Total confirmed cases (by week, 2015)

SUMMARY

No confirmed cases of Ebola virus disease (EVD) were reported in the week to 3 January. On 29 December, WHO declared that human-to-human transmission of Ebola virus has ended in Guinea, after the completion of 42 days with zero cases since the last person confirmed to have EVD received a second consecutive negative blood test for Ebola virus RNA. Guinea has now entered a 90-day period of heightened surveillance. Guinea, Liberia, and Sierra Leone have all now succeeded in interrupting human-to-human transmission linked to the original outbreak in West Africa.

Human-to-human transmission linked to the most recent cluster of cases in Liberia will be declared to have ended on 14 January 2016, 42 days after the 2 most-recent cases received a second consecutive negative test for Ebola virus, if no further cases are reported. In Sierra Leone, human-to-human transmission linked to the primary outbreak was declared to have ended on 7 November 2015. The country has now entered a 90-day period of enhanced surveillance scheduled to conclude on 5 February 2016.

The most recent cluster of cases in Liberia was the result of the re-emergence of Ebola virus that had persisted in a previously infected individual. Although the probability of such re-emergence events is low, the risk of further transmission following a re-emergence underscores the importance of implementing a comprehensive package of services for survivors that includes the testing of appropriate bodily fluids for the presence of Ebola virus RNA. The governments of Liberia and Sierra Leone, with support from partners including WHO and the US Centres for Disease Control and Prevention, have implemented voluntary semen screening and counselling programmes for male survivors in order to help affected individuals understand their risk and take necessary precautions to protect close contacts. 405 male survivors had accessed semen screening services up to 3 January 2016 in Liberia and Sierra Leone. A network of clinical services for survivors is also being expanded in Liberia and Sierra Leone, with plans for comprehensive national policies for the care of EVD survivors due to be completed in January 2016. To date approximately 3000 survivors have accessed basic care services.

In order to effectively manage and respond to the consequences of residual Ebola risks, Guinea, Liberia, and Sierra Leone have each put surveillance systems in place to enable health workers and members of the public to report any case of illness or death that they suspect may be related to EVD to the relevant authorities. In the week to 3 January, 645 alerts were reported in Guinea from 33 of the country’s 34 prefectures, with the vast majority of alerts (639) being reports of community deaths. Over the same period 9 operational laboratories in Guinea tested a total of 282 new and repeat samples (18 samples from live patients and 264 from community deaths) from only 16 of the country’s 34 prefectures. In Liberia, 633 alerts were received from all of the country’s 15 counties, the vast majority of which (529) were for live patients. The country’s 5 operational laboratories tested 588 new and repeat samples (420 from live patients and 168 from community deaths) for Ebola virus over the same period. In Sierra Leone 952 alerts were reported in the week to 3 January from all of the country’s 14 districts. The vast majority of alerts (878) were for community deaths. 976 new and repeat samples (8 from live patients and 968 from community deaths) were tested for Ebola virus by the country’s 8 operational laboratories over the same period.

The deployment of rapid-response teams following the detection of a new confirmed case continues to be a cornerstone of the national response strategy in Guinea, Liberia, and Sierra Leone. Each country has at least 1 national rapid-response team, with strengthening of national and subnational rapid-response capacity and validation of incident-response plans continuing throughout January.

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 3351 0 2083 Probable 453 * 453 Suspected 0 * ‡ Total 3804 0 2536 Liberia Confirmed 3151 - ‡ Probable 1879 - ‡ Suspected 5636 - ‡ Total 10 666 - 4806 Liberia** Confirmed 9 0 3 Probable * * ‡ Suspected ‡ * ‡ Total 9 0 3 Sierra Leone§ Confirmed 8704 0 3589 Probable 287 * 208 Suspected 5131 * 158 Total 14 122 0 3955 Total Confirmed 15 215 0 ‡ Probable 2619 * ‡ Suspected 10 767 * ‡ Total 28 601 0 11 300

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Figure 2: Geographical distribution of new and total confirmed cases in Guinea, Liberia, and Sierra Leone

