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WHO: Ebola situation report 2 September 2015

2 septembre 2015 Organisation mondiale de la santé

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EBOLA SITUATION REPORT EBOLA SITUATION REPORT 02 SEPTEMBER 2015

SUMMARY  There were 3 confirmed cases of Ebola virus disease (EVD) reported in the week to 30 August: 2 in Guinea and 1 in Sierra Leone. The case in Sierra Leone is the first in the country for over 2 weeks. Overall case incidence has remained stable at 3 confirmed cases per week for 5 consecutive weeks. In addition, the number of contacts under observation continues to fall, from approximately 600 on 23 August to approximately 450 on 30 August. Of those, over 400 are located in Guinea. All 48 contacts under follow-up in Sierra Leone are associated with the most recently reported case from the western district of Kambia, which borders Guinea. A rapid-response team has been deployed to the area due to the likelihood of further localised transmission associated with the case. Both cases reported from Guinea this week had symptom onset in or near the capital, Conakry. One of the cases was symptomatic for an extended period in the community. There remains a risk of short-term increases in case incidence as a result of isolated, high-risk cases, and rapid-response teams are on alert to deal with any such cases.  The 2 confirmed cases reported from Guinea in the week to 30 August were identified in or near the Ratoma area of the capital, Conakry. The first case, a 9-month-old girl, was not a registered contact and had onset of symptoms on the outskirts of Conakry in Dubreka, before being taken to the Ratoma area of the capital by her family, where she died before she could be admitted to an Ebola treatment centre. The second case is a 56year-old male and registered contact of a case reported from Ratoma on 18 August. Of 410 contacts who were under follow-up on 30 August in Guinea, 289 were located in Conakry, with 26 in Dubreka and 95 in Forecariah. The previous week 600 contacts were located in 4 western prefectures (Conakry, Coyah, Dubreka, and Forecariah).  No new cases were reported from Liberia in the week to 30 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. Surveillance continues to be strengthened, with approximately 800 samples tested for EVD in the week to 30 August.  One new confirmed case was reported from Sierra Leone in the week to 30 August: the first case reported from the country for over 2 weeks. The case was a woman approximately 60 years of age who was identified as EVD-positive after post-mortem testing. She had symptom onset in the village of Sella Kafta, Tonko Limba chiefdom in Kambia, and was treated in the community before her death. Kambia, which borders the Guinean prefecture of Forecariah, had not reported a confirmed case for 48 days. A rapid-response team was immediately deployed to the area. As at 30 August a total of 48 contacts had been identified, although this figure is expected to rise in due course. The origin of infection remains under investigation. The Phase 3 efficacy trial of the VSV-EBOV vaccine has now been extended from Guinea to Sierra Leone. Contacts and contacts of contacts associated with the confirmed case in Kambia will therefore be offered the vaccine. Contacts associated with all other chains of transmission in Sierra Leone have now completed follow-up.  No new health worker infections were reported in the week to 30 August. There have been a total of 881 confirmed health worker infections reported from Guinea, Liberia, and Sierra Leone since the start of the outbreak, with 513 reported deaths.

EBOLA SITUATION REPORT Figure 1: Confirmed, probable, and suspected EVD cases worldwide (data up to 30 August 2015) Cases Deaths

Guinea Liberia Sierra Leone Italy Mali Nigeria Senegal Spain United Kingdom United States of America Total

1 0 8 6 20 8 1 0 1 0 1 0 4 1

3792 2529 4808 3953

10 672 13 609

11 305

28 109

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION Table 1: Confirmed, probable, and suspected cases in Guinea, Liberia, and Sierra Leone Country Case classification Confirmed Guinea Probable Suspected Total Confirmed Probable Suspected Liberia** Total Confirmed Probable Suspected Total Confirmed Sierra Leone Probable Suspected Total Confirmed Total Probable Suspected Total Cumulative cases 3337 452 3 3792 3151 1879 5636 10 666 6 * ‡ 6 8698 287 4624 13 609 15 192 2618 10 263 28 073 Cases in past 21 days 8 * * 8 Cumulative deaths 2077 452 ‡ 2529 ‡ ‡ ‡ 4806 2 ‡ ‡ 2 3587 208 158 3953 ‡ ‡ ‡ 11 290

0 * * 0 1 * * 1 9 * * 9

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. **Cases reported before 9 May 2015 are shaded blue. Due to ongoing surveillance and retrospective validation of cases and deaths, these totals may be subject to revision.

