Total confirmed cases (by week, 2015)

SUMMARY

There were 3 confirmed cases of Ebola virus disease (EVD) reported in the week to 9 August: 2 in Guinea and 1 in Sierra Leone. The total number of confirmed cases for the previous week (week to 2 August) has been revised up from 2 to 3, after one confirmed case from Tonkolili in Sierra Leone was added retrospectively. Case incidence has been below 10 confirmed cases per week for 3 consecutive weeks, but there remains a significant risk of further transmission and an increase in case incidence in the near and medium term. Only 1 of the 3 cases reported in the week to 9 August was a registered contact, but was lost to follow-up and has generated multiple high-risk contacts in several health facilities in Conakry. The detection by post-mortem testing of a confirmed case with a possible link to an unsafe burial in the Moussayah sub-prefecture of Forecariah, Guinea, suggests that transmission may have gone undetected in the community. In addition, a new confirmed case in the Sierra Leonean capital Freetown has generated a number of high-risk contacts. Over 1600 contacts remain under observation across 4 prefectures in Guinea and 2 districts in Sierra Leone; compared with over 1800 contacts across 5 prefectures and 4 districts in the previous week.

Of the 2 confirmed cases reported from Guinea in the week to 9 August, one arose from an unknown source of infection and one was a registered contact who was lost to follow-up. The case reported from Forecariah was identified after post-mortem testing of a community death in the sub-prefecture of Moussayah. Preliminary investigations suggest that the case is linked to attendance of the unsafe burial of a family member who is thought to have died with symptoms compatible with EVD. The other case was reported from the Ratoma area of the capital, Conakry. The case is a registered contact of a known chain of transmission, but was lost to follow-up, and visited several health facilities throughout Conakry whilst symptomatic before being identified as EVD-positive. Many of the high-risk contacts identified in association with the case are health workers. 927 contacts remain under follow-up in 4 western prefectures in Guinea, compared with 1080 in 5 prefectures the previous week. Over half (55%) of all contacts are located in Forecariah, with 40% located in Conakry.

No new cases were reported from Liberia in the week to 9 August. All contacts in Liberia have now completed their 21-day follow-up period. The last 2 patients with EVD in Liberia were discharged after completing treatment and testing negative for EVD for a second time on 23 July.

The single confirmed case in Sierra Leone was reported from Freetown (Western Area Urban), and is linked to a branch of the Western Area Urban chain of transmission. The case is an 8 month-old female who had onset of symptoms on 4 August, and who was admitted to Ola During Children’s Hospital in Freetown on 6 August with fever, vomiting, and diarrhoea. A total of 29 high-risk contacts have been identified so far, 24 of whom are currently in voluntary quarantine. A total of 694 contacts remain under follow-up in Sierra Leone, compared with 811 the previous week. The vast majority of contacts, 638, are located in Tonkolili (associated with the case reported in the week ending 26 July), with the remaining 56 located in Freetown.

For the second consecutive week no health worker infections were reported from any of the affected countries. 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 512 reported deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 27 929 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1) up to 9 August, with 11 283 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). Two new confirmed cases were reported in Guinea and 1 in Sierra Leone in the week to 9 August.

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.

No new health worker infections were reported in the week to 9 August. 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 512 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 3329 7 2072 Probable 452 * 452 Suspected 6 * ‡ Total 3787 7 2524 Liberia§ Confirmed 3151 - ‡ Probable 1879 - ‡ Suspected 5636 - ‡ Total 10 666 - 4806 Liberia** Confirmed 6 0 2 Probable 0 * ‡ Suspected ‡ * ‡ Total 6 0 2 Sierra Leone Confirmed 8697§ 6 3585 Probable 287 * 208 Suspected 4486 * 158 Total 13 470 6 3951 Total Confirmed 15 183 13 ‡ Probable 2618 * ‡ Suspected 10 128 * ‡ Total 27 929 13 11 283

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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 1589

(29) 1735

(32) 529

(11) 1894

(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 9 August 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 9 August for Guinea and Sierra Leone and 6 August for Liberia. ¶One confirmed case in Tonkolili was retrospectively reported, with date of report 2 August 2015. ‡Includes Freetown.

Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 9 August 2015

Sub-prefectures/chiefdoms/districts that reported one or more confirmed cases in the 7 days to 9 August 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. ¶One confirmed case in Tonkolili was retrospectively reported, with date of report 2 August 2015.

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 99 Liberia* 378 192 Sierra Leone 307 221‡ Total 880 512

GUINEA

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

Two confirmed cases were reported from 2 prefectures—Conakry and Forecariah—in the week to 9 August (table 3, table 4, figure 2, figure 3).