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PHASE 3 RESPONSE FRAMEWORK 28 601 confirmed, probable, and suspected cases have been reported in Guinea, Liberia, and Sierra Leone, with 11 300 deaths (table 1; figure 1; figure 2) since the onset of the Ebola outbreak. The majority of these cases and deaths were reported between August and December 2014, after which case incidence began to decline as a result of the rapid scale-up of treatment, isolation, and safe burial capacity in the three countries. This rapid scale-up operation was known as phase 1 of the response, and was built on in the first half of 2015 during a period of continuous refinement to surveillance, contact tracing, and community engagement interventions. This period, termed phase 2, succeeded in driving case incidence to 5 cases or fewer per week by the end of July 2015. This marked fall in case incidence signalled a transition to a distinct third phase of the epidemic, characterised by limited transmission across small geographical areas, combined with a low probability of high consequence incidents of re-emergence of EVD from reservoirs of viral persistence. In order to effectively interrupt remaining transmission chains and manage the residual risks posed by viral persistence, WHO, as lead agency within the Interagency Collaboration on Ebola and in coordination with national and international partners, designed the phase 3 Ebola response framework. The phase 3 response framework builds on the foundations of phase 1 and phase 2 to incorporate new developments in Ebola control, from vaccines and rapid-response teams to counselling and welfare services for survivors. The indicators below detail progress made towards attaining the two primary objectives of the phase 3 framework. PHASE 3 RESPONSE INDICATORS

Key performance indicators for the phase 3 response framework are shown for Guinea, Liberia, and Sierra Leone (table 2). A full list of phase 3 response indicators can be found in annex 2.

Human-to-human transmission linked to the most recent cluster of cases in Liberia will be declared to have ended on 14 January 2016, 42 days after the 2 most-recent cases received a second consecutive negative test for Ebola virus, if no further cases are reported. Human-to-human transmission linked to the primary outbreak in Guinea was declared to have ended on 29 December 2015, 42 days after the country’s most recent case, reported on 29 October (figure 5), received a second consecutive negative blood test for Ebola virus RNA. The country has now entered a 90-day period of enhanced surveillance. In Sierra Leone, human-to-human transmission linked to the primary outbreak was declared to have ended on 7 November 2015. The country has now entered a 90-day period of enhanced surveillance scheduled to conclude on 5 February 2016.

Investigations into the origin of infection of the cluster of 3 confirmed cases of EVD reported from Liberia in the week to 22 November 2015 have established that the cluster arose as a result of a rare re-emergence of persistent virus from a survivor. Although the probability of such re-emergence events is low, the risk of further transmission following an incident of re-emergence underscores the importance of implementing a comprehensive package of services for survivors that includes the testing of appropriate bodily fluids for the presence of Ebola virus RNA. The governments of Liberia and Sierra Leone, with support from partners including WHO and US CDC, have implemented voluntary semen screening and counselling programmes for male survivors in order to help affected individuals understand their risk and take necessary precautions to protect close contacts. As of 3 January 2016, 405 males had been screened (Table 2; this number does not include individuals enrolled in viral persistence research studies).

A network of clinical services for survivors is also being expanded in Liberia and Sierra Leone, with plans for comprehensive national policies for the care of EVD survivors due to be completed in January 2016. Approximately 3000 survivors have accessed basic care services up to 3 January 2016 in the two countries (table 2). Planning is also underway in Guinea, but is currently at an earlier stage of development.

To manage and respond to the consequences of residual Ebola risks, Guinea, Liberia, and Sierra Leone have each put surveillance systems in place to enable health workers and members of the public to report any case of febrile illness or death that they suspect may be related to EVD to the relevant authorities. In the week to 3 January, 645 alerts were reported in Guinea from 33 of the country’s 34 prefectures, with the vast majority of alerts (639) being reports of community deaths. In Liberia, 633 alerts were received from all of the country’s 15 counties, the vast majority of which (529) were for live patients. In Sierra Leone 952 alerts were reported in the week to 3 January from all of the country’s 14 districts. The vast majority of alerts (878) were for community deaths.

As part of each country’s EVD surveillance strategy, blood samples or oral swabs should be collected from any live or deceased individuals who have or had clinical symptoms compatible with EVD. In the week to 3 January, 9 operational laboratories in Guinea tested a total of 282 new and repeat samples from only 16 of the country’s 34 prefectures. The trend in the number of samples tested each week has remained flat for the past two months but has shown a sharp fall this week. 94% of all samples tested in Guinea were swabs collected from dead bodies. By contrast, 71% of the 588 new and repeat samples tested in Liberia over the same period were blood samples collected from live patients. In addition, 14 of the 15 counties in Liberia submitted samples for testing by the country’s 5 operational laboratories. 976 new and repeat samples were collected from all 14 districts in Sierra Leone and tested by 8 operational laboratories. 99% of samples in Sierra Leone were swabs collected from dead bodies (table 2; figures 3 and 4).

