Total confirmed cases (by week, 2015)

SUMMARY

A total of 33 confirmed cases of Ebola virus disease (EVD) was reported in the week to 26 April. Two areas, Forecariah in Guinea and Kambia in Sierra Leone, accounted for 25 (76%) of all confirmed cases reported. Improved community engagement in these areas is required to ensure that all remaining chains of transmission can be tracked and ultimately brought to an end.

Guinea reported 22 confirmed cases in the week to 26 April, compared with 19 cases the previous week. Sierra Leone reported 11 confirmed cases, compared with 12 cases the previous week. Liberia reported no confirmed cases for the fifth consecutive week. Of 55 districts in Guinea, Liberia, and Sierra Leone that have reported at least one confirmed case of EVD since the start of the outbreak, 39 have not reported a case for over 6 weeks.

A total of 5 Guinean prefectures reported at least one confirmed case in the week to 26 April. No cases were reported from the capital, Conakry. The vast majority of cases (17 of 22: 77%;) were reported from the western prefecture of Forecariah, which borders the Sierra Leonean district of Kambia.

Three districts in Sierra Leone reported new confirmed cases in the week to 26 April, compared with 4 districts the previous week. In addition to 8 confirmed cases reported from Kambia, 1 case was reported from Western Area Urban, which includes the capital Freetown, and 2 new cases were reported from Western Area Rural.

In Sierra Leone, a total of 4 confirmed cases were identified in the community after post-mortem testing (all from Kambia) in the week to 26 April, compared with 3 the previous week. Additionally, half (50%) of new cases reported in the week to 19 April (the most recent period for which data are available) arose among known contacts of previous cases. Laboratory indicators reflect a heightened degree of vigilance, with 1406 new samples tested in the week to 26 April. Less than 1% of samples tested positive for EVD.

Response indicators for Guinea present a similarly mixed picture. A total of 8 confirmed EVD cases in the week to 26 April were identified after post-mortem testing of deaths identified in the community, compared with 6 the previous week. A total of 66 unsafe burials were reported in the week to 26 April. The percentage of confirmed cases that arose among registered contacts decreased to 27% (6 of 22) in the week to 26 April, from 53% the previous week. However, laboratory indicators continue to improve with a seventh consecutive weekly rise in the number of laboratory samples tested to 585.

In both Guinea and Sierra Leone, the fact that cases continue to be identified after post-mortem testing, together with the fact that around half of all cases arise in people not identified as contacts of previous cases, suggest that surveillance and community engagement still require improvement in some areas. A case-finding and community-awareness campaign took place in the Guinean prefecture of Coyah from 24 to 27 April, with over 57 000 households visited over 4 days. 44 alerts were reported over the 4-day operation: an increase of 91% compared with the previous week. None of the alerts resulted in confirmed cases, although 10 laboratory samples are still pending. Similar initiatives are planned for the prefectures of Boffa, Conakry, Dubreka, and Kindia.

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 4 days to 23 April, 194 new laboratory samples were tested for EVD, with no confirmed cases. On 9 May, 42 days will have elapsed since the burial of the last confirmed case.

For the second consecutive week, no new health worker infections were reported in the week to 26 April.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 26 277 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 10 884 reported deaths (outcomes for many cases are unknown). A total of 22 new confirmed cases were reported in Guinea, 0 in Liberia, and 11 in Sierra Leone in the 7 days to 26 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 3158 69 1962 Probable 415 * 415 Suspected 11 * ‡ Total 3584 69 2377 Liberia** Confirmed 3151 0 ‡ Probable 1879 * ‡ Suspected 5292 * ‡ Total 10 322 0 4608 Sierra Leone Confirmed 8586 32 3533 Probable 287 * 208 Suspected 3498 * 158 Total 12 371 32 3899 Total Confirmed 14 895 101 ‡ Probable 2581 * ‡ Suspected 8801 * ‡ Total 26 277 101 10 884

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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 1695

(31) 1841

(34) 558

(12) 1975

(42) 980

(63) Liberia 2959

(149) 2893

(147) 994

(58) 3171

(186) 1209

(226) Sierra Leone 5510

(193) 5849

(202) 2370

(98) 6299

(243) 2484

(336)

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Figure 2: Geographical distribution of new and total confirmed cases

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GUINEA

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

A total of 22 confirmed cases were reported in the 7 days to 26 April (figure 3), compared with 19 cases the previous week (2 confirmed cases reported last week were retrospectively discarded).

A total of 5 prefectures reported at least one confirmed case, compared with 4 the previous week. Of 25 prefectures that have reported at least one confirmed case of EVD since the beginning of the outbreak, 18 have not reported a confirmed case for over 6 weeks.

The vast majority (17 of 22: 77%) of cases were reported from the western prefecture of Forecariah, which borders the Sierra Leonean district of Kambia. No new cases were reported from the capital, Conakry. The western prefectures of Boffa (1 case), Dubreka (1 case), Fria (2 cases), and Kindia (1 case) reported new cases (figure 2; figure 4; figure 6).

