Incorporating the WHO Activity Report

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SUMMARY

A total of 79 new confirmed cases of Ebola virus disease (EVD) were reported in the week to 22 March: the lowest weekly total in 2015. There were 45 new confirmed cases reported from Guinea. Having reported no cases for 3 consecutive weeks, a new confirmed case was reported from Liberia on 20 March. Sierra Leone reported 33 new confirmed cases in the week to 22 March.

With the exception of the case in Liberia, transmission has been restricted to districts in and around Conakry to the north and Freetown to the south. A total of 10 districts in Guinea, Liberia, and Sierra Leone reported a confirmed case in the week to 22 March. An additional 4 districts have reported a confirmed case in the past 21 days: Boffa, Dubreka, and Kindia in Guinea, and Koinadugu in Sierra Leone. The epicentre of the outbreak, in the tri-border area around the Guinean prefecture of Gueckedou, the Liberian county of Lofa, and the Sierra Leonean district of Kailahun, has not reported a confirmed case of EVD for over 90 days.

Response indicators for Guinea suggest some improvements compared with recent weeks. Case incidence declined compared with the previous week in every prefecture to have reported a case in the past 21 days. Of 37 total reported EVD deaths in the week to 22 March, 7 were identified post-mortem in the community, compared with 28 of 49 the previous week. Similarly, in the week to 15 March, 38% of confirmed cases arose from registered contacts, compared with 28% the previous week. However, 26 unsafe burials were reported in the week to 22 March, compared with 22 the previous week. Notwithstanding these improvements, the fact that fewer than half of cases arose from known contacts, and the number of reported unsafe burials has increased suggests that the outbreak in Guinea continues to be driven by unknown chains of transmission.

Investigations into the origin of the newly reported case in Liberia are ongoing. Heightened vigilance is being maintained throughout the country. In the week to 22 March, 238 laboratory samples were tested for EVD.

Response indicators for Sierra Leone continue to improve. In the week to 15 March 84% of confirmed cases came from registered contacts, compared with 67% the previous week. There were no reports of unsafe burials in the week to 22 March; however, over the same period, 7 of 56 confirmed deaths from EVD were identified from post-mortem testing in the community.

WHO is supporting the Liberian Ministry of Health to implement a heightened surveillance framework. Cross-border surveillance capacity has already been reinforced in Nimba and Grand Cape Mount counties; preliminary work to reinforce cross-border controls has already started in other border counties.

In the context of falling case incidence and a receding zone of transmission, treatment capacity now far exceeds demand in both Liberia and Sierra Leone. Accordingly, and with technical guidance from WHO, national authorities in both countries have begun to implement plans for the phased safe decommissioning of surplus facilities. Each country will retain a core capacity of high-quality Ebola treatment centres, strategically located to ensure complete geographic coverage, with additional rapid-response capacity held in reserve.

There was 1 new health worker infection in the week to 22 March, reported from Conakry, Guinea. This brings the total number of health worker infections reported across the three most-affected countries since the start of the outbreak to 853, with 494 deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been almost 25 000 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (table 1), with over 10 000 reported deaths (outcomes for many cases are unknown). A total of 45 new confirmed cases were reported in Guinea, 1 in Liberia, and 33 in Sierra Leone in the 7 days to 22 March.

The total number of confirmed and probable cases is similar in males and females (table 3). 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 are children.

A total of 853 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 494 reported deaths (table 5).

Table 1: Confirmed, probable, and suspected cases reported by Guinea, Liberia, and Sierra Leone

Country Case definition Cumulative cases Cases in past 21 days Cumulative deaths Guinea Confirmed 3011 198 1865 Probable 398 * 398 Suspected 20 * ‡ Total 3429 198 2263 Liberia Confirmed 3151 1 ‡ Probable 1879 * ‡ Suspected 4572 * ‡ Total 9602 1 4301 Sierra Leone Confirmed 8520 144 3381 Probable 287 * 208 Suspected 3034 * 158 Total 11 841 144 3747 Total Confirmed 14 682 343 ‡ Probable 3564 * ‡ Suspected 7626 * ‡ Total 24 872 343 10 311

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Table 3: 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 1627

(30) 1746

(32) 538

(12) 1890

(41) 925

(59) Liberia 2897

(146) 2845

(145) 970

(57) 3113

(182) 1181

(221) Sierra Leone 5396

(189) 5736

(198) 2312

(95) 6194

(239) 2419

(327)

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GUINEA

Key performance indicators for the EVD response in Guinea are shown in table 2.

A total of 45 confirmed cases were reported in the 7 days to 22 March (figure 1).

At present transmission is confined to an area around and including the capital Conakry (11 confirmed cases), with the nearby prefectures Coyah (6 cases) and Forecariah (28 cases) being the only other prefectures to report cases in the week to 22 March (figure 1, figure 4). In the east of the country, Macenta was the last prefecture to report a confirmed case, over 21 days ago.

