to several small areas in western Guinea and Sierra Leone, marking a transition to a distinct, third phase of the epidemic. Improvements to case investigation and contact tracing, rapid isolation and treatment, and effective engagement with affected communities have all played a part in reducing case incidence to its current low level. A refined phase-3 response coordinated by the Interagency Collaboration on Ebola will build on these measures to drive case incidence to zero, and ensure a sustained end to EVD transmission. Enhanced capacity to rapidly identify a reintroduction (either from an area of active transmission or from an animal reservoir), or re-emergence of virus from a survivor, improved testing and counselling capacity as part of a comprehensive package to safeguard the welfare of survivors, and the increased use of innovative technologies—from vaccines to rapid diagnostic tests—are central to the phase-3 response framework.

coordinated by the Interagency Collaboration on Ebola will build on these measures to drive case incidence to zero, and ensure a sustained end to EVD transmission. Enhanced capacity to rapidly identify a reintroduction (either from an area of active transmission or from an animal reservoir), or re-emergence of virus from a survivor, improved testing and counselling capacity as part of a comprehensive package to safeguard the welfare of survivors, and the increased use of innovative technologies—from vaccines to rapid diagnostic tests—are central to the phase-3 response framework. All 4 confirmed cases reported from Guinea this week had symptom onset in Forecariah, and are registered contacts of a 10-year-old girl who sought treatment in Forecariah after traveling from the Ratoma area of the capital, Conakry. She subsequently died on 14 September in the Forecariah sub-prefecture of Kaliah. Two of the 4 new cases are traditional healers who are reported to have treated the girl. Over 450 contacts are under follow-up in Guinea, including 1 in the prefecture of N’Zerekore due to the movement of a contact associated with the Ratoma chain of transmission. The majority of contacts (311) are located in Forecariah, with 147 in Conakry. All contacts are associated with the Ratoma chain of transmission. From 28 September to 1 October an active case-finding operation is taking place in the Conakry districts of Dixinn and Ratoma during which approximately 900 households will be visited.

No new confirmed cases were reported from Sierra Leone in the week to 27 September: the second consecutive week with zero cases. Over 700 contacts remain under follow-up in Bombali related to the last reported case on 13 September. All contacts associated with the Kambia chain of transmission were scheduled to complete follow-up on 28 September.

Robust surveillance measures are essential to ensure the rapid detection of any reintroduction or re-emergence of EVD in currently unaffected areas. A total of 784 samples were tested by 8 operational laboratories in Guinea in the week to 27 September. Analyses of the geographical distribution of samples collected indicate that 18 of 34 Guinean prefectures did not collect any samples from either live or dead suspected cases of EVD over the 1-week period. In Liberia, 1373 samples were collected from 100% (15 of 15) of counties in the week to 27 September. Laboratory capacity in the country has increased following the opening of a laboratory in Montserrado, bringing the total number of operational laboratories in the country to 4. Over the same period, 1969 samples were collected from 100% (14 of 14) of districts in Sierra Leone and tested by 9 operational laboratories. Surveillance in the three countries will be enhanced in line with the phase-3 response framework.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

Since the beginning of the outbreak there have been a total of 28 388 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia, and Sierra Leone (figure 1, table 1) up to 27 September, with 11 296 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). Four new cases, all from Guinea, were reported in the week to 27 September.

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 years of age are approximately four times more likely to be affected in Guinea and Liberia, and three times more likely to be affected in Sierra Leone. Adults aged 45 years and above are approximately five times more likely to be affected in Guinea, and approximately four times more likely in Liberia and Sierra Leone.

