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WHO: Ebola situation report 11 February 2015

February 11, 2015 World Health Organization

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EBOLA SITUATION REPORT EBOLA SITUATION REPORT 11 FEBRUARY 2015

Guinea

1995

3044 3826 8881 10 934

CASES/ DEATHS (data up to 8 February 2015)

Liberia Sierra Leone Mali Nigeria 8 6 20 8 1 0 1 0 1 0 4 1

3341

Senegal Spain United Kingdom United States of America Total

9177

22 894

SUMMARY  Total weekly case incidence increased for the second consecutive week, with 144 new confirmed cases reported in the week to 8 February. Guinea reported a sharp increase in incidence, with 65 new confirmed cases compared with 39 the week before. Transmission remains widespread in Sierra Leone, which reported 76 new confirmed cases, while the resurgence in cases in the western district of Port Loko continued for a second week. Liberia continues to report a low number of new confirmed cases. Despite improvements in case finding and management, burial practices, and community engagement, the decline in case incidence has stalled. The spike in cases in Guinea and continued widespread transmission in Sierra Leone underline the considerable challenges that must still be overcome to get to zero cases. The infrastructure, systems, and people needed to end the epidemic are now in place; response measures must now be fully implemented. The surge of new confirmed cases reported by Guinea was driven primarily by transmission in the capital, Conakry (21 confirmed cases) and the western prefecture of Forecariah (26 confirmed cases). Community engagement continues to be a challenge in Conakry and Forecariah, and in Guinea more widely. Almost onethird of the country’s EVD-affected prefectures reported at least one security incident in the week to 8 February. Effective contact tracing, which relies on the cooperation of communities, has also proved challenging. In the week to 1 February, just 7 of 42 cases arose among registered contacts. A total of 34 unsafe burials were reported, with 21 EVD-positive deaths reported in the community. Seven new confirmed cases were reported in the east-Guinean prefecture of Lola. A field team is currently deployed to Côte d’Ivoire to assess the state of preparedness in western areas of the country that border Lola. Follow-up preparedness missions are planned for Mali and Senegal later this month, culminating in a tri partite meeting between Guinea, Mali, and Senegal to strengthen cross-border surveillance. A total of 3 confirmed cases was reported from Liberia. All of the cases originated from the same area of Montserrado county, linked to a single chain of transmission. Following the steep decline in case incidence in Sierra Leone from December until the end of January, incidence has now stabilized. A total of 76 cases were reported in the week to 8 February, a decrease from the 80 confirmed cases reported in the week to 1 February, but higher than the 65 confirmed cases reported in the week to 25 January. Transmission remains widespread, with 7 districts reporting new confirmed cases. A total of 41 unsafe burials were reported in the week to 8 February. The case fatality rate among hospitalized cases (calculated from all confirmed and probable hospitalized cases with a reported definitive outcome) remains high, at between 53% and 60% in the 3 affected countries.

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EBOLA SITUATION REPORT COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION  There have been almost 23 000 reported confirmed, probable, and suspected cases1 of EVD in Guinea, Liberia and Sierra Leone (table 1), with almost 9000 reported deaths (outcomes for many cases are unknown). A total of 65 new confirmed cases were reported in Guinea, 3 in Liberia, and 76 in Sierra Leone in the 7 days to 8 February (data missing for 8 February in Liberia). At the start of the epidemic many reported suspected cases were genuine cases of EVD. At this stage, with improved surveillance systems in place, a far smaller proportion of suspected cases are confirmed to have EVD. Consequently, the incidence of new confirmed cases gives a more accurate picture of the epidemic. A stratified analysis of cumulative confirmed and probable cases indicates that the number of cases in males and females is similar (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 almost four times more likely to be affected than are children. A total of 830 confirmed health worker infections have been reported in the 3 intense-transmission countries; there have been 488 reported deaths (table 4). Country Case definition Confirmed Guinea Probable Suspected Total Confirmed Liberia** Probable Suspected Total Confirmed Sierra Leone Probable Suspected Total Total Cumulative cases 2674 352 18 3044 3146 1873 3862 8881 8135 287 2512 10 934 22 859 Cases in past 21 days 134 * * 134 12 * * 12 221 * * 221 367 Cumulative deaths 1643 352 ‡ 1995 3826 ‡ ‡

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

3826 2975 208 158 3341 9162

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. *Not reported due to the high proportion of probable and suspected cases ‡ that are reclassified. Data not available. **Data are missing for 8 February.