The case in Conakry was reported from the Ratoma area of the city, which has been the site of active transmission for over a month. The case is an 18-year-old male and is a registered contact of a known chain of transmission, but was lost to follow-up and visited several health facilities throughout Conakry whilst symptomatic before being identified as EVD-positive and transferred to an Ebola treatment centre. 369 contacts remain under follow-up in the prefecture.

The case reported from Forecariah is the first to be reported from the prefecture for more than 2 weeks, and the first to be reported from the sub-prefecture of Moussayah since the week ending 14 June. The case was a 26-year-old woman, and was identified after post-mortem testing of a community death. Preliminary investigations suggest that the case is linked to the unsafe burial of a family member several weeks ago. Evidence of the continued practice of unsafe burials in Moussayah indicates that transmission may have gone undetected in the community. 508 contacts remain under follow-up in the prefecture.

An interim analysis of the Ebola ça suffit! ring vaccination trial in Guinea suggests that the investigational rVSV-ZEBOV Ebola vaccine protects people exposed to EVD. The trial will continue in Guinea, with all rings around confirmed cases now receiving immediate vaccination. Previously, rings were randomly allocated to receive either immediate vaccination or vaccination 21 days after the confirmation of a case.

927 contacts remain under follow-up in 4 western prefectures in Guinea, compared with 1080 in 5 prefectures the previous week. Over half (55%) of all contacts are located in Forecariah, with 40% located in Conakry.

There were 6 (1%) unsafe burials reported in Guinea out of 577 recorded community deaths in the week to 9 August, compared with 3 (0.6%) unsafe burials out of 525 recorded community deaths in the previous week.

Including both initial and repeat testing, a total of 768 laboratory samples were tested in the week to 9 August. Most tests (81% in the week to 9 August) are of post-mortem swabs taken to rule out EVD as the cause of death.

Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7. No health worker infections were reported from Guinea in the week to 9 August.

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.

The single confirmed case in Sierra Leone in the week to 9 August was reported from Freetown (Western Area Urban), and is linked to a branch of the Western Area Urban chain of transmission (table 3, figure 2, figure 3, figure 5, figure 6). The case is an 8 month-old female who had onset of symptoms on 4 August, and who was admitted to Ola During Children’s Hospital in Freetown on 6 August with fever, vomiting, and diarrhoea. A total of 29 high-risk contacts have been identified so far, with 24 currently in voluntary quarantine.

A total of 694 contacts remain under follow-up, compared with 811 the previous week. The vast majority of contacts, 638, are located in Tonkolili, with the remaining 56 located in Freetown.

Locations of the 10 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7. No health worker infections were reported in the week to 9 August.

Laboratory indicators continue to reflect a heightened degree of vigilance, with 1938 new samples tested in the 7 days to 9 August. Fewer than 1% of samples tested positive for EVD. Most tests (79% in the week to 9 August) are of post-mortem swabs taken to rule out EVD as the cause of death.

Locations of the 9 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. One confirmed case in Tonkolili was retrospectively reported, with date of report 2 August 2015. §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 each April and May.

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

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 60 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. The last case was discharged after testing negative for EVD for a second time on 23 July. All contacts have now completed follow-up.

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.

Between October 2014 and July 2015 WHO has undertaken over 255 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 have provided support on a country-by-country basis. Activities in the last week are highlighted below.

In Cameroon, a PST follow-up visit is underway from 10 to 14 August. The team is focusing primarily on strengthening public health measures at land border crossings and on strengthening surveillance.

In Ghana, WHO is supporting a training course on safe and dignified burials from 10 to 13 August.

In Guinea-Bissau, two WHO sub-offices have been established and staffed in the regions of Gabu and Tombali, which share a border with Guinea. The offices are involved with ongoing activities with the regional health authorities. In Tombali region, WHO teams have worked to reinforce and improve surveillance, including integration of local communities, strengthen capacity at border crossings, and work with partners to set up screening procedures at health centres. In Gabu, WHO and the regional health authority have strengthened registration, screening, and triage procedures at the Gabu regional hospital. WHO has also provided waste management and IPC guidance and materials to health facilities in both Tombali and Gabu regions. A WHO emergency coordinator has been recruited to further support the coordination of preparedness activities in Guinea Bissau.

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, 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.

Exercise planning will take place in Gambia in the last week of August. Trainings in Gambia (rapid response teams), Mauritania (points-of-entry), and Côte d’Ivoire (clinical management and IPC in Guiglo and Toulepleu) are currently being planned.

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