Response indicators for Guinea continue to present a mixed picture (table 3). Of 18 confirmed deaths from EVD in the week to 26 April, 8 were identified in the community post-mortem, suggesting that unknown chains of transmission persist. The percentage of confirmed cases that arose among registered contacts decreased to 27% (6 of 22) in the week to 26 April, from 53% the previous week. However, laboratory surveillance continues to improve. The number of laboratory samples tested increased for a seventh consecutive week to 585 in the week to 26 April. 9% tested positive for EVD (this includes repeat testing).

Implementation is continuing of a new policy governing safe burials, which requires that 100% of dead bodies in Conakry and surrounding prefectures be buried safely, regardless of the cause of death. In the week to 26 April, 66 unsafe burials were reported (20% of 328 reported community deaths), indicating there is still a degree of resistance to the policy. However, this is an improvement on the previous week’s 163 reported unsafe burials (39% of 414 community deaths).

A case-finding and community-awareness campaign took place in the prefecture of Coyah from 24 to 27 April, with over 57 000 households visited over 4 days. 44 alerts were reported over the 4-day operation. None of the alerts resulted in confirmed cases, although 10 laboratory samples are still pending. Almost half of the alerts (48%) came from Maneah sub-prefecture in western Coyah, on the border with Conakry, and 34% from the neighbouring sub-prefecture of Commune Urbaine (central Coyah). The 4-day campaign resulted in a 91% increase in alerts compared with the previous week.

The security situation in Guinea continues to present challenges, with violent clashes between government and opposition supporters hampering the ability of responders to carry out necessary work.

Locations of 8 operational Ebola treatment centres (ETCs) are shown in figure 7. For the second consecutive week, no health worker infections were reported in the week to 26 April.

Locations of the 8 operational laboratories in Guinea are shown in figure 8.

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 4 days to 23 April (figure 2; figure 4). The last confirmed case died on 27 March and was buried on 28 March. On 9 May, 42 days will have elapsed since the burial of the last confirmed case (figure 6).

Heightened vigilance is being maintained throughout the country. In the 4 days to 23 April, 194 new laboratory samples were tested for EVD, with no confirmed cases. No counties other than Montserrado have reported a new confirmed case for over 8 weeks.

Locations of the 13 operational Ebola treatment centres (ETCs) in Liberia are shown in figure 7. Three ETCs closed in the week to 28 April: 1 each in the counties of Bomi, Grand Bassa, and Nimba.

Locations of the 4 operational laboratories in Liberia are shown in figure 8.

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 11 confirmed cases were reported in the week to 26 April, compared with 12 the previous week.

Three districts reported cases, compared with 4 districts the previous week. Of 14 districts that have ever reported a confirmed case since the beginning of the outbreak, 7 have not reported a confirmed case for over 6 weeks.

The majority of cases (8 of 11: 73%) were reported in the north-western district of Kambia, which borders the Guinean prefecture of Forecariah. Western Area Urban, which includes the capital Freetown, reported 1 confirmed case, with Western Rural Area reporting 2 cases (figure 2; figure 5; figure 6).

Response indicators from Sierra Leone present a mixed picture. A total of 4 confirmed cases were identified in the community after post-mortem testing (all from Kambia) in the week to 26 April, compared with 3 the previous week. Additionally, half (50%) of new cases reported in the week to 19 April (the most recent period for which data are available) arose among known contacts of previous cases. However, laboratory indicators reflect a heightened degree of vigilance, with 1406 new samples tested in the week to 26 April. Less than 1% tested positive.

A National Ebola Response Centre analysis of incoming calls to the 117 Ebola surveillance hotline suggests that the number of calls reporting potential EVD cases has declined steadily since the stay-at-home campaign at the end of March. The decline is particularly concerning in Kambia. In the week that included the stay-at-home period approximately 55 calls reporting potential EVD cases originated in Kambia, compared with 15 in the week ending 19 April. A similar decline was seen in Port Loko, where the volume of calls reporting suspect cases decreased from 190 and 60 over the same period.

Locations of the 13 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7. One new ETC opened in Kambia in the week to 26 April. No new health worker infections were reported over the same period.

Locations of the 13 operational laboratories in Sierra Leone are shown in figure 8.

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

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, 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, 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 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 ongoing, 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 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 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.

Further modules will be dispatched this week for 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 in Dubai, and will be 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 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.

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 1 month.

In Mauritania, technical support is being provided for a logistics assessment. Technical assistance is also being provided to accelerate the completion of an Ebola Treatment Centre in Nouakchott.

Epidemiology and logistics support are being provided for Senegal’s training plan, both at the central level and in regions that border Guinea.

Training

A clinical case-management training of trainers will take place in Senegal this week. Participants from Cameroon, Mauritania, Benin, Togo, Niger, Côte D’Ivoire, and Burkina Faso will attend. The preparedness strengthening team 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