IDSR Epidemiology Bulletin 2017 Epi Week 22 (May 29 – June 4, 2017)

Country Population: 4,373,279 l Volume 09, Issue 22 May 29 – June 4, 2017 l Data Source: CSOs from 15 Counties and Lab Highlights

Keynotes and Events of Public Health Figure 1. Public Health Events Reported in Epi-week 22

Significance  Seventy-two cases of public health events were reported across the country

 99% completeness in reporting from health facilities

 88% reporting timeliness from health facilities o Three counties health facilities timeliness was below the 80% target

 Six confirmed measles cases reported from the National Reference Laboratory

 Three ELISA-Antigen positive Lassa fever cases reported from the National Reference Laboratory

sent late report to the National level

Reporting Coverage

Table 1. Weekly IDSR Reporting Coverage, Liberia, Epi week 22, 2017

Number of Number Number Health Facility of Reports Received Completeness Timeliness 756 (98%) County Report Expected Received on Time (%) (%) Health facilities Bomi 23 23 23 100 100 out of 761 Bong 55 55 55 100 100 reported IDSR Gbarpolu 15 15 11 100 73 data Grand Bassa 33 33 33 100 100 Grand Cape Mount 32 32 32 100 100 Grand Gedeh 24 24 24 100 100 Grand Kru 19 19 13 100 68 90 (100%) Lofa 59 59 59 100 100 Health districts out of Margibi 44 44 44 100 100 90 reported Maryland 25 25 25 100 100 IDSR data Montserrado 284 280 205 99 72 Nimba 75 74 74 99 99 Rivercess 19 19 19 100 100 River Gee 19 19 19 100 100 671 (88%) Sinoe 35 35 35 100 100 Health facility timeliness for Liberia 761 756 671 99 88 weekly IDSR reporting Legend ≥80 <80

 The national target for weekly IDSR reporting is 80%

IDSR Weekly Epidemiology and Surveillance Bulletin Page 1

Liberia IDSR Epidemiology Bulletin 2017 Epi Week 22 (May 29 – June 4, 2017)

IDSR Weekly Epidemiology and Surveillance Bulletin Page 2

Liberia IDSR Epidemiology Bulletin 2017 Epi Week 22 (May 29 – June 4, 2017)

Vaccine Preventable Diseases Measles  Nineteen suspected cases were reported from: Montserrado (6), Nimba (3), Margibi (3), Grand Cape Mount (3), Grand Bassa (2), Grand Gedeh (1), and Lofa (1)  Of the 19 suspected cases reported this week, 6 (32%) were reported to have been previously vaccinated and 13 (68%) had unknown vaccination status  Five (26%) of the suspected cases were <5 years and fourteen (74%) were ≥5 years of age  The six confirmed cases were reported from Commonwealth (2) and Somalia Drive (1) in , Gola Konneh (1) in , Sanniquellie Mah (1) in Nimba, and Gbarma (1) in  Cumulatively, since Epi week one, 864 suspected cases have been reported, of which 684 were tested: 84 (12.2%) positive, 568 (65.7%) negative and 32 (4.7%) equivocal. One hundred twenty of the suspected cases were compatible and epi-linked while sixty pending laboratory confirmation. Of the 600 equivocal and negative cases, 291 (48.5%) samples have been tested for rubella, of which, 135 (46.4%) were positive

Public Health Actions  Active case search ongoing in affected Counties  In , , re-active immunization was cconducted, case management and surveillance is ongoing  Samples were collected from 17 suspected cases and sent to the National Reference Laboratory for confirmation

Figure 3. Comparison of Suspected Cases of Measles Reported, Liberia, Epi weeks 1 – 22, 2016 & 2017

Acute Flaccid Paralysis (Suspected Polio)  Two cases of Acute Flaccid Paralysis were reported from Bong and Lofa counties  Cumulatively, since Epi week one, 64 AFP cases have been reported, of which, 59 (92%) have been tested negative for poliovirus and 5 (8%) are pending laboratory confirmation

