Liberia IDSR Epidemiology Bulletin

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Country Population: 4,433,398 Volume 11, Issue 5, January 28 - Feb 3, 2019 Data Source: CSOs from 15 Counties and Lab Highlights Figure 1. Public Health Events Reported in Epi week 5 Keynotes and Events of Public Health Significance • A total of 105 events of public health importance including 10 deaths were reported

• Completeness and timeliness of health facility reports were both 98%

• Ongoing Lassa fever outbreaks in Grand Bassa and Nimba Counties

• Ongoing Measles outbreaks in Grand Gedeh and Gbarpolu Counties

Reporting Coverage

Table 1. Health Facility Weekly IDSR Reporting Coverage, Liberia, Epi week 5, 2019 Number of Number of Number Expected Report Reports Received Completeness Timeliness 867(98%) County from Health Facility Received on Time (%) (%) Health Bomi 26 26 26 100 100 facilities Bong 57 57 57 100 100 reported IDSR Gbarpolu 16 16 16 100 100 data Grand Bassa 34 34 34 100 100 Grand Cape Mount 34 34 34 100 100 Grand Gedeh 24 24 24 100 100 Grand Kru 19 19 19 100 100 92(99%) Lofa 59 59 59 100 100 Health districts reported IDSR Margibi 59 57 57 97 97 data Maryland 26 26 26 100 100 Montserrado 367 354 354 96 96 Nimba 84 84 84 100 100

Rivercess 20 20 20 100 100 River Gee 20 20 20 100 100 867(98%)

Sinoe 37 37 37 100 100 Health facilities out of 882 Liberia 882 867 867 98 98 reported timely Legend: ≥80 <80 IDSR data

• The national target for weekly IDSR reporting is 80% • All counties submitted weekly IDSR report on time to national level

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Vaccine Preventable Diseases Measles • Fifty (50) suspected cases were reported from Montserrado (18), Grand Gedeh (6), Grand Kru (6), Sinoe (6), Margibi (4), Grand Bassa (4), Rivercess (2), Nimba (2), Bong (1) and River Gee (1) • Forty (40) specimens were collected; thirty-five tested by the National Public Health Reference Laboratory o Eight lab-confirmed (positive): Montserrado (2), Margibi (2), River Gee (1), Sinoe (1), Rivercess (1), Grand Kru (1) o Twenty-seven discarded (negative) o Two pending testing while three pending arrival • Tchien District in Grand Gedeh County and Bokomu in Gbarpolu County are currently in outbreak • Vaccination status: o Vaccination status among suspected cases: 24 (48%) vaccinated, 9 (18%) not vaccinated and 17 (34%) unknown o Vaccination status among confirmed cases: 3 vaccinated, 2 not vaccinated and 3 unknowns • Age distribution o Age distribution among suspected cases: <1 year: 3 (6%), 1 – 4 years: 14 (28%) and ≥5 years: 33 (66%) o Age distribution among confirmed cases: <1 year: 1 (12.5%), ≥5 years: 7 (87.5%) • Cumulatively, since Epi-week one, 170 suspected cases including zero deaths have been reported. Of these, 109 have been tested by the laboratory and results showed 31 positive, 75 negative and 3 equivocal • Epi-classification are as follows: 92 (54%) confirmed (lab confirmed 31, clinically confirmed 47, epi-linked 14) cases, 3 (1.8%) indeterminate and 75 (44%) discarded. See table 2

Public Health Action • Active case search, health education, and community engagement are ongoing in districts that reported • Mini vaccination campaign ongoing in the surrounding communities of affected community