GUINEA   Key performance indicators for the EVD response in Guinea are shown in table 3. A total of 65 confirmed cases were reported in the 7 days to 8 February 2015 (figure 1), compared with 39 the week before. This is the third week in a row that case incidence has increased in Guinea, and the highest weekly total since the first week of 2015 The recent surge in cases is driven primarily by the western district of Forecariah (26 confirmed cases) and the capital, Conakry (21 confirmed cases). The 26 confirmed cases reported from Forecariah represent the highest ever weekly total reported from the prefecture. To the immediate south, the Sierra Leonean district of Kambia reported 11 confirmed cases in the week to 8 February, highlighting the need for close cross-border cooperation in order to stymie transmission. Community engagement continues to be a challenge in many areas of Guinea, with approximately one-third of EVD-affected prefectures reporting at least one security incident in the week to 8 February. A total of 8 prefectures reported a confirmed or probable case during the reporting period (figure 1).

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Case definition recommendations for Ebola or Marburg Virus Diseases: http://www.who.int/csr/resources/publications/ebola/ebola-case-definitioncontact-en.pdf?ua=1

EBOLA SITUATION REPORT   Seven new confirmed cases were reported from the eastern prefecture of Lola, on the border with Côte d’Ivoire. A team is deployed to Cote d’Ivoire to assess the state of preparedness for an imported case. The north Guinean prefecture Mali, which borders Senegal, has reported its second confirmed case. The case is the aunt of the first case reported in the prefecture: a man who travelled from Monrovia. Three prefectures along Guinea’s northern border have reported confirmed cases in the past 21 days (figure 4). Twelve districts that have previously reported confirmed cases did not report any confirmed cases in the 21 days to 8 February; 9 have reported no cases for over 42 days (figure 4, figure 5). Locations of 6 operational Ebola treatment centres (ETCs) are shown in figure 6. 100% (2/2) of ETCs assessed met minimum standards for infection prevention and control (IPC). No new health worker infections were reported in the week to 8 February. The case fatality rate (CFR) during the month of December was 57% among hospitalized confirmed cases for whom a definitive outcome was reported. Western districts reported a lower CFR from October to December 2014 (43% in Conakry, 45% in Coyah) compared with eastern districts (66% in Kerouane, 65% in Macenta, and 61% in N’Zerekore). Possible explanations for this variation include differences in treatment, and distance required to travel to a treatment facility. Locations of the 5 operational laboratories in Guinea are shown in figure 7. In the week to 1 February, 17% of new confirmed and probable cases arose among registered contacts; a drop from 55% the previous week. During the week to 8 February, 89% of all registered contacts were seen on a daily basis. A total of 21 EVD-positive deaths were reported in the community in the week to 8 February. Ideally all cases should be identified and treated in an Ebola-specific facility; there should be no EVD-related deaths in the community. A total of 34 unsafe burials were reported in the same period. The high number of community deaths and reported unsafe burials, combined with widespread reports of security incidents related to the EVD response, underscore the need to improve community engagement strategies in many areas of the country. Key performance indicators for the EVD response in Liberia are shown in table 3. A total of 3 confirmed cases were reported in the 7 days to 8 February (figure 2). All confirmed cases were reported from Montserrado, the county that includes the capital, Monrovia (figure 2 and figure 4). All cases are reported to be linked to the same chain of transmission. Eleven districts in Liberia have not reported a confirmed case for over 42 days (figure 5). Locations of the 18 operational Ebola treatment centres (ETCs) in Liberia are shown in figure 6. Locations of the 8 operational laboratories in Liberia are shown in figure 7. In the 7 days to 8 February, 1 of 3 (33%) new confirmed cases arose among registered contacts; down from 100% of cases during the previous 9-day period. During the week to 8 February 2015, all registered contacts were seen on a daily basis. Two counties in Liberia reported an instance of community resistance in the week to 4 January.

