Corrected on 23 April 2015

Total confirmed cases (by week, 2015)

SUMMARY

The decline in confirmed cases of Ebola virus disease (EVD) has halted over the last three weeks. To accelerate the decline towards zero cases will require stronger community engagement, improved contact tracing and earlier case identification. In the week to 19 April, a total of 33 confirmed cases was reported, compared with 37 and 30 in the preceding weeks.

In the week to 19 April, Guinea reported 21 confirmed cases, compared with 28 cases the previous week. Sierra Leone reported 12 confirmed cases, compared with 9 cases reported the previous week. Liberia reported no confirmed cases.

A total of 4 Guinean prefectures reported at least one confirmed case in the week to 19 April, compared with 5 the previous week. Transmission remains confined to the west of the country and is primarily focused on the prefecture of Forecariah, bordering Sierra Leone, which reported 86% of national confirmed cases.

In Sierra Leone, Western Area Urban, which includes the capital Freetown, reported 6 confirmed cases, which represent half of the cases reported nationally, a slight increase from 4 cases the previous week. Koinadugu, which borders Guinea to the north, reported 1 new confirmed case of unknown origin. Other districts reporting new confirmed cases were Kambia (4 cases) and Port Loko (1 case) in the west of the country. In the week to 19 April, 4 districts reported at least one confirmed case compared to 3 districts the previous week.

Response indicators from Sierra Leone present a mixed picture. The number of EVD-positive deaths that were identified in the community after post-mortem testing was 3 (1 in Kambia, 1 in Western Area Urban, 1 in Koinadugu) in the week to 19 April and the percentage of new cases arising from known contacts was below 50% in the week to 12 April (44%). Laboratory indicators reflect heightened vigilance: large numbers of samples were collected (1467) and less than 1% these tested EVD-positive (12 of 1467 samples).

Response indicators for Guinea also present a mixed picture. A total of 6 deaths from EVD in the week to 19 April were identified post-mortem in the community compared with 8 deaths the previous week. The percentage of confirmed cases that arose among registered contacts remained below 50% for the third consecutive week, at 46% in week to 12 April (the most recent week for which data are available), but an increase on 29% reported in the previous week. Laboratory indicators improved with the number of laboratory samples tested increasing for a fifth consecutive week to 565 samples tested in the week to 19 April and the number of positive samples dropping to 6% compared to 10% the previous week.

Community engagement appears to be steadily improving in Guinea and Sierra Leone, but more needs to be done to identify all chains of transmission. A case-finding and community awareness-raising campaign took place in the Guinean prefecture of Forecariah from 12 to 15 April, identifying 12 new confirmed cases, 7 of these from post-mortem testing. This represents 52% (12 of 23) confirmed cases reported in Forecariah during the period 12 to 18 April. A similar campaign is planned for the prefecture of Coyah (expected launch date 24 April) and later in the prefectures of Dubreka, Conakry, Kindia and Boffa.

The last confirmed case in Liberia died on 27 March and was buried on 28 March. Heightened vigilance is being maintained throughout the country. In the 5 days to 19 April, 212 new laboratory samples were tested for EVD, with no confirmed cases. Forty-two days will have elapsed since burial of the last confirmed case on 9 May.

There were no new health worker infections reported in the week to 19 April.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 26 044 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 10 808 reported deaths (outcomes for many cases are unknown). A total of 21 new confirmed cases were reported in Guinea, 0 in Liberia, and 12 in Sierra Leone in the 7 days to 19 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 children.

A total of 865 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 504 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 3136 70 1943 Probable 415 * 415 Suspected 14 * ‡ Total 3565 70 2358 Liberia** Confirmed 3151 0 ‡ Probable 1879 * ‡ Suspected 5182 * ‡ Total 10 212 0 4573 Sierra Leone Confirmed 8575 30 3511 Probable 287 * 208 Suspected 3405 * 158 Total 12 267 30 3877 Total Confirmed 14 862 100 ‡ Probable 2581 * ‡ Suspected 8601 * ‡ Total 26 044 100 10 808

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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 1685

(31) 1831

(34) 556

(12) 1966

(42) 972

(62) 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

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

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GUINEA

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

A total of 21 confirmed cases were reported in the 7 days to 19 April (figure 3), compared with 28 cases the previous week.

A total of 4 prefectures reported at least one confirmed case, compared with 5 prefectures the previous week. Transmission remains centred in the west of the country, particularly in the prefecture of Forecariah bordering Sierra Leone, which accounted for 86% of all confirmed cases reported from Guinea in the week to 19 April. The capital Conakry reported 1 new case, a decrease from 6 cases the week before. The nearby prefectures of Coyah and Fria reported 1 new case each (figure 2, figure 6).