Table 2. Cumulative Measles Cases Reported by County and Epi-classification, Liberia, Epi-week 1 - 5, 2019 Epi-classification Annualized Non- Lab Epi- Clinically Measles Febrile Reporting County confirmed linked confirmed Indeterminate Discarded Total Rash Illness Rate Bomi 0 0 0 0 0 0 0.0 Bong 4 0 1 1 5 11 11.9 Gbarpolu 4 0 0 0 0 4 0.0 Grand Bassa 0 2 10 0 5 17 18.7 Grand Cape Mount 0 0 0 0 1 1 6.5 Grand Gedeh 8 8 1 0 10 27 66.1 Grand Kru 4 4 3 0 3 14 42.9 Lofa 0 0 1 0 0 1 0.0 Margibi 3 0 0 1 4 8 15.8 Maryland 0 0 0 0 0 0 0.0 Montserrado 5 0 1 1 26 33 18.6 Nimba 0 0 1 0 4 5 7.2 River Gee 1 0 0 0 9 10 111.5 Rivercess 1 0 1 0 5 7 57.9 Sinoe 1 0 28 0 3 32 24.2 Liberia 31 14 47 3 75 170 17.6 Target Achieved >=2 Below Target <2

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Figure 2. Confirmed Measles Cases Reported by Health District, Liberia, Epi-week 5, 2019

Acute Flaccid Paralysis (Suspected Polio) • One (1) case was reported from Grand Bassa County • Specimen was collected and pending shipment • Cumulatively, since Epi week one, 6 cases have been reported and pending laboratory confirmation

Table 3. Non-polio AFP rate per 100,000 population less than 15 years, Liberia, Epi-week 1 - 5, 2019 # of AFP # of Cases # of cases <14 < 15 Cases with Lab Non-Polio days specimen % of stool # of % of County years pop Reported Result AFP Rate collected <14days NPENTs NPENT Bomi 47576 0 0 0.0 0 0% 0 0% Bong 196480 0 0 0.0 0 0% 0 0% Gbarpolu 47163 0 0 0.0 0 0% 0 0% Grand Bassa 125386 1 0 10.4 1 100% 0 0% Grand Cape Mount 71872 1 0 18.1 1 100% 0 0% Grand Gedeh 70844 0 0 0.0 0 0% 0 0% Grand Kru 32755 0 0 0.0 0 0% 0 0% Lofa 156050 0 0 0.0 0 0% 0 0% Margibi 118729 1 0 10.9 1 100% 0 0% Maryland 76884 0 0 0.0 0 0% 0 0% Montserrado 653849 1 0 2.0 1 100% 0 0% Nimba 261314 0 0 0.0 0 0% 0 0% Rivercess 40444 0 0 0.0 0 0% 0 0% River Gee 37775 0 0 0.0 0 0% 0 0% Sinoe 57910 0 0 0.0 0 0% 0 0% Liberia 1995031 4 0 2.6 4 100% 0 0% <2 <80% Non-Polio <10% Non-Polio AFP Rate Stool adequacy Silent ≥ 2 ≥80% Enterovirus ≥10% IDSR Weekly Epidemiology and Surveillance Bulletin © 2019 Page 3

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Neonatal Tetanus • Zero case was reported • Cumulatively, since Epi-week one, 1 clinically diagnosed case has been reported

Viral Hemorrhagic Diseases Ebola Virus Disease (EVD) • Three alerts were reported from Montserrado County • Specimens were collected and tested negative • Cumulatively, since Epi-week one, 6 EVD alerts have been reported and tested negative

Lassa fever • Six (6) suspected cases were reported from Nimba County o All specimens were collected and pending testing • Cumulatively, since Epi week one, 15 suspected cases have been reported o Of these, eight have been tested by the laboratory. Epi-classification are as follows: 2 lab-confirmed, 6 not a case and 7 pending testing

Yellow fever • One (1) suspected case was reported from River Gee County o Specimen was collected and pending testing • Cumulatively, since Epi-week one, 9 suspected cases have been reported; eight tested negative and one pending testing

Monkey pox • One (1) case was reported from Bong County • Specimen was collected and pending shipment • Cumulatively, since Epi-week one, 3 suspected cases have been reported pending shipment