No new health worker infections were reported in the week to 27 September. Since the start of the outbreak a total of 881 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 513 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 3344 6 2080 Probable 453 * 453 Suspected 8 * ‡ Total 3805 6 2533 Liberia§ Confirmed 3151 - ‡ Probable 1879 - ‡ Suspected 5636 - ‡ Total 10 666 - 4806 Liberia** Confirmed 6 0 2 Probable * * ‡ Suspected ‡ * ‡ Total 6 0 2 Sierra Leone Confirmed 8704 5 3589 Probable 287 * 208 Suspected 4920 * 158 Total 13 911 5 3955 Total Confirmed 15 205 11 ‡ Probable 2619 * ‡ Suspected 10 564 * ‡ Total 28 388 11 11 296

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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 1596

(29) 1742

(32) 532

(11) 1902

(41) 861

(55) Liberia§ 1911

(96) 1838

(93) 561

(33) 2060

(121) 703

(132) Sierra Leone 4823

(169) 5118

(176) 1992

(82) 5636

(218) 2140

(290)

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Figure 2: Geographical distribution of confirmed cases reported in the week to 27 September 2015

Table 3: Cases and contacts by district/prefecture 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 27 September 2015 for Guinea and Sierra Leone.

Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 27 September 2015

Sub-prefectures/chiefdoms that reported one or more confirmed cases in the 7 days to 27 September 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.

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 196 100 Liberia* 378 192 Sierra Leone 307 221‡ Total 881 513

GUINEA

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

Four new confirmed cases were reported from Guinea during the week ending 27 September (table 3, table 4, figure 2, figure 3). All 4 cases were reported from Forecariah, and are registered contacts of the 10-year old girl who was identified as an EVD-positive community death in Forecariah the previous week. She had travelled with her family to Forecariah after developing symptoms at home in the Ratoma area of the capital Conakry, and visited traditional healers in the Forecariah sub-prefecture of Kaliah before her death on 14 September. Two of the 4 new cases (both males, 26 and 46 years of age) are traditional healers. A wife of one of the traditional healers also tested positive for EVD a day after her husband. The remaining case is the sister of the 10-year-old girl. There are over 300 contacts (table 3) who have been identified in Forecariah in association with the movement of the 10-year-old girl, with approximately 150 contacts in Conakry associated with same chain of transmission.

The Ebola ça suffit! ring vaccination trial is continuing in Guinea. All rings comprised of contacts and contacts of contacts associated with confirmed cases now receive immediate vaccination with the rVSV-ZEBOV Ebola vaccine. Previously, rings were randomly allocated to receive either immediate vaccination or vaccination 21 days after the confirmation of a case. On 1 September, the eligibility criteria for the trial were amended to allow the vaccination of children aged 6 years and above.

From 28 September to 1 October Operation Porte-a-Porte will take place in the Conakry districts of Dixinn and Ratoma. Approximately 900 households will be visited during the operation, which will focus on active case finding and community engagement. Infection prevention and control (IPC) teams will also visit all health facilities within the area of operation to strengthen IPC capacity.

458 contacts were under follow-up on 27 September in Guinea in two adjacent prefectures, Conakry (147 contacts) and Forecariah (311 contacts). The prefecture of N’Zerekore also hosts a single contact. All contacts in Guinea are associated with the Ratoma chain of transmission.

There was 1 (0.2%) unsafe burial reported in Guinea out of 521 reported community deaths during the week to 27 September, compared with 4 (0.8%) unsafe burials out of 520 reported community deaths during the previous week.

Including both initial and repeat testing, a total of 784 laboratory samples were tested in the week to 27 September. Most tests (82% in the week to 27 September) are of post-mortem swabs taken to rule out EVD as the cause of death (figure 7, figure 8). Analyses of the geographical distribution of samples tested indicate that no samples from live or dead suspected cases of EVD were tested from over half (18 of 34) of Guinean prefectures during the week to 27 September (figure 7, figure 8). Most of the 18 prefectures with zero samples tested are located in the north and east of the country. Locations of the 8 operational laboratories in Guinea are shown in figure 8.

Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 6. No health worker infections were reported in the week to 27 September.

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.

No new confirmed cases were reported from Sierra Leone in the week to 27 September. This is the second consecutive week that the country has recorded zero cases.