639 deaths in the community were reported from Guinea in the week to 3 January through the country’s alert system (table 2). This represents approximately 28% of the 2248 community deaths expected based on estimates of the population and a crude mortality rate of 11 deaths per 1000 people per year. 104 deaths in the community were reported from Liberia over the same period, representing approximately 11% of the 982 community deaths expected per week. 878 deaths in the community were reported from Sierra Leone over the same period, representing approximately 42% of the 2075 community deaths expected per week.

The deployment of rapid-response teams following the detection of a new confirmed case continues to be a cornerstone of the national response strategy in Guinea, Liberia, and Sierra Leone. Each country has at least 1 national rapid-response team (table 2), with strengthening of national and subnational rapid-response capacity and validation of incident-response plans continuing through December 2015 and January 2016.

Table 2: Key performance indicators for phase 3 in Guinea, Liberia, and Sierra Leone in the week to 3 January 2016

All data provided by WHO country offices. For definitions of key performance indicators see Annex 1. §Number of estimated survivors not yet confirmed. *Data correspond to the week ending 13 December 2015. **Number of male survivor’s semen tested positive not yet reported. #Data correspond to the week ending 20 December 2015

Figure 3: Location of laboratories and geographical distribution of samples from live patients in Guinea, Liberia, and Sierra Leone in the week to 3 January 2016

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Figure 4: Location of laboratories and geographical distribution of samples from dead bodies in Guinea, Liberia, and Sierra Leone in the week to 3 January 2016

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Figure 5: Time since last confirmed case in Guinea, Liberia, and Sierra Leone

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PREVIOUSLY AFFECTED COUNTRIES

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.

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, Ethiopia, Gambia, Ghana, Mauritania, Niger, 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.

From October 2014 to January 2016, WHO has undertaken over 347 field deployments to work with ministries of health to address gaps or as part of multi-partner teams to support preparedness efforts and to assist with the implementation of national plans.

Over the past 12 months, technical assistance in priority countries has led to significant progress in Ebola preparedness. The Preparedness Dashboard demonstrates an increase in overall preparedness at the country-level from 19% (at baseline) to 62% (31 December 2015) among the priority countries. Furthermore, 11 of the 14 countries have achieved a score of 50% against the Ebola Preparedness Checklist, which signals they are equipped to test their response systems.

Contingency stockpiles of PPE are in place in all countries on the African continent and at the United Nations Humanitarian Response Depots in Accra and Dubai where they are available to any country in the event that they experience a shortage.

Ongoing follow-up support to priority countries

After a phase of targeted activities to strengthen Ebola preparedness, WHO is now strengthening preparedness for a broader range of risks and extending activities to other countries including Chad, Democratic Republic of Congo, Guinea, Liberia, Malawi, Sierra Leone, Tanzania, and Uganda.

Technical support is provided at the request of the respective ministries of health to strengthen emergency preparedness for health emergencies by operationalizing plans, testing systems, building capacity, and providing technical guidance.

Current priority activities target six interlinked areas at the country level: national mechanisms for coordinating health emergencies, surveillance for early detection, rapid response, outbreak operations and logistics, system testing, infection prevention and control, and occupational health and safety.

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, Guinea-Bissau, Mauritania, Niger, Senegal, and Togo.

Training, exercises, and simulations

Priority countries that have achieved a minimum of 50% implementation of Ebola preparedness checklist activities are encouraged to test outbreak preparedness and response by undertaking a series of skill drills and simulations on elements of an EVD response.

Two technical staff have been appointed and are currently working with high priority countries to conduct needs assessment for surveillance training.

In Togo, WHO will be providing support to the Ministry of Health with risk mapping to prioritise risks and develop targeted preparedness plans in January 2016.

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: EBOLA RESPONSE PHASE 3 KEY PERFORMANCE INDICATORS

ANNEX 2: KEY EBOLA RESPONSE PHASE 3 PERFORMANCE INDICATORS