IDSR Epidemiology Bulletin 2016 Epi Week 46 (November 14 – 20)

Data Source: CSOs from 15 Counties and Lab Highlights  Seven neonatal deaths reported from three counties  Twenty-three suspected cases of measles reported from three counties, of which seven were reported from a single facility in ,  Eighteen clinically confirmed cases of pertussis were reported from  Thirteen laboratory results received for measles, of which one was positive from

Reporting Coverage 99% (737/745) of expected health facilities reported from 90 health districts across 15 counties. 99% (731/737) of health facilities submitted timely reports to the district level. 98% (86/88) of health districts submitted timely reports to county level. Two (2) districts in did not report. 100% (15/15) of counties submitted timely reports to the national level.

Vaccine Preventable Diseases Measles  Twenty-three (23) suspected cases reported. Montserrado (14), Margibi (8) and Lofa (1).  Specimens were collected from sixteen (16) out of the twenty (20) cases for laboratory confirmation.  Cumulatively, 967 cases have been reported: Lab-confirmed (125), Epi-linked (484), compatible (149), suspected (46) and discarded (163) (Figure 2). CFR 0.8% (n=5).  Liberia's annualized non-measles febrile rash illness rate stands at 4.5 per 100,000. Grand Cape Mount, Nimba, Rivercess, River Gee and Sinoe Counties are below the target of 2/100,000 (Table 1).  Of the total 967 cases reported (Lab confirmed, Epi-linked and suspected), 15% were reportedly previously vaccinated, 39% were unvaccinated, and 47% had unknown vaccination status.  33% of the confirmed and suspected cases are below 5 years.

1 Liberia IDSR Epidemiology Bulletin 2016 Epi Week 46 (November 14 – 20)

Table 1. Distribution of Reported Measles Cases by County and Epi-Classification, Liberia, Week 1 - 46, 2016

Annualized Non Lab Epi- Measles Febrile County Confirmed Linked Compatible Suspected Discarded Total Rash Illness Rate Bomi 2 2 3 0 17 24 19.3 Bong 10 49 3 3 13 78 3.7 Gbarpolu 0 0 5 0 4 9 4.6 Grand Bassa 20 116 5 0 13 154 5.6 Grand Cape Mount 0 0 1 0 0 1 0.0 Grand Gedeh 0 0 15 3 6 24 4.6 Grand Kru 0 0 0 0 3 3 5.0 Lofa 4 29 75 8 15 131 5.2 Margibi 47 163 0 12 44 266 20.1 Maryland 0 0 0 0 5 5 3.5 Montserrado 41 104 35 19 32 231 2.7 Nimba 1 21 5 0 8 35 1.7 Rivercess 0 0 0 0 1 1 1.4 River Gee 0 0 1 0 0 1 0.0 Sinoe 0 0 0 1 2 3 1.9 NP 0 0 1 0 0 1 Liberia 125 484 149 46 163 967 4.5 Target Achieved >=2 Below Target <2

Acute Flaccid Paralysis  Two (2) suspected cases reported. Grand Cape Mount (1) and Montserrado (1).  Cumulatively, 65 cases of AFP have been recorded: Zero confirmed, 49 discarded and 16 pending lab confirmation.  As of week 46, the annualized non-polio AFP rate is at 4 per 100,000 population in less than 15 years of age (Table 2). Table 2: Non-polio AFP rate/100,000 <15yrs, Liberia, Epi week 1-46, 2016 Non-Polio AFP % of stool County < 15 years pop Reported % of NPENT Rate <14days Bomi 44700 4 10.1 100% 50% Bong 177210 10 6.4 60% 20% Gbarpolu 44312 1 2.6 100% 0% Grand Bassa 117807 3 2.9 67% 67% Grand Cape Mount 67527 2 3.3 100% 0% Grand Gedeh 66562 3 5.1 100% 0% Grand Kru 30775 2 7.3 100% 0% Lofa 147124 7 5.4 100% 0% Margibi 111552 5 5.1 100% 100% Maryland 72237 2 3.1 100% 0% Montserrado 594229 12 2.3 58% 33% Nimba 245519 7 3.2 71% 14% Rivercess 35492 1 3.2 100% 0% River-Gee 38000 2 5.9 50% 0% Sinoe 54410 4 8.3 100% 50% Liberia 1847457 65 4.0 80% 28% <2 = Non-Polio AFP Rate ≥ 2 = <80% = Stool adequacy ≥80% = <10% = Non-Polio Enterovirus ≥10% = Silent