EBOLA SITUATION REPORT  There have been a total of 28 073 reported confirmed, probable, and suspected cases1 of EVD in Guinea, Liberia, and Sierra Leone (figure 1, table 1) up to 30 August, with 11 290 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 one in Sierra Leone in the week to 30 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 30 August. Since the start of the outbreak a total of 881 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 513 reported deaths (table 5). Figure 2: Geographical distribution of confirmed cases reported in the week to 30 August 2015

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. 1

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 Table 2: Cumulative number of confirmed 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 1594 1738 530 1898 860 Guinea (29) (32) (11) (41) (55) 1911 1838 561 2060 703 § Liberia (96) (93) (33) (121) (132) 4813 5102 1989 5616 2138 Sierra Leone (169) (176) (82) (217) (289) Population figures are based on estimates from the United Nations Department of Economic and Social Affairs. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. *Excludes cases for which data § on sex are not available. ‡Excludes cases for which data on age are not available. Data are until 9 May 2015. 2

Table 3: Cases and contacts by district/prefecture/county over the past 3 weeks 24 25 26 27 Prefecture/ Week Aug Aug Aug Aug District/ 33 34 Mon Tues Wed Thurs County Conakry 2 3 0 0 0 1 Guinea Dubreka 0 0 0 1 0 0 Forecariah 1 0 0 0 0 0 Subtotal 3 3 0 1 0 1 Sierra Kambia 0 0 0 0 0 0 Leone Subtotal 0 0 0 0 0 0 Liberia Montserrado 0 0 0 0 0 0 Subtotal 0 0 0 0 0 0 Total 3 3 0 1 0 1

28 Aug

29 Aug

30 Aug

Fri 0 0 0 0 0 0 0 0 0

Sat 0 0 0 0 1 1 0 0 1

Sun 0 0 0 0 0 0 0 0 0

Week 35 1 1 0 2 1 1 0 0 3

Contacts under follow up*

289 26 95 410 48 48 0 0 458

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 Dubreka—in the week to 30 August (table 3, table 4, figure 2, figure 3).  Both cases were reported in or near the Ratoma area of Conakry. The first case, a 9-month-old girl, was not a registered contact and had onset of symptoms on the outskirts of Conakry in Dubreka, before being taken to the Ratoma area of the capital by her family, where she died before she could be admitted to an Ebola treatment centre. The second case is a 56-year-old male and registered contact of a case reported from Ratoma on 18 August.  An interim analysis of the Ebola ça suffit! ring vaccination trial in Guinea suggests that the investigational rVSVZEBOV 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.  410 contacts remain under follow-up in 3 western prefectures in Guinea (Conakry, Dubreka, and Forecariah), compared with 600 in 4 prefectures the previous week (table 3). 289 contacts are located in Conakry, with 26 in Dubreka and 95 in Forecariah.

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

EBOLA SITUATION REPORT  There were 5 (0.9%) unsafe burials reported in Guinea out of 568 community deaths in the week to 30 August, compared with 1 (0.2%) unsafe burial out of 573 recorded community deaths in the previous week.  Including both initial and repeat testing, a total of 760 laboratory samples were tested in the week to 30 August. Most tests (88% in the week to 30 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 in the week to 30 August.  Locations of the 10 operational laboratories in Guinea are shown in figure 8. Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 30 August 2015 Country Prefecture/ District/ County Conakry Guinea Subtotal Sierra Leone Subtotal Liberia Subtotal All Dubreka Forecariah Kambia Subprefecture/ Chiefdom/ District Matam Ratoma Dubreka-centre Moussayah Tonko Limba Greater Monrovia Week 33 (10 - 16 Aug 2015) 2 0 0 1 3 0 0 Montserrado 0 0 3 Week 34 (17 - 23 Aug 2015) 0 3 0 0 3 0 0 0 0 3 Cases Week 35 (24 - 30 August 2015) On Unknown Epicontact source of link* list infection‡ 1 1 1 0 1 1 0 0 1 1 1 1 1 Confirmed community death§ Date of last confirmed case 13/08/2015 27/08/2015 25/08/2015 14/08/2015 27/08/2015 29/08/2015 29/08/2015 12/07/2015 0 1 0 0 0 2 0 2 12/07/2015

1 1 2 1 1 0 0 3

Sub-prefectures/chiefdoms/districts that reported one or more confirmed cases in the 7 days to 30 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 (epilink), or have no known link to a previous case.