IDSR Weekly Epidemiology and Surveillance Bulletin Page 3

Liberia IDSR Epidemiology Bulletin 2017 Epi Week 22 (May 29 – June 4, 2017)

Public Health Actions  Samples were collected from the two cases reported and sent to laboratory for confirmation  Active surveillance ongoing in all fifteen (15) counties

Table 2: Non-polio AFP rate/100,000 <15yrs, Liberia, Epi weeks 1 - 22, 2017 # of cases # of AFP # of Cases <14 days <15 years Cases with Lab Non-Polio specimen % of stool # of % of County pop Reported Result AFP Rate collected <14days NPENTs NPENT Bomi 45639 4 4 20.7 4 100 1 25 Bong 180932 3 2 3.9 3 100 0 0 Gbarpolu 45243 0 0 - - - - - Grand Bassa 120281 2 2 3.9 1 50 2 100 Grand Cape Mount 68945 2 2 6.9 2 100 0 0 Grand Gedeh 67959 4 4 13.4 4 100 1 25 Grand Kru 31421 1 0 7.5 0 - - - Lofa 150214 9 8 14.2 8 89 0 0 Margibi 113895 8 8 16.6 8 100 2 25 Maryland 73754 2 2 6.4 1 50 0 0 Montserrado 606708 11 11 4.3 5 45 0 0 Nimba 250675 7 6 6.6 7 100 1 17 Rivercess 36237 6 6 39.1 5 83 3 50 River-Gee 38798 3 2 18.3 1 33 1 50 Sinoe 55553 2 2 8.5 1 50 0 0 Liberia 1886254 64 59 8.0 50 78 11 19

<2 <80% Non-Polio <10% Non-Polio AFP Rate Stool Adequacy Silent ≥2 ≥80% Enterovirus ≥10%

Neonatal Tetanus  Zero cases of Neonatal tetanus were reported  Cumulatively, since Epi week one, 6 clinically diagnosed cases have been reported

Viral Hemorrhagic Diseases Ebola Virus Disease (EVD)  One EVD alert was reported from  Cumulatively, since Epi week one, 297 EVD alerts have been reported, all of which have been tested negative

Lassa fever  Two suspected cases including one death attributed to Lassa Fever were reported from Grand Bassa (alive) and Margibi (dead) Counties  Twelve cases results were received from the National Reference Laboratory, of which, three (3) were ELISA- Antigen positive, two (2) ELISA-Antibody IgM positive, six (6) ELISA-Antibody IgG positive, and one (1) negative  Cumulatively, since Epi week one, 25 suspected cases have been reported including five deaths. Of the total cases, seven (7) have been confirmed positive by RT-PCR and ELISA-Antigen, 10 negative and 8 are pending Epi classification. The case fatality rate in confirmed cases is 29%. Public Health Actions  Samples have been collected and sent to the laboratory for confirmation  The live case has been isolated and clinical management is ongoing

Yellow fever  Four suspected cases were reported from Grand Kru (2), Grand Gedeh (1) and Lofa (1) Counties  Cumulatively, since Epi-week one, 111 suspected cases have been reported, 68 samples tested negative and 42 are pending laboratory confirmation. One case with date of onset in 2016 was confirmed positive for ELISA IgM, but PCR testing done in 2017 was negative IDSR Weekly Epidemiology and Surveillance Bulletin Page 4

Liberia IDSR Epidemiology Bulletin 2017 Epi Week 22 (May 29 – June 4, 2017)

Public Health Actions  Specimens were collected from all suspected cases and pending Laboratory confirmation  Active case search ongoing in affected counties

Meningitis  One suspected case of meningitis was reported from River Gee County.  Cumulatively, since Epi week one, 14 suspected cases have been reported. An additional 31 cases (including 13 deaths) have been reported as part of an outbreak in three counties (Grand Bassa, Montserrado and Sinoe), with Neisseria meniningitidis serogroup C confirmed in 13 cases (including 11 deaths and 3 alive)  Three (3) negative results from Grand Kru, Grand Bassa including the one case reported from River Gee.