2 Liberia IDSR Epidemiology Bulletin 2016 Epi Week 46 (November 14 – 20)

Neonatal Tetanus  Zero cases reported.  Cumulatively, 21 cases have been reported. CFR is 33% (n=7).

Viral Hemorrhagic Diseases Ebola Virus Disease (EVD)  A total of sixty-one (61) suspected cases Figure 3: Number of EVD alerts reported, Liberia, Epi week 1-46, 2016 reported (4 alive and 57 dead) of which 1600 1500 1400 samples were collected from sixty (60). 1300 1200 1100  40 samples tested (6 whole blood and 34 oral 1000 900 800 swab). 39 samples were tested negative and 1 700 600 indeterminate. Overall samples were submitted 500 400 300 from 12 counties. 200 Number of suspected cases reported cases suspected of Number 100

 Cumulatively, 29,154 alerts have been reported 0

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Week44 Week45 out of which three (3) were confirmed. CFR in Week46 Reporting week confirmed cases is 33.3% (n=1). Alive Dead

Table 3. Count of patient samples tested for EVD by county and samples type, Liberia, Epi-week 43 - 46, 2016

Geographical Week 43 Week 44 Week 45 Week 46 Distribution Whole Oral Whole Oral Whole Oral Whole Oral Blood Swab Blood Swab Blood Swab Blood Swab All Counties 10 166 12 79 6 92 6 34

By County

Bomi 6 16 1 3 0 14 1 3 Bong 0 4 1 0 2 1 1 5 Gbarpolu 0 1 0 0 0 0 0 2 Grand Bassa 0 3 0 3 0 0 1 4 Grand Cape Mount 0 0 0 0 0 1 2 2 Grand Gedeh 0 1 0 0 0 9 0 3 Grand Kru 0 0 3 0 0 0 0 0 Lofa 0 10 0 6 0 8 0 1 Margibi 0 5 4 2 3 4 0 4 Maryland 1 2 0 0 0 7 0 0 Montserrado 2 86 0 43 0 31 0 6 Nimba 0 28 3 17 0 7 0 0 Rivercess 0 0 0 1 0 6 0 3 River Gee 0 2 0 2 0 2 1 0 Sinoe 0 8 0 2 1 2 0 1 Unknown 0 0 0 0 0 0 0 0

Lassa Fever  Zero cases reported.  Cumulatively, 68 cases have been reported, of which 12 confirmed, 29 not a case, 27 suspected (13 awaiting lab confirmation: 5 from Epi week 38, 3 for Epi week 39, 2 from Epi week 43 and 1 each from Epi week 40, 42 and 44).  CFR for suspected and confirmed cases is 61% and for confirmed cases is 33%.  Bong County accounts for 58% of the total confirmed cases.

3 Liberia IDSR Epidemiology Bulletin 2016 Epi Week 46 (November 14 – 20)

Yellow Fever  Four (4) cases reported. Bomi (2), Margibi (1) and Grand Cape Mount (1).  Cumulatively, 44 cases have been reported, of which thirty (30) tested negative and thirteen (13) are pending laboratory confirmation.

Meningitis  Zero cases reported.  Cumulatively, 26 suspected cases have been reported.

Events of Public Health Importance Maternal Mortality  Six (6) maternal deaths reported. Bong (2), Montserrado (1), Margibi (1), Gbarpolu (1) and Grand Cape Mount (1).  Primary causes of deaths were post-partum hemorrhage (2), eclampsia, severe anemia, amniotic fluid embolism and circulatory collapse.  All of the deaths were reported to have occurred in health facilities.  Cumulatively, 268 maternal deaths have been reported, of which 81% (217) were reported from health facilities and 19% (51) from communities.  Annualized maternal mortality ratio is at 172 per 100,000 live births (Table 3). The expected MMR based on 2013 Demographic Health Survey (DHS) is 1072 deaths per 100,000 live births.