46% of all cases reported from the three affected countries came from Forecariah prefecture in Guinea and the neighbouring Sierra Leonean district of Kambia (figure 1, figure 4). A memorandum of understanding has been agreed between Sierra Leone and Guinea to encourage the free sharing of information. District surveillance officers from both areas will be free to investigate cases on either side of the border.

Response indicators have shown some improvement compared with recent weeks, though many cases are still arising from unknown chains of transmission. In the week to 15 March, fewer than half of confirmed EVD cases (38%) arose among known contacts: an increase compared with 28% the previous week. In the week to 22 March, 7 of 37 (19%) EVD-positive deaths occurred in the community, a 3-fold reduction compared with 28 of 49 (57%) in the previous week. Similarly, the proportion of laboratory samples that tested positive for EVD fell to 22% in the week to 22 March, compared with 31% the previous week. There was, however, an increase in the number of reported unsafe burials, from 22 in the week to 15 March to 26 in the week to 22 March.

Locations of 8 operational Ebola treatment centres (ETCs) are shown in figure 6. Two ETCs have been assessed and have met minimum standards for infection prevention and control (IPC). IPC assessments have also been extended to non-Ebola health facilities. Of 6 such facilities assessed to date, one met minimum IPC standards. One new health worker infection was reported from Conakry in the week to 22 March.

Locations of the 9 operational laboratories in Guinea are shown in figure 7. All 430 samples tested in the week to 22 March were processed within 1 day of arrival at a laboratory.

Table 2: Key performance indicators for Guinea for Phase 2 of the Ebola Response

For definitions of key performance indicators see Annex 2. For the WHO activity report see Annex 3. Data are given for 7-day periods *Includes repeat samples. ‡Data missing for 0–3% of cases. #Outcome data missing for 3–14% of hospitalized confirmed cases.

Figure 1: 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.

One new confirmed case was reported from the greater Monrovia area of Montserrado county in the week to 22 March: the first such case for over 3 weeks. The patient self-presented to hospital triage on 19 March, and was laboratory confirmed as EVD positive on 20 March. The patient is not a contact associated with the country’s last confirmed case, who tested negative for EVD for a second time on 3 March. Investigations into how the patient was exposed to EVD are ongoing. At the time of writing, 71 contacts have been identified and are being monitored for follow-up. Heightened vigilance is being maintained throughout the country. In the week to 22 March, a total of 238 new laboratory samples were tested for EVD.

No other counties have reported a confirmed case within the past 21 days (figure 5). All contacts associated with the previously last known chain of transmission have now completed 21-day follow-up.

Locations of the 18 operational Ebola treatment centres (ETCs) in Liberia are shown in figure 6. All of the 12 facilities that have been assessed met minimum standards for infection prevention and control. A total of 12 non-Ebola health-care facilities have also been assessed to date (2 in Montserrado county, 10 in Nimba county): 5 (42%) met minimum IPC standards.

Case fatality rates for people hospitalized with confirmed EVD for whom a definitive outcome was reported were 53%, 52% and 50% for the months of October, November and December, respectively. On average, it took 2.6 days between the onset of symptoms and hospitalization of a confirmed, probable or suspected case during February.

Locations of the 5 operational laboratories in Liberia are shown in figure 7. 91% of samples were processed within 1 day of arrival at a laboratory.

Table 4: Key performance indicators for Liberia for Phase 2 of the Ebola Response

For definitions of key performance indicators see Annex 2. For the WHO activity report see Annex 3. Data are for 7-day periods. ‡Data missing for 4–27% of cases. Outcome data missing for 2–34% of hospitalized confirmed cases.

Figure 2: Confirmed weekly Ebola virus disease cases reported nationally and by district from Liberia

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SIERRA LEONE

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

A total of 33 confirmed cases were reported in the week to 22 March, compared with 55 the previous week. This is the lowest weekly total since early June 2014.

Cases were reported from 6 northern and western districts around and including the capital Freetown, which reported 13 new confirmed cases. The neighbouring districts of Bombali (1 case), Kambia (8 cases), Moyamba (1 case), Port Loko (6 cases) and Western Rural (4 cases) also reported cases.

Koinadugu is the only other district to have reported a confirmed case within the past 21 days.

The proportion of confirmed EVD cases that arose among known contacts increased for the third consecutive week, to 84%. However, the proportion of confirmed cases identified after post-mortem testing of dead bodies found in the community increased from 6 of 62 (10%) in the week to 15 March, to 7 of 56 (13%) in the week to 22 March.

According to the National Ebola Response Centre, 89% of credible reports of potential EVD cases were investigated within 24 hours in the week to 15 March: a marginal decline compared with the previous week. Potential cases were identified through contact tracing or case finding, or from reports to a dedicated national Ebola alert hotline. Heightened vigilance is being maintained throughout the country: of 1671 new samples tested in the week to 22 March, 2% were EVD positive.