Public Health Actions  Active surveillance ongoing  Specimen was collected and tested negative

Events of Public Health Importance Maternal Mortality  Five maternal deaths were reported from Margibi (2), Bomi (1), Grand Bassa(1), and Grand Cape Mount (1) Counties  Reported causes of deaths were postpartum hemorrhage (2), postpartum sepsis (1), ruptured uterus (1) and eclampsia (1)  Three of the deaths were reported to have occurred in health facility and two in the community.  Cumulatively, since Epi-week one, 109 maternal deaths have been reported (see Table 3 for causes of death)

Figure 4. Comparison of the trend of Maternal Table 3. Causes of Maternal Death, Liberia, Epi Deaths Reported, Liberia, Epi weeks 1-22, 2016 & weeks 1-22, 2017 (n=109) 2017 Maternal Death Number Percentage Post-partum hemorrhage 38 34.8 Sepsis 15 13.7 Anemia 14 12.8 Eclampsia 7 6.4 Ruptured uterus 6 5.5 Renal failure 4 3.6 Congestive heart failure 4 3.6 Abruptio placenta 3 2.8 Unknown 3 2.8 Pre-eclampsia 3 2.8 Multiple organ failure 2 1.8 Obstructed labor 2 1.8 Cardiac pulmonary failure 2 1.8 Disseminated intravascular coagulation 1 1.0 Amniotic fluid embolism 1 1.0 Respiratory distress 1 1.0 Umbilical hernia (Omphalocele) 1 1.0 Spinal shock 1 1.0 Prolonged labor 1 1.0 Total 109 100

IDSR Weekly Epidemiology and Surveillance Bulletin Page 5

Liberia IDSR Epidemiology Bulletin 2017 Epi Week 22 (May 29 – June 4, 2017)

Table 4. Cumulative Maternal Deaths Reported by Counties, Liberia, Epi weeks 1-22, 2017

Cumulative Annualized Annual Live Current Maternal % of Cumulative Maternal Mortality County birth1 week deaths Maternal deaths Rate/ 100,000 Bomi 4361 1 7 6 522 Grand Bassa 11494 1 13 12 368 Grand Kru 3002 0 3 3 325 River Gee 3707 0 3 3 263 Sinoe 5308 0 4 5 245 Maryland 7048 0 5 6 231 Bong 17289 0 10 10 188 Lofa 14354 0 8 8 181 Margibi 10883 2 8 7 239 Nimba 23953 0 13 13 176 Montserrado 57974 0 31 30 174 Rivercess 3463 0 1 1 94 Gbarpolu 4323 0 1 1 75 Grand Gedeh 6494 0 1 1 50 Grand Cape Mount 6588 1 1 1 49 Liberia 180242 5 109 100 197

Neonatal Mortality

 Fourteen neonatal Figure 5. Causes of Neonatal Death, Liberia, Epi weeks 1-22, 2017 (n=266)

deaths were reported

from Montserrado (4),

Bong (3) River Gee (2),

Maryland (2) Lofa (1),

Margibi (1), and Sinoe

(1) Counties

 Reported causes of

death were:

o Neonatal sepsis (6 )

o Birth asphyxia (6)

o Pneumonia (1)

o Acidosis (1)

 Thirteen of the deaths

were reported to have

occurred at health

facility and one in the

community

 Cumulatively, since Epi

week one, 266 neonatal

deaths have been

reported

1 Number of live birth is at 4.3% of the estimated population for 2017 (Source: EPI/MoH) IDSR Weekly Epidemiology and Surveillance Bulletin Page 6

Liberia IDSR Epidemiology Bulletin 2017 Epi Week 22 (May 29 – June 4, 2017)