Meningitis • One (1) case was reported from Nimba County • Specimen was collected and tested negative • Cumulatively, since Epi-week one, 6 suspected cases have been reported and all tested negative

Events of Public Health Importance Maternal Mortality • Three (3) deaths were reported from Grand Bassa, Margibi and Montserrado Counties • Reported causes of deaths were: o Eclampsia (2), Postpartum Hemorrhage (1) • All deaths were reported to have occurred in health facilities • Cumulatively, since Epi-week one, 24 maternal deaths have been reported (See Table 4)

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Table 4. Annualized and Cumulative Maternal Deaths Reported by Counties, Liberia, Epi-week 1 - 5, 2019

Estimated Annual % of Cumulative Annualized Maternal County Live birth (4.3%) Current week Cumulative Maternal deaths Mortality Ratio/100,000 Grand Gedeh 6494 0 2 8 320 Maryland 7048 0 2 8 295 Margibi 10883 1 3 13 287 Grand Bassa 11494 1 3 13 271 Gbarpolu 4323 0 0 0 271 Bong 17289 0 3 13 180 Nimba 23953 0 3 13 130 Montserrado 57974 1 7 29 126 Lofa 14354 0 1 4 72 River Gee 3707 0 0 0 0 Bomi 4361 0 0 0 0 Grand Kru 3002 0 0 0 0 Rivercess 3463 0 0 0 0 Sinoe 5308 0 0 0 0 Grand Cape Mount 6588 0 0 0 0 Liberia (National) 190636 3 24 100 138

Neonatal Mortality • Sis (6) deaths were reported from Montserrado (3) and Bong (3) Counties • Reported causes of deaths were o Sepsis (5) o Preterm (1) • All deaths were reported to have occurred in health facilities • Cumulatively, since Epi-week one, 51 neonatal deaths have been reported (See Table 5)

Table 5. Annualized and Cumulative Neonatal Deaths Reported by Counties, Liberia, Epi-week 1 - 5, 2019 Estimated Annual Live Current % of Cumulative Annualized Neonatal County birth (4.3%) Week Cumulative Neonatal deaths Mortality Rate/1000 Maryland 7048 0 5 10 18.4 Grand Kru 3002 0 2 4 17.3 River Gee 3707 0 2 4 14.0 Montserrado 57974 3 26 51 11.7 Lofa 14354 0 6 12 10.9 Bong 17289 3 4 8 6.0 Bomi 4361 0 1 2 6.0 Margibi 10883 0 2 4 4.8 Grand Bassa 11494 0 2 4 4.5 Grand Gedeh 6494 0 1 4 4.0 Rivercess 3463 0 0 6 0.0 Gbarpolu 4323 0 0 0 0.0 Sinoe 5308 0 0 0 0.0 Nimba 23953 0 0 0 0.0 Grand Cape Mount 6588 0 0 0 0.0 Liberia (National) 190636 6 51 100 7.3

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Other Reportable Disease Exposure to Human Rabies (Animal Bites) • Twenty-three (23) cases were reported from Nimba (7), Montserrado (5), Rivercess (3), Grand Bassa (3), Margibi (2) Bong (2) and Maryland (1) • Cumulatively, since Epi-week one, 145 suspected cases of animal bites have been reported in human

Acute Bloody Diarrhea (Suspected Shigellosis) • Nine (9) suspected cases were reported from Rivecess (3), Grand Gedeh (2), Grand Kru (1), Maryland (1), Margibi (1) and Sinoe (1) Counties • Six specimens were collected; two tested negative and four pending testing • Cumulatively, since Epi-week one, 20 acute bloody diarrhea cases were reported with 12 stool specimens collected;

two tested positive, six negative and four pending testing

Severe Acute Watery Diarrhea (Cholera) • Zero case was reported • Cumulatively, since Epi-week one, 9 suspected cases has been reported

Unexplained Cluster of Health Events • One (1) death reported from Seema Town, Vahun District, Lofa County • No specimen was collected • Cumulatively, since Epi-week one, one case of unexplained death have been reported.

