Total confirmed cases (by week, 2015)

SUMMARY

There were 20 confirmed cases of Ebola virus disease (EVD) reported in the week to 21 June, compared with 24 cases the previous week. Weekly case incidence has stalled at between 20 and 27 cases since the end of May, whilst cases continue to arise from unknown sources of infection, and to be detected only after post-mortem testing of community deaths. In Guinea, 12 cases were reported from the same 4 prefectures as reported cases in the previous week: Boke, Conakry, Dubreka, and Forecariah. In Sierra Leone, 8 cases were reported from 3 districts: Kambia, Port Loko, and the district that includes the capital, Freetown, which reported confirmed cases for the first time in over 2 weeks.

Although cases have been reported from the same 4 prefectures in Guinea for the past 3 weeks, the area of active transmission within those prefectures has changed, and in several instances has expanded.

In the northern prefecture of Boke, which borders Guinea-Bissau, the main focus of transmission has switched from the coastal sub-prefecture of Kamsar to the more urbanised sub-prefecture of Boke Centre. Of particular concern, 2 of the cases reported from Boke in the week to 21 June were health workers.

The single case reported this week from Conakry was from the Matam area of the city, and arose from an unknown source of infection. Three cases reported over the previous 2 weeks in Conakry are suspected to have generated a large number of high-risk, untraced contacts.

As has been the case for several months, the prefecture of Forecariah continues to be the most complex in terms of transmission, with multiple chains of transmission active across 3 sub-prefectures. Three of the 5 cases reported from Forecariah in the week to 21 June arose from an unknown chain or chains of transmission, and 2 of those 3 cases were reported from a sub-prefecture, Benty, that has not reported a confirmed case since mid-March. Both cases from Benty and another possibly related case from a neighbouring sub-prefecture were identified after the post-mortem testing of community deaths.

Compared with Guinea, transmission in Sierra Leone has been more geographically confined over the past 3 weeks, with cases clustered in several chiefdoms of Kambia and Port Loko districts. However, the week to 21 June saw 2 cases reported from Marampa chiefdom in Port Loko for the first time since the beginning of March. The cases were a mother who died during childbirth, and her newly born child, and are associated with a large number of high-risk contacts. Two cases were also reported from the area that includes the capital, Freetown, for the first time in over 2 weeks. Both cases arose in the densely populated Magazine Wharf area of the city, and although one case has an epidemiological link to a previous case, both cases are associated with multiple high-risk contacts.

Only 6 of the 12 cases reported from Guinea and 4 of the 8 cases reported from Sierra Leone in the week to 21 June were registered contacts of previous cases. Four of the 20 cases reported were identified after post-mortem testing of community deaths. On 21 June there were 2003 contacts being monitored across 4 prefectures in Guinea, with 1023 contacts were under follow-up in 3 districts in Sierra Leone.

After over 2 months with no new health worker infections in Guinea, 2 new health worker infections were reported from Boke. In Sierra Leone a new health worker infection was reported for the first time since 14 May. There have been a total of 872 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 27 443 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11 207 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 12 new confirmed cases were reported in Guinea and 8 in Sierra Leone in the 7 days to 21 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), 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.

A total of 872 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 3257 34 2030 Probable 443 * 443 Suspected 18 * ‡ Total 3718 34 2473 Liberia§ Confirmed 3151 0 ‡ Probable 1879 * ‡ Suspected 5636 * ‡ Total 10 666 0 4806 Sierra Leone Confirmed 8657 37 3562 Probable 287 * 208 Suspected 4115 * 158 Total 13 059 37 3928 Total Confirmed 15 065 71 ‡ Probable 2609 * ‡ Suspected 9769 * ‡ Total 27 443 71 11 207

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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 1563

(29) 1689

(31) 508

(11) 1859

(40) 840

(54) Liberia§ 1911

(96) 1838

(93) 561

(33) 2060

(121) 703

(132) Sierra Leone 4768

(167) 5050

(174) 1966

(81) 5561

(215) 2116

(286)

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Figure 2: Geographical distribution of confirmed cases reported in the week to 21 June 2015

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

Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 21 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 189 94 Liberia* 378 192 Sierra Leone 305 221‡ Total 872 507

GUINEA

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

Twelve confirmed cases were reported from 4 prefectures—Boke, Conakry, Dubreka, and Forecariah—in the 7 days to 21 June (table 3, table 4, figure 2, figure 3). All cases reported from Guinea over the past 3 weeks have come from the same 4 prefectures, but the areas of active transmission within these prefectures has changed and, in some cases, expanded.

In the northwestern prefecture of Boke, which borders Guinea-Bissau, the main focus of transmission has switched from the coastal sub-prefecture of Kamsar to the more urbanised sub-prefecture of Boke Centre (table 3, table 4, figure 2). There is no clear link between chains of transmission in the two areas, with the single case reported from Kamsar in the week to 21 June arising from an unknown source of transmission. All 4 of the cases reported from Boke Centre were registered contacts of a previous case. Of particular concern, however, the case from Kamsar and one of those from Boke Centre are health workers.

The single case reported from Conakry came from the Matam area of the city. Unlike other cases reported in Conakry over the past month, which all acquired infection elsewhere before travelling to the capital, this most recent case arose from an unknown source of infection. Three cases reported over the previous 2 weeks in the city are suspected to have generated a large number of high-risk, untraced contacts.

In Dubreka, a single case was reported from the sub-prefecture of Tanene. Although the origin of the case is not known, preliminary investigations indicate it is linked to previous cases in the same sub-prefecture.