Table 5: Ebola virus disease infections in health workers in Guinea, Liberia, and Sierra Leone Country Cases Guinea Liberia* Sierra Leone Total 196 378 307 881

Deaths 100 192 221 ‡

513

Data are confirmed cases and deaths only, apart from deaths in Sierra Leone, which include confirmed, probable, and suspected deaths. ‡ *Data are until 9 May 2015. Data as of 17 February 2015.

EBOLA SITUATION REPORT Table 6: Key response 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 0–3% of hospitalized confirmed cases.

‡

SIERRA LEONE  Key performance indicators for the EVD response in Sierra Leone are shown in table 7.  One new confirmed case was reported from Sierra Leone in the week to 30 August: the first case reported from the country for over 2 weeks. The case was a woman approximately 60 years of age who was identified as EVD-positive after post-mortem testing. She had symptom onset in the village of Sella Kafta, Tonko Limba chiefdom in Kambia, and was treated in the community before her death. Kambia, which borders the Guinean prefecture of Forecariah, had not reported a confirmed case for 48 days. A rapid-response team was immediately deployed to the area. As at 30 August a total of 48 contacts had been identified, although this figure is expected to rise in due course. The origin of infection remains under investigation.  The Ebola ça suffit! ring vaccination Phase 3 efficacy trial of the VSV-EBOV vaccine has now been extended from Guinea to Sierra Leone. Contacts and contacts of contacts associated with the confirmed case in Kambia will therefore be offered the vaccine.

EBOLA SITUATION REPORT  All contacts associated with other chains of transmission in Sierra Leone have now completed 21-day follow-up. There are currently no patients with EVD in any of the countries ETCs. The last case to be treated for EVD in an Ebola treatment centre was discharged on 24 August after testing negative twice for EVD.  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 30 August.  Laboratory indicators continue to reflect a heightened degree of vigilance, with 1880 new samples tested in the 7 days to 30 August. One new sample tested positive for EVD. Most tests (78% in the week to 30 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 response performance indicators for Sierra Leone

For definitions of key performance indicators see Annex 2. Data are for 7-day periods. Laboratory data missing for 14 July. Data missing # for 7–14% of cases. Outcome data missing for 0–77% of hospitalized confirmed cases. An outcome is known for only 6 hospitalized, confirmed cases in each April and May.

‡

EBOLA SITUATION REPORT Figure 3: Geographical distribution of new and total confirmed cases in Guinea, Liberia and Sierra Leone

EBOLA SITUATION REPORT Figure 4: Confirmed weekly Ebola virus disease cases reported nationally and by prefecture from Guinea

EBOLA SITUATION REPORT Figure 5: Confirmed weekly Ebola virus disease cases reported nationally and by district from Sierra Leone

EBOLA SITUATION REPORT Figure 6: Time since last confirmed case in Guinea, Liberia, and Sierra Leone

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. 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.

EBOLA SITUATION REPORT Figure 7: Location of Ebola treatment centres in Guinea, Liberia, and Sierra Leone

ETCs scheduled for closure will be decommissioned only when and where the epidemiological situation and the strength of referral pathways through non-EVD facilities allow. Several ETCs will be unstaffed but remain on a stand-by level of readiness, whereby stocks of protective equipment and essential medicines will be kept on-site such that the facility can become operational within 48 hours. This transition would be triggered by higher occupancy rates in nearby ETCs. Strategically located core ETCs will remain fully operational at their current capacity (Maintain). 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.

EBOLA SITUATION REPORT Figure 8: Location of laboratories in Guinea, Liberia, and Sierra Leone

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.