Table 5. Cumulative Neonatal Deaths Reported by Counties, Liberia, Epi weeks 1-22, 2017 Annual Live Current Cumulative % of Cumulative Annualized Neonatal County birth2 week Neonatal Deaths Neonatal Deaths Mortality Rate/1,000 River Gee 3707 2 17 6 14.9 Maryland 7048 2 30 11 13.8 Sinoe 5308 1 17 6 10.4 Grand Kru 3002 0 9 4 9.7 Rivercess 3463 0 6 3 7.5 Bong 17289 3 29 11 5.5 Lofa 14354 1 18 7 4.4 Montserrado 57974 4 103 39 5.8 Grand Gedeh 6494 0 7 3 3.5 Gbarpolu 4323 0 3 2 2.3 Margibi 10883 1 7 3 2.2 Nimba 23953 0 11 4 1.5 Grand Bassa 11494 0 5 3 1.4 Bomi 4361 0 1 0 0.7 Grand Cape Mount 6588 0 1 1 0.5 Liberia 180242 14 266 100 4.8

Human Exposure to Animal Bites (Suspected Rabies)  Fourteen cases of animal bites were reported from Montserrado (8), Lofa (1), Grand Bassa (1), River Gee (1), Rivercess (1) , Grand Cape Mount (1) and Nimba (1)  Cumulatively, since Epi week one, 699 events of animal bites have been reported

Public Health Actions  All cases received post-exposure prophylaxis (anti-rabies vaccine)

Bloody Diarrhea (Shigellosis)  Nine cases of bloody diarrhea were reported from Sinoe (5), Montserrado (2), Lofa (1) and Grand Bassa (1) Counties  Cumulatively, since Epi week one, 122 cases of bloody diarrhea have been reported, of which 5 (4%) were confirmed positive for shigella, 55 (45%) were negative and 55 (45%) are pending laboratory testing

Severe Acute Watery Diarrhea (Cholera)  One suspected case of cholera were reported from  Cumulatively, since Epi week one, 116 suspected cases of cholera have been reported, including 4 deaths attributable to cholera. Of the 30 samples collected, 2 (7%) were confirmed positive, 9 (30%) have tested negative, 19 (63%) are pending laboratory confirmation and 5 (17%) were rejected for sample inadequacy

Public Health Measures National level  National Reference Laboratory has received samples of cases from the affected Counties and are being processed for analysis  Work with Counties to determine response state of preparedness (lab specification for CSF collection and transportation, medical supplies and IPC)  Implementation of an Auto Visual AFP detection and reporting (AVADAR) surveillance in 4 districts in Montserrado County

2 Number of live birth is at 4.3% of the estimated population for 2017 (Source: EPI/MoH) IDSR Weekly Epidemiology and Surveillance Bulletin Page 7

Liberia IDSR Epidemiology Bulletin 2017 Epi Week 22 (May 29 – June 4, 2017)

 Follow up with counties to conduct maternal deaths investigation, revision of forms and implementation of recommendations made  Counties are encouraged to conduct health education for all public health diseases based on risk  Counties are encouraged to update their cholera preparedness plans and review existing stocks of supplies for prepositioning

Notes  Completeness refers to the proportion of expected weekly IDSR reports received (target: ≥80%)  Timeliness refers to the proportion of expected weekly IDSR reports received by the next level on time (target: ≥80%). Time requirement for weekly IDSR reports: o Health facility - required on or before 5:00pm every Saturday to the district level o Health district - required on or before 5:00pm every Sunday to the county level o County - required on or before 5:00pm every Monday to the national level  Non-polio AFP rate is the proportion of non-polio AFP cases per 100,000 among the estimated population under 15 years of age in 2017 (annual target: ≥2/100,000)  Non-measles febrile rash illness rate refers to the proportion of discarded measles cases per 100,000 population  Annualized maternal mortality rate refers to the maternal mortality rate of a given period less than one year and it is the number of maternal deaths per 100,000 live births  Annualized neonatal mortality rate refers to the neonatal mortality ratio of a given period less than one year and it is the number of maternal deaths per 1,000 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  Confirmed case refers to a case whose specimen has tested positive or reactive upon laboratory testing, or has been classified as confirmed by either epidemiologic linkage with a confirmed case, or clinical compatibility with the disease or condition  Case Fatality Rate (CFR) is the proportion of deaths among confirmed cases