Response indicators for Guinea continue to present a mixed picture (table 3). Of 11 confirmed deaths from EVD in the week to 19 April, 6 were identified in the community post-mortem. In the week to 12 April, 46% cases arose among registered contacts – a proportion remaining under 50% for the third consecutive week. However, there are encouraging signs that surveillance is improving. The number of laboratory samples tested increased for a fourth consecutive week to 565 in the week to 19 April (compared with 518 the week before), with 6% testing positive for EVD (compared with 10% the previous week). In the week to 19 April, 163 unsafe burials have been reported compared to 72 in the previous week. This is thought to be due to increased vigilance resulting from a recent policy change on safe and dignified burials.

As part of a 45-day campaign to reinforce emergency measures in western Guinea, door-to-door campaigns to improve community participation in surveillance activities and identify suspected cases have been carried out in the prefecture of Forecariah from 12 to 15 April. The campaign reached 91% of the population and identified 12 new confirmed cases, 7 from post-mortem testing. This represents 52% (12 of 23) confirmed cases reported in Forecariah during the period 12 to 18 April. A similar campaign is planned for the prefecture of Coyah (expected launch date 24 April) and later in the prefectures of Dubreka, Conakry, Kindia and Boffa.

The security situation in Guinea continues to present challenges with 4 prefectures (Boffa, Boke, Conakry and Kindia) reporting instances of community resistance in the week to 19 April. Conakry has reported at least 1 incident of community resistance per day for the past 6 weeks.

Locations of 8 operational Ebola treatment centres (ETCs) are shown in figure 7. No health worker infections were reported in the week to 19 April.

Locations of the 9 operational laboratories in Guinea are shown in figure 8. Of 565 samples tested in the week to 19 April, 99% were processed within 1 day of collection.

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 19 April (figure 2; figure 4). The last confirmed case died on 27 March and was buried on 28 March. Forty-two days will have elapsed since burial of the last confirmed case on 9 May.

Heightened vigilance is being maintained throughout the country. In the 5 days to 19 April, 212 new laboratory samples were tested for EVD, with no confirmed cases. No counties other than Montserrado have reported a new confirmed case for over 7 weeks.

Locations of the 16 operational Ebola treatment centres (ETCs) in Liberia are shown in figure 7.

Locations of the 4 operational laboratories in Liberia are shown in figure 8. Of samples tested in week 16, 78% of samples were processed within one day of collection.

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 375* 189* Sierra Leone 303 221** Total 865 504

SIERRA LEONE

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

A total of 12 confirmed cases were reported in the week to 19 April, an increase on 9 cases the previous week.

Western Area Urban, which includes the capital Freetown, reported 6 confirmed cases, representing half of cases reported nationally. This is a slight increase from 4 cases reported the previous week. Koinadugu, which borders Guinea to the north, reported 1 new confirmed case. Other districts reporting new confirmed cases were Kambia (4 cases) and Port Loko (1 case) in the west of the country (figure 2; figure 5; figure 6).

Response indicators for Sierra Leone present a mixed picture. The number of EVD-positive deaths that were identified in the community after post-mortem testing was 3 (1 in Kambia, 1 in Western Urban, 1 in Koinadugu) in the week to 19 April and the percentage of new cases arising from known contacts was below 50% in the week to 12 April (44%). However, a high number of samples was being collected and tested (1467) in the week to 19 April and less than 1% of laboratory samples tested EVD-positive (12 of 1467 samples).

There has been a significant decline in the number of ‘alerts’, suggesting there are fewer people presenting for Ebola triaging and testing. The number of alerts for sick patients received during the week to 19 April was 392, compared to 599 one month earlier (the week to 15 March). Of the 392 alerts received, 246 were registered in Western Area (Urban and Rural, 63%), 36 from Bombali (9%), and the rest mostly from Port Loko and Kambia.

Locations of the 12 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7. Three ETCs were closed in the week to 19 April: 1 in Moyamba and 2 in Western Rural. No new health worker infections were reported in the week to 19 April.

Locations of the 13 operational laboratories in Sierra Leone are shown in figure 8. A total of 82% of samples was tested within 1 day of collection in the week to 19 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 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. 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 (IHR) (2005).

A programme 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, Mauritania and Ethiopia. Deployments to all other priority countries are being finalized.

Standard viral haemorrhagic fever PPE modules have been delivered to Mali, Guinea-Bissau, Côte d'Ivoire, Senegal, Mauritania, Burkina Faso, Benin, Chad, Gambia, Niger, Nigeria, Togo, Egypt, and Ghana. 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 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; operationalize 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 completed an assessment of EVD readiness in South Sudan on 18 April 2015. The mission reviewed the preparedness status across the 11 components of the EVD preparedness checklist. In implementing preparedness activities in South Sudan, a number of factors continue to be considered, including the protracted humanitarian crisis, financial constraints, security limitations, and the significant involvement of international partners in supporting service delivery in the health system.

In Guinea Bissau, WHO conducted a training course for national staff on safe and dignified burials and has provided technical assistance to the national logistics sub-committee.

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 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