EBOLA SITUATION REPORT 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 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.  From October 2014 to August 2015 WHO has undertaken over 285 field deployments to priority countries to assist with the implementation of national plans.  WHO provides personal protective equipment (PPE) modules containing minimum stocks to cover staff protection and other equipment needs to support 10 patient-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 1 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 initial PST assessment missions to the 14 priority countries in 2014, a second phase of preparednessstrengthening activities have provided support on a country-by-country basis. Activities in the week to 30 August are highlighted below.  In Gambia, WHO supported the training of a National Rapid Response Team in Banjul from 24 to 28 August.  In Guinea Bissau, preparedness support continues to be provided at the central level, and in two priority regions (Tombali and Gabu) through WHO sub-offices. Weekly progress updates are undertaken to identify and address any issues. Activities implemented by WHO and partners and with the national authorities during the reporting period include: a community engagement activity with a well-known traditional healer; a meeting with the Governor of Gabu to update him on plans and activities in the region; health worker training in health centres and Gabu regional hospital.

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.  Simulations are being scheduled in Benin, Burkina Faso, Ethiopia, Ghana, and Mauritania.  Rapid-response team training is currently being planned for points-of-entry in Mauritania.  Training in clinical management and IPC is being planned for Côte d’Ivoire.

EBOLA SITUATION REPORT 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 that share a border with affected countries: Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal.  An interactive preparedness dashboard based on the WHO EVD checklist3 is available online.

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, 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 Case management Case finding, laboratory services, and contact tracing Safe and dignified burials Lead agency WHO WHO International Federation of Red Cross and Red Crescent Societies (IFRC)

Community engagement and social mobilization UNICEF

3 4

See: http://who.int/csr/resources/publications/ebola/ebola-preparedness-checklist/en/ See: http://apps.who.int/ebola/preparedness/map

EBOLA SITUATION REPORT ANNEX 2: DEFINITION OF KEY PERFORMANCE INDICATORS FOR PHASE 2 OF THE EBOLA RESPONSE Indicator Cases and deaths Number of confirmed cases Number of confirmed deaths Number of confirmed deaths that occurred in the community Diagnostic Services Number of samples tested and percentage with positive EVD results Contact tracing Percent of new confirmed cases from registered contacts Hospitalization Time between symptom onset and hospitalization (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 hospitalization of confirmed, probable or suspected cases (geometric mean number of days) # of confirmed cases Guinea: Daily WHO situation reports Sierra Leone: Daily Ministry of Health Ebola situation reports Guinea: Daily WHO situation reports Sierra Leone: Daily Ministry of Health Ebola situation reports Guinea: Weekly WHO situation reports Sierra Leone: Daily Ministry of Health N/A

Numerator

Numerator source

Denominator

Denominator source Jan

N/A

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

N/A

N/A 25 Jan

# of new samples tested # of new samples tested with a positive EVD result 18 Jan

Guinea: Laboratory database Sierra Leone: Daily Ministry of Health Ebola situation reports

N/A # of new samples tested

Guinea: Laboratory database Sierra Leone: Daily Ministry of Health Ebola situation reports 25 Jan

# of new confirmed cases registered as a contact

Guinea: Weekly WHO situation reports Sierra Leone: Weekly Ministry of Health Surveillance Report

# of new confirmed cases

Guinea: Daily WHO situation reports Sierra Leone: Daily Ministry of Health Ebola situation Reports

Clinical investigation records

N/A

Clinical investigation records

Infection Prevention and Control (IPC) and Safety18 Jan25 Jan Number of newly Guinea: Daily WHO situation reports # of newly infected health infected health Sierra Leone: Daily Ministry of Health workers workers Ebola situation Reports Safe and dignified burials18 Ja25 Jan # of reports/alerts of Guinea: Daily WHO situation reports Number of unsafe burials that were not Sierra Leone: Ministry of Health burials reported known to be safe situation reports 18 Jan Social mobilization Number of districts # of districts with at least with at least one one security incident or Guinea: Daily WHO situation reports security incident or other form of refusal to Sierra Leone: UNICEF other form of refusal cooperate in the past week to cooperate

N/A

N/A Jan

N/A 18 Jan25 Jan

N/A

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Technical Documents

Date d'adoption 2 septembre 2015

Source Organisation mondiale de la santé