The Ebola ça suffit! ring vaccination Phase 3 efficacy trial of the rVSV-ZEBOV vaccine has now been extended from Guinea to Sierra Leone. Contacts and contacts of contacts associated with new confirmed cases and who meet the trial’s eligibility criteria will therefore be offered the vaccine.

Over 750 contacts have been identified in association with the single case reported from Bombali on 13 September (table 3): a 16 year-old girl identified as EVD-positive after post-mortem testing. All contacts associated with the Kambia chain of transmission were scheduled to complete follow-up on 28 September.

Locations of the 10 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 6. No health worker infections were reported in the week to 27 September.

Laboratory indicators continue to reflect a heightened degree of vigilance, with 1969 new samples from all 14 Sierra Leonean districts tested in the week to 27 September (figure 7, figure 8). Most tests (77% in the week to 27 September) are of post-mortem swabs taken to rule out EVD as the cause of death (figure 7, figure 8).

In the week to 27 September there were 199 alerts of people who showed any symptom compatible with EVD, all of which were responded to within the same day. During the same period, there were 1647 notifications of burials, of which 1617 (96%) were responded to within the same day.

Locations of the 8 operational laboratories in Sierra Leone are shown in figures 7 and 8.

Table 7: Key performance indicators for Sierra Leone

For definitions of key performance indicators see Annex 2. Data are for 7-day periods. §One unsafe burial reported in the district of Pujehun. ‡Data missing for 7–14% of cases. #Outcome data missing for 0–77% of hospitalized, confirmed cases.

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

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Figure 6: Location of Ebola treatment centres and time since last confirmed case in Guinea, Liberia, and Sierra Leone

OTHER AFFECTED AND PREVIOUSLY AFFECTED COUNTRIES

Liberia was declared free of Ebola virus transmission in the human population on 3 September 2015, 42 days after the country’s last laboratory-confirmed case completed treatment and was confirmed as EVD-negative. It is now 78 days since symptom onset of the last reported confirmed case (figure 6). The country has now entered a 90-day period of heightened surveillance. 1373 samples were collected from all of the country’s 15 counties in the week to 27 September. Laboratory capacity in the country has increased following the opening of a laboratory in Montserrado, bringing the total number of operational laboratories in the country to 4. 88% of samples were blood samples taken from live suspect cases in the week to 27 September.

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 laboratories and geographical distribution of samples from live patients in Guinea, Liberia, and Sierra Leone

Figure 8: Location of laboratories and geographical distribution of samples from dead bodies in Guinea, Liberia, and Sierra Leone

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.

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 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.

From October 2014 to September 2015, WHO has undertaken 286 field deployments to priority countries to assist with the implementation of national plans.

WHO provides personal protective equipment (PPE) modules containing minimum stocks to cover staff protection and other equipment needs to support 10 patient-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 a 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 initial PST assessment missions to the 14 priority countries in 2014, a second phase of preparedness-strengthening activities have provided support on a country-by-country basis. Activities in the week to 30 September are highlighted below.

In Guinea-Bissau, preparedness support continues to be provided at the central level, and in two priority regions (Tombali and Gabu) through WHO sub-offices. Significant improvements in waste management and infection prevention and control have been noted at the regional health centres, and training will be provided on the use of incinerators and waste management in the coming week.

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, offer specific technical support in their respective areas of expertise, and develop capacity of national WHO staff. Preparedness officers are currently deployed to Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Ghana, Guinea-Bissau, Mali, Mauritania, Niger, 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 a series of drills on elements of an EVD response and a functional exercise to test the coordination of the Ebola operations centre.

Simulation exercises aimed at testing preparedness capabilities are being planned in Benin, Burkina Faso, Ethiopia, Ghana, Guinea Bissau, Mauritania, Niger and Togo and will start in the coming weeks or months.

Logistics training is currently being organised in collaboration with the Bioforce Institute, and is planned for mid-November and December. The training will involve ministry of health logisticians, and will help to strengthen the ability of a country to implement relevant logistics capacities swiftly and efficiently, in the event of an outbreak.

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 that share a border with 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