The remaining 5 cases in Guinea were reported from the prefecture of Forecariah (figure 2, table 3, table 4), which continues to be the most widely affected prefecture. Cases were reported from 3 sub-prefectures in the week to 21 June, including one, Benty, which had not reported a case since mid-March. Both of the cases reported from Benty and the single case reported from Farmoriah sub-prefecture are thought to be linked to the same previously undetected chain of transmission. All 3 cases were detected after post-mortem testing of community deaths, and it is highly likely that further cases will be generated from the same chain of transmission. The remaining 2 cases from Forecariah were reported from the sub-prefecture of Sikhourou. Both cases were registered contacts.

Overall, 6 (50%) of the 12 cases reported from Guinea in the week to 21 June were registered contacts. As at 21 June there were 2003 contacts being monitored across 4 Guinean prefectures (table 3). Of the 6 cases that arose from unknown sources of infection, 3 were detected after post-mortem testing of community deaths.

The number of unsafe burials reported from Guinea was the same as the previous week but decreased as a proportion of all recorded community deaths, at 15 (3%) unsafe burials out of 459 recorded community deaths in the week to 21 June compared with 15 (4%) of 355 recorded community deaths in the week to 14 June.

Including both initial and repeat testing, a total of 671 laboratory samples were tested in the week to 21 June. Between 30 May and 14 June, over 80% of samples were collected post-mortem. In the week to 14 June, almost two-thirds of samples were collected in two prefectures: Conakry (50%) and Forecariah (15%). No samples were collected in 20 prefectures during the same period.

Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7; 1 new ETC remains under construction in Boke. Two health worker infections were reported in Guinea in the week to 21 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 8 confirmed cases were reported from 3 districts (Kambia, Port Loko, and Western Area Urban) in the week to 21 June (table 3, figure 2, figure 3, figure 5, figure 6).

Both cases in Kambia were reported from Tonko Limba chiefdom, which has been the primary focus of transmission in Kambia for the past 3 weeks. Both cases are registered contacts and were residing in a quarantined dwelling at the time of symptom onset.

Half (4) of all cases reported from Sierra Leone in the week to 21 June were reported from Port Loko. Two cases were reported from Kaffu Bullom chiefdom, which has been the origin of the majority of cases reported from Sierra Leone over the past 3 weeks. One of the cases, a health worker, is a registered contact of a previous case and was quarantined at the time of symptom onset. However, the remaining case reported from Kaffu Bullom arose from an as-yet unknown source of transmission. In addition, 2 cases were reported from the Marampa chiefdom for the first time since early March. Although the origin of infection is known for both cases, the circumstances in which infection was detected—post-mortem testing of a woman who died during childbirth, and the subsequent testing of her child—mean there is a substantial risk of further transmission.

Two cases reported from the Magazine Wharf area of the capital, Freetown, represent the first confirmed cases in Western Area Urban for over 2 weeks. One case has an epidemiological link to a previous case, and both cases are associated with multiple high-risk contacts.

Overall, 4 (50%) of the 8 cases reported from Sierra Leone in the week to 21 June were registered contacts of a previous case (table 4). As at 21 June, total of 1023 contacts were being monitored in 3 districts: Kambia, Port Loko, and Western Area Urban (table 3).

No data are available on the number of reported unsafe burials for the most recent week. However, investigations are underway into a series of anecdotal reports of unsafe burials in the capital, Freetown.

In the week to 21 June, 99% of 375 credible reports of sick people with possible EVD-like symptoms were responded to within 24 hours. More than two-thirds (67%) of reports came from Freetown and the surrounding rural area. In addition, 1614 reports of deaths were received during the same period, 99% of which were responded to within 24 hours, with a roughly even geographical distribution taking population density into account. The health worker infection reported from Port Loko was the first in Sierra Leone since 14 May. 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 1899 new samples tested in the week to 21 June: the third consecutive weekly increase in new samples tested. Less than 1% tested positive for EVD. Between 30 May and 14 June, over 80% of samples were collected post-mortem. All districts submitted samples for testing over the 2-week period, with most samples collected in Freetown (12%) and Port Loko (10%) in the week to 14 June. The eastern Kailahun submitted the fewest samples for testing, accounting for 1% of the total.

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 21 June, an average of 33 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 09/06/2015 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 support each national plan fully; Contribute to the International Health Regulations (2005) strengthening of national core capacities and the resilience of health systems.

A technical support mission is deployed to The Gambia this week (22 to 26 June) to strengthen clinical management capacity in Ebola Treatment Centres and other health facilities. Training on various aspects of EVD response, coordination, planning and budgeting will also be reviewed.

Two epidemiologists and 2 community engagement experts have been deployed to Guinea-Bissau to provide additional support to the regions of Tombali and Gabu, both of which border Guinea. I addition, a preparedness strengthening mission deployed to the country from 17 to 21 June to support contingency planning and further strengthening of capacities to deal with an imported case. A cross-border meeting of partners from Guinea, Guinea-Bissau, Senegal, and The Gambia is planned for 29 June.

In Cote d’Ivoire, WHO is supporting the organization of exercises to simulate the introduction of an EVD case in regions that border Guinea and Liberia.

An infection prevention and control specialist is currently deployed to Benin.

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 WHO Team supported the Centre des Operations d’Urgence Sanitaire (COUS) to run a simulation exercise to assess capacity to detect a suspect case at a point of entry, patient isolation, epidemiological investigation, patient transport, contact tracing, safe burial, and overall coordination and communication. The main areas identified for further strengthening include the use of standard operating procedures and clarification of roles.

In Togo, WHO supported the regional training of trainers on EVD infection prevention and control from 5 to 22 June. 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 long-term strategic development and maintenance of health security preparedness.

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