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LIBERIA       

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Table 2: Cumulative number of confirmed and probable cases by sex and age group in Guinea, Liberia, and Sierra Leone Cumulative cases By sex* By age group‡ Country (per 100 000 population) (per 100 000 population) Male Female 0–14 years 15–44 years 45+ years 1413 1508 460 1648 791 Guinea (26) (28) (10) (35) (51) 2801 2746 943 2981 1145 Liberia (141) (140) (55) (175) (214) 5037 5400 2201 5751 2298 Sierra Leone (177) (186) (91) (222) (311) Population figures are based on estimates from the United Nations Department of Economic and Social Affairs. *Excludes cases for which data on sex are not available. ‡Excludes cases for which data on age are not available. 2 2

United Nations Department of Economic and Social Affairs: http://esa.un.org/unpd/wpp/Excel-Data/population.htm

EBOLA SITUATION REPORT Figure 1: Confirmed weekly Ebola virus disease cases reported nationally and by district from Guinea

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

Systematic data on laboratory confirmed cases have been available since 3 November nationally, and since 16 November for each district. Data are missing for 8 February.

EBOLA SITUATION REPORT Table 3: Key performance indicators for phase 2 of the Ebola response

For the lead agencies coordinating the 4 key lines of action see Annex 1. For definitions of key performance indicators see Annex 2. *Different time period used by Liberia. #Includes new confirmed and probable cases. ‡Percentage of cases for which isolation is not recorded is 4-12% in Guinea, 48-66% in Liberia and 30-35% in Sierra Leone. ##Percentage of hospitalized confirmed and probable cases which do not have a final outcome recorded is between 4-5% in Guinea, 19-40% in Liberia and 34-78% in Sierra Leone. **Does not include foreign medical § teams. 34 prefectures in Guinea, 15 counties in Liberia and 14 districts in Sierra Leone.

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

EBOLA SITUATION REPORT Table 4: Ebola virus disease infections and deaths in health workers in the three countries with intense transmission Country Cases Deaths Guinea Liberia Sierra Leone Total 166 371 293 830 88 179 221 488

Data are confirmed cases and deaths only, apart from deaths in Sierra Leone, which include confirmed, probable, and suspected deaths.

Figure 4: 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.

SIERRA LEONE   Key performance indicators for the EVD response in Sierra Leone are shown in table 3. Following a steep decline from December to late January, weekly case incidence now seems to have stabilized out. A total of 76 cases were reported in the week to 8 February, a decrease from the 80 confirmed cases

EBOLA SITUATION REPORT reported in the week to 1 February, but higher than the 65 confirmed cases reported in the week to 25 January. The west of the country remains the area of most intense transmission. The capital, Freetown, reported 19 new confirmed cases, compared with 22 the previous week. The neighbouring district of Port Loko saw a continuation of its recent resurgence of cases, with 28 new confirmed cases compared with 36 the previous week (figure 3, figure 4). The district of Kambia, which borders the Guinean prefecture of Forecariah, reported 11 new confirmed cases. Transmission remains widespread throughout the country. A total of 7 out of 14 districts reported at least one new confirmed case in the week to 8 February. In the south, Bo, Bonthe, Kailahun, and Pujehun have all reported no cases for more than 21 days (figure 5). Locations of the 24 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 6. A total of 43 of 50 (86%) of assessed Ebola health facilities met minimum standards for infection prevention and control. There are 12 operational laboratories and 1 pending in Sierra Leone (figure 7). During the week to 8 February 2015, 98% of all registered contacts were visited on a daily basis. In the week to 8 February 10 deaths from EVD were reported to have occurred in the community, and 41 unsafe burials were reported. Two districts in Sierra Leone reported an instance of community resistance in the week to 4 February.

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

February 8 is counted as day 0.

EBOLA SITUATION REPORT Figure 6: Location of Ebola treatment centres in Guinea, Liberia, and Sierra Leone

Locations of community care centres and community transit centres are not shown.