4 Liberia IDSR Epidemiology Bulletin 2016 Epi Week 46 (November 14 – 20)

Table 4: Cumulative Maternal Deaths Reported by Counties, Liberia, Epi week 1-46,2016 No. of Maternal Deaths % of Deaths Annualized Maternal Counties Reported Reported Mortality Ratio Bomi 14 5 371 Sinoe 13 5 283 Grand Kru 7 3 269 Grand Cape Mount 15 6 263 Bong 36 13 240 Gbarpolu 8 3 214 Margibi 20 7 212 River Gee 6 2 200 Maryland 12 4 197 Rivercess 5 2 156 Grand Bassa 15 6 151 Grand Gedeh 8 3 142 Montserrado 66 25 131 Nimba 27 10 130 Lofa 16 6 129 Liberia 268 100 172

Neonatal Mortality  Seven (7) neonatal deaths were reported. Montserrado (3), Bong (3) and River Gee (1),  Primary causes of deaths were prematurity (3) birth asphyxia (2), neonatal sepsis and pneumonia.  All reported deaths occurred in health facilities.  Cumulatively, 468 neonatal deaths have been reported.  Annualized neonatal mortality rate is 6 per 1,000 live births. The expected NNMR based on 2013 DHS is 26 deaths per 1,000 live births.

5 Liberia IDSR Epidemiology Bulletin 2016 Epi Week 46 (November 14 – 20)

Table 5: Cumulative Neonatal Deaths Reported by Counties, Liberia, Epi week 1-46,2016 Annualized Neonatal Cumulative number of % of Deaths Mortality Rate Per 1,000 Live Counties Neonatal Deaths Reported Reported Births Grand Kru 20 4 16 River Gee 17 4 12 Grand Gedeh 29 6 11 Bong 75 16 10 Rivercess 13 3 8 Gbarpolu 14 3 8 Maryland 22 5 8 Montserrado 164 35 7 Sinoe 13 3 6 Lofa 32 7 5 Bomi 9 2 5 Grand Cape Mount 12 3 4 Grand Bassa 20 4 4 Margibi 10 2 2 Nimba 18 4 2 Liberia 468 100 6

Human Exposure to Animal Bites (Suspected Rabies)  Twenty-six (26) suspected cases reported. Montserrado (16), Grand Bassa (4), Lofa (3), Grand Gedeh (2) and Grand Kru (1).  Cumulatively, 958 suspected cases have been reported including 8 deaths. CFR is <1%.  Laboratory confirmation of rabies is currently unavailable in Liberia.

Bloody Diarrhea (Shigellosis)  One (1) case reported from Grand Kru County.  Cumulatively, 323 suspected cases have been reported.

Severe Acute Watery Diarrhea (Cholera)  Three (3) cases reported from Grand Kru County  Specimens was collected for all cases.  Cumulatively, 150 suspected cases have been reported including 2 deaths.

6 Liberia IDSR Epidemiology Bulletin 2016 Epi Week 46 (November 14 – 20)

Unexplained Cluster of Health Events Whooping Cough (Pertussis)  Seventeen (18) clinically confirmed cases were reported from Dorbor district in Grand Kru County.  Out of the 18 cases, 9 males and 9 females. 7 of the cases less than 5 years.  Erythromycin was given all of the cases.  Vaccination status shows that fifteen (15) unknown and three (3) pending investigation.

Public Health Measures National level i. Border counties are encouraged to heighten surveillance activities at PoEs and border communities due to reported outbreak of Rift Valley fever in Niger. ii. Counties encouraged to collect adequate samples for bacteriology testing from all suspected cases of cholera and bloody diarrhea with appropriate specimen collection kits. iii. IDSR National Training of Trainers is currently ongoing. iv. Dead body management training for community involvement is ongoing. v. Counties are encouraged to collect oral swab and report appropriately.