Locations of the 20 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 6. A total of 12 of 17 assessed ETCs met minimum standards for IPC, along with 9 of 15 assessed community care centres.

Locations of the 13 operational laboratories in Sierra Leone are shown in figure 7. A total of 87% of samples were tested within 1 day of arrival at a laboratory.

Table 6: Key performance indicators for Sierra Leone for Phase 2 of the Ebola Response

For definitions of key performance indicators see Annex 2. For the WHO activity report see Annex 3. Data are for 7-day periods. ‡Data missing for 6–11% of cases. #Outcome data missing for 32–76% of hospitalized confirmed cases.

Figure 3: Confirmed weekly Ebola virus disease cases reported nationally and by district from Sierra Leone

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Figure 4: Geographical distribution of new and total confirmed cases

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Table 5: Ebola virus disease infections in health workers in the three countries with intense transmission

Country Cases Deaths Guinea 179 93 Liberia 372 180 Sierra Leone 302 221* Total 853 494

Figure 5: 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 6: 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 adequate 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 7: 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, Democratic Republic of the Congo and South Sudan.

Since 20 October 2014, 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 visits 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 visits were able to strengthen cross-border surveillance and the sharing of outbreak data under the framework of the International Health Regulations. A program 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, and Ethiopia.

Follow-up PST 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; operationalise 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 mission to Benin completed its work on 21 March 2015, with follow-up activities planned for the next 60 days in the following areas: surveillance, early detection and rapid response; founding of a national ETC; capacity building for safe burials and clinical management; and infection prevention and control.

In Gambia, a follow-up mission completed various training programmes designed to improve national capacity of rapid response and safe case management.

A follow up visit to Togo is ongoing, with support provided to national authorities in the areas of response coordination, logistics and rapid response. A 2-day training of programme for regional medical officers is underway, and will address surveillance, early detection and the management of alerts, case investigation, and contact tracing.

Training

A pilot rapid-response 5-day training session with the Eastern Mediterranean Regional Office (EMRO) took place from 15 to 19 March in Khartoum, with participants from both Sudan and Yemen. The course includes 3 days of simulations. The course is now being adapted for roll-out to other countries.

Surveillance and preparedness indicators

Indicators based on surveillance data, case management capacity, laboratory testing and equipment stocks are collected on a weekly basis from the four countries neighbouring Guinea, Liberia, and Sierra Leone.

An interactive preparedness dashboard based on 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 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

Indicator Numerator Numerator source Denominator Denominator source Cases and deaths Number of confirmed cases # of confirmed cases Guinea: Daily WHO situation reports Liberia / Sierra Leone: Daily Ministry of Health Ebola situation reports N/A N/A Number of confirmed deaths # of confirmed deaths Guinea: Daily WHO situation reports Liberia / Sierra Leone: Daily Ministry of Health Ebola situation reports N/A N/A Number of confirmed deaths that occurred in the community # of deaths in the community with positive EVD swab results Guinea: Weekly WHO situation reports Liberia / Sierra Leone: Daily Ministry of Health situation reports N/A N/A Diagnostic services Number of samples tested and percentage with positive EVD results # of new samples tested # of new samples tested with a positive EVD result Guinea: Laboratory database Liberia/Sierra Leone: Daily Ministry of Health Ebola situation reports N/A # of new samples tested Guinea: Laboratory database Liberia/Sierra Leone: Daily Ministry of Health Ebola situation reports Contact tracing Percent of new confirmed cases from registered contacts # of new confirmed cases registered as a contact Guinea: Weekly WHO situation reports Liberia: Daily Ministry of Health Ebola situation reports Sierra Leone: Weekly Ministry of Health Surveillance Report # of new confirmed cases Guinea: Daily WHO situation reports Liberia / Sierra Leone: Daily Ministry of Health Ebola situation reports Hospitalization Time between symptom onset and case hospitalization (days) Time between symptom onset and hospitalization of confirmed, probable or suspected case (geometric mean # of days) Clinical investigation records N/A N/A Outcome of treatment Case fatality rate (among hospitalized cases) # of deaths among hospitalized cases (confirmed) Clinical investigation records # of hospitalized cases (confirmed) with a definitive survival outcome recorded Clinical investigation records Infection Prevention and Control (IPC) and Safety Number of newly infected health workers # of newly infected health workers Guinea / Sierra Leone: Daily WHO situation reports Liberia: Daily Ministry of Health Ebola situation reports N/A N/A Safe and dignified burials Number of unsafe burials reported # of reports/alerts of burials that were not known to be safe Guinea: Weekly WHO situation reports Liberia / Sierra Leone: Ministry of Health situation reports N/A N/A Social mobilization Number of districts with at least one security incident or other form of refusal to cooperate # of districts with at least one security incident or other form of refusal to cooperate in the past week Guinea: Daily WHO situation reports Liberia / Sierra Leone: UNICEF N/A N/A

ANNEX 3: WHO ACTIVITIES REPORT