IDSR Weekly Epidemiology and Surveillance Bulletin Page 8

Liberia IDSR Epidemiology Bulletin 2017 Epi Week 22 (May 29 – June 4, 2017)

Appendix 1: Summary of immediately reportable diseases, conditions, and events by County during Epi week 22 and cumulative reports, Liberia, 2017

VHF

Lassa Lassa

Fever

Other

(Polio)

Tetanus

Measles

vere Acute

Paralysis

Neonatal

(Cholera)

Meningitis

Districts

reported

(Shigellosis)

Animal bites Animal

Yellow Fever

Se

Acute Flaccid Acute Flaccid

(including EVD) (including

Diseases/Events

No. of Health ofNo. Health

Bloody Diarrhoea Bloody

Watery Diarrhoea Diarrhoea Watery

(Suspected Rabies)

Maternal Mortality Maternal

Neonatal Mortality Neonatal

Human Exposure to Human

Counties District ofNo. Health A D A D A D A D A D A D A D D D A D A D A D A D Bomi 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 Bong 8 8 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 Gbarpolu 5 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Grand Bassa 8 8 0 0 1 0 1 0 1 0 1 0 2 0 0 0 1 0 0 0 0 0 0 0 0 0 Grand Cape Mount 5 5 0 0 0 0 0 0 1 0 0 0 3 0 0 0 1 0 0 0 0 0 0 0 0 0 Grand Gedeh 6 6 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 Grand Kru 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 Lofa 6 6 1 0 1 0 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 Margibi 4 4 0 0 0 0 0 0 0 0 0 1 3 0 0 0 2 1 0 0 0 0 0 0 0 0 Maryland 6 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 Montserrado 7 7 0 0 2 0 0 0 8 0 0 0 6 0 0 0 0 4 0 0 0 0 0 0 0 0 Nimba 6 6 0 0 0 0 0 0 1 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 Rivercess 6 6 0 0 0 0 0 0 1 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 1 0 0 0 0 0 1 0 0 2 0 0 0 0 0 0 0 0 Sinoe 10 10 0 0 5 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 Total Weekly 90 90 2 0 9 0 1 0 14 0 1 1 19 0 1 0 0 0 0 0 0 0 0 0 0 0

Cumulative Reported 64 0 122 0 116 5 699 1 16 9 864 1 12 2 109 266 6 0 29 268 110 1 1794 23

Cumulative Laboratory 0 0 5 0 2 0 0 0 5 2 84 0 0 0 0 0 0 0 0 0 0 0 Confirmed

Note: A = Alive Editorial Team - MoH: Roseline N. George – Deputy Director/DPC; Advertus N. Mianah – Surveillance Coordinator/DPC; Irene Pewu & Himiede W. Wilson – Epidemiologist/DIDE; Sumo Nuwolo, Musand Kromah, Lasee W. Colee, T. Lafayette Hall, Alberta B. Corvah, Sumor Flomo & Samuel Zayzay – Disease Investigators/DIDE; Trokon O. Yeabah – Data Manager/DIDE; Patrick Hardy – D = Dead NRL/NPHIL; Partners: Dr. E. Kainne Dokubo, Carl Kinkade & Cheryl L. Williams – CDC; George Sie Williams, Kwuakuan D.M. Yealue & Jeremy Sesay – WHO

IDSR Weekly Epidemiology and Surveillance Bulletin Page 9

Epidemiological bulletin published with support of WHO and CDC

For comments or questions, please contact

Thomas K. Nagbe, PA Dip., BSc, MPH

Director, Infectious Disease and Epidemiology Division

National IHR Focal Person

National Public Health Institute of Liberia

Republic of Liberia

Email: [email protected] Phone: 0886 937386/0777442444 Website: www.moh.gov.lr

IDSR Weekly Epidemiology and Surveillance Bulletin Page 10