County Level  Full investigation for whooping cough is ongoing in Grand Kru County.  A three (3) days EnMOC training is ongoing in Grand Kru county  Temperature screening at PoEs and active surveillance ongoing in communities and health facilities.  Health education ongoing for Cholera, Measles and other notifiable diseases.

Maternal and Neonatal deaths  Maternal and newborn death review ongoing in Counties.

Vaccine Preventable Diseases  Isolation, management and active case search for measles cases ongoing in Margibi and Montserrado County  Investigation and management of suspected Yellow fever cases ongoing in affected Counties. Human Exposure to Animal Bite  Cases of animal bites (suspected human rabies) received post-exposure prophylaxis (anti-rabies vaccine) in Montserrado, Grand Bassa and Lofa. No information provided for Grand Kru.

Note  Completeness refers to the proportion of health facilities in the country that reported during the week.  Timeliness of report is based on the proportion of health facilities that submitted reports on or before 12 noon every Monday to the Division of Disease Prevention and Control (DPC), Ministry of Health (MoH).  Non-polio AFP rate is calculated by dividing the number of reported non-polio AFP cases by the expected cases per 100,000 populations under 15 years of age.  Non-measles febrile rash illness rate refers to the proportion of discarded cases per 100,000population.  Annualized maternal mortality ratio refers to the maternal mortality ratio ofa given period less than one year and it is the number of maternal deaths per 100,000 live births.  Epi-linked refers to any suspected case that has not had a specimen taken for serologic confirmation but is linked to a laboratory confirmed case.  Compatible case refers to a suspected measles case that is not epidemiologically linked to any lab confirmed case and whose specimen was not tested for laboratory confirmation.  Confirmed case refers to a case whose specimen has tested positive on laboratory testing.  Case Fatality Rate (CFR) is the proportion of deaths among confirmed cases.

7 Liberia IDSR Epidemiology Bulletin 2016 Epi Week 46 (November 14 – 20)

Epidemiological bulletin published with support of WHO and CDC

For comments or questions, please contact

Thomas K. Nagbe, PA DIP, BSC, MPH Director, Disease Prevention and Control National IHR Focal Point Ministry of Health Republic of Liberia Email: [email protected] Phone: 0886 937386/0777442444

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Liberia IDSR Epidemiology Bulletin 2016 Epi Week 46 ( November 14-20) Appendix 1: Summary of suspected cases and conditions by County during Epi week 46 and cumulative numbers, Liberia, 2016

ty

AFP

Other

Rabies

Cholera

Measles

Districts

Natal Tetanus Natal

Meningitis -

Lassa Lassa Fever

Yellow Yellow Fever

No. of No. Health of No. Health

Diseases/Events

District reportedDistrict

Bloody Bloody Diarrhoea

Maternal Mortality Maternal Neonatal Mortali Neo

Counties Exposure to Human

VHF (including EVD) VHF (including C D C D C D C D C D C D C D D D C D C D C D C D Bomi 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 2 0 0 0 Bong 8 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 3 0 0 4 11 0 0 0 0 Gbarpolu 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 Grand Bassa 8 8 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Grand Cape Mount 5 5 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 3 1 0 0 0 Grand Gedeh 6 6 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Grand Kru 5 5 0 0 1 0 3 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18 0 Lofa 6 6 0 0 0 0 0 0 3 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 Margibi 4 4 0 0 0 0 0 0 0 0 0 0 8 0 0 0 1 0 0 0 0 5 1 0 0 0 Maryland 6 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 Montserrado 7 7 1 0 0 0 0 0 16 0 0 0 14 0 0 0 1 3 0 0 0 16 0 0 0 0 Nimba 6 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Rivercess 6 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 River Gee 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 3 0 0 0 0 Sinoe 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 0 0 0 Total Weekly 90 90 2 0 1 0 3 0 26 0 0 0 23 0 0 0 6 7 0 0 4 57 4 0 18 0

Cumulative 65 0 323 3 150 2 958 8 66 28 967 7 24 1 268 468 19 7 22766 6348 41 3 781 3 Reported

Cumulative 0 0 0 0 0 0 0 0 8 4 599 5 0 0 10 7 2 1 0 0 0 0 Confirmed

Note: C = Case, D= Dead

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