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 reported a case or cases imported from a country with widespread and intense transmission. In the United Kingdom, public health authorities confirmed a case of EVD in Glasgow, Scotland, on 29 December 2014 (table 5). The case was a health worker who returned from volunteering at an ETC in Sierra Leone. The patient was isolated on 29 December and received treatment in London. On 23 January the patient tested negative twice for EVD, and on 24 January the patient was discharged. All contacts have completed 21-day follow-up.

EBOLA SITUATION REPORT Table 5: Ebola virus disease cases and deaths in the United Kingdom Cumulative cases Confirmed Probable Health workers Country Contacts under follow-up Suspect Deaths

Contact tracing Contacts who have Date last completed patient tested 21-day negative follow-up 55 23/01/2015

Number of days since last patient tested negative 18

United Kingdom

100%

Figure 7: Location of laboratories in Guinea, Liberia, and Sierra Leone

Location of one pending laboratory in Freetown, Sierra Leone, is not shown.

EBOLA SITUATION REPORT PREPAREDNESS OF COUNTRIES TO RAPIDLY DETECT AND RESPOND TO AN EBOLA EXPOSURE  The introduction of a 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 support teams (PSTs), direct technical assistance to countries, and the provision of technical guidance and tools.

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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 and Togo. Technical working group meetings, field visits, highlevel 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. A rapid response assessment team has been deployed to the western border area of Côte d'Ivoire to evaluate levels of preparedness for an imported case of EVD. The neighboring Guinean district of Lola has recently reported a cluster of cases. A technical support team has also been deployed to Côte d'Ivoire, and is focusing on cross-border collaboration with Guinea, response coordination, surveillance, and resource mobilisation. A training plan is being accelerated to strengthen capacity in these areas.. Follow-up PSTs are planned in February for Guinea-Bissau, Mali, and Senegal.

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ANNEX 1: COORDINATION OF THE EBOLA RESPONSE 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 Case management Case finding, lab and contact tracing Safe and dignified burials Community engagement and social mobilization Lead agency WHO WHO International Federation of Red Cross and Red Crescent Societies (IFRC) UNICEF

EBOLA SITUATION REPORT ANNEX 2: DEFINITIONS OF KEY PERFORMANCE INDICATORS Response monitoring indicators are calculated using the following numerators and denominators: Indicator Cases and deaths Number of confirmed cases Number of confirmed deaths Number of confirmed deaths that occurred in the community Contact tracing Percent of new confirmed cases from registered contacts Isolation Time between symptom onset and case isolation (days) Outcome of treatment Case fatality rate (among hospitalized cases) # of deaths among hospitalized cases (confirmed) # of hospitalized cases (confirmed) with a definitive survival outcome recorded Clinical investigation records Time between symptom onset and isolation of confirmed or probable cases (geometric mean number of days)

Numerator # of confirmed cases # of confirmed deaths

Numerator Source Daily WHO country situation reports Daily WHO country situation reports Guinea: Daily WHO country situation reports Liberia: Ministry of Health report Sierra Leone: Ministry of Health report Guinea: Weekly country situation reports Liberia: Incident Management System Sierra Leone: WHO Country Office

Denominator N/A N/A

Denominator Source Jan

N/A N/A

# of deaths that occurred in the community with positive EVD swab results 18 Jan

N/A

25 Jan

# of new confirmed cases registered as a contact (includes probable cases in Guinea)

Number of new confirmed cases (includes probable cases in Guinea)

Daily WHO country situation reports

Clinical investigation records

N/A

Clinical investigation records

Infection Prevention and Control (IPC) and Safety18 Jan25 Jan Percent of IPC assessed ETCs # of IPC assessed ETCs IPC Reports Daily country situation reports Guinea: Weekly country situation reports Liberia: WHO Country Office Sierra Leone: Ministry of Health report 18 Jan

# of operational ETCs N/A

WHO

Number of newly # of newly infected health infected health workers workers Safe and dignified burials18 Ja25 Jan Number of unsafe burials reported 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 # of reports/alerts of burials that were not known to be safe

N/A

Jan

18 Jan25 Jan

Guinea: Daily country situation reports Liberia: WHO Country Office Sierra Leone: UNICEF