Points of Entry • Zero IDSR alerts detected and verified during this week • A total of 4763 travelers were recorded for the week (See Table 6)

Table 6. Total Travelers, IDSR Alerts Detected and Verified at Points of Entry, Liberia, Epi-week 5, 2019 Yellow Yellow Book Type of Weekly Book Damage/Card Travelers IDSR Alerts Ports Point of Entry total Arrival Departure Issued Replaced Vaccinated Alerts Verified Airport James S. 79 42 37 0 0 0 0 0 Paynes Robert International 3208 1478 1730 33 33 0 0 0 Airport Seaport Freeport of 124 62 62 0 0 0 0 0 Monrovia Buchanan Port 124 62 62 0 0 0 0 0

Ground Bo Water Side 538 186 352 38 38 0 0 0 Crossing Ganta 147 81 66 29 29 0 0 0 Yekepa 86 58 28 0 0 0 0 0 Loguatuo 320 163 157 0 0 0 0 0

Nursing 137 122 115 137 43 94 0 0 Division Total Traveler for the 4763 2254 2509 237 143 94 0 0 Week Note: Yellow book issue for both arrival and departure; Vaccination coverage for both arrival and departure

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AFRO Public Health Events The National Public Health Institute of Liberia continues to monitor acute public health emergencies and outbreaks occurring in the African Region in order to ensure to preparedness and preventive measures are implemented

During this week, 60 events are being monitored through WHO Health Emergencies Program in the African Region. Key events highlighted during the week include the following:

▪ Ebola virus disease in the Democratic Republic of the Congo ▪ Lassa fever in Nigeria ▪ Cholera in Burundi ▪ Humanitarian crisis in Democratic Republic of the Congo ▪ Humanitarian crisis in Ethiopia

Source: WHO Week 5 Bulletin on Outbreaks and Other Emergencies

Outbreaks

Tchien District, Grand Gedeh County : Measles • Four new cases were reported Source:Sanniquellie WHO Week 4 Bulletin Mah, on OutbreaksNimba andCounty: Other Emergencies Lassa fever • Health education and radio talk show ongoing • Six new cases reported

• County Health Team continues to respond to the • Specimens were collected for all and pending outbreak testing

• Suspected cases are admitted at Ganta UMC and Bokomu District, Gbarpolu County: Measles • Still in outbreak phase Saclepea Comprehensive Health Center • Mini vaccination campaign is ongoing • Two of the 6 new cases died after specimen • Active case search and daily follow up continues collection • 28 contacts have been identified (all family District 3A&B, Grand Bassa County: Lassa fever members) • As of date, no new case identified • The initial case was discharge 4th February 2019 • All 20 contacts have completed 21 days follow up • The 20 contacts have two more days to complete • The case patient recovered and was discharged on 21 days follow-up th 4 February 2019 o 14 health workers • Residents encouraged to enforce hygiene practices o 6 family members • Active case search and Community engagement • Community engagement and active case search continues ongoing in affected communities

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Public Health Measures National level:

• Providing technical remote support to Counties to: o Heighten surveillance in affected and surrounding communities County level:

• Case management for all reported cases ongoing • Active case search ongoing in affected communities for Measles, and Lassa fever

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: • Health facility - required on or before 5:00pm every Saturday to the district level • Health district - required on or before 5:00pm every Sunday to the county level • 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

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Immediately reportable diseases, conditions, and events by County during Epi week 5 and cumulative reports, Liberia, 2019

ity

ever

Exposure to to Exposure

VHF

Lassa Lassa

(Polio)

Events

Tetanus

Rabies)

Measles

Neonatal

Meningitis

Districts

(Shigellosis)

Reported

Yellow Fever Yellow

(including EVD) (including

Other Other Diseases/

No. of Health No. Health of

Maternal Mortality Maternal

Neonatal Mortal Neonatal

Diarrhoea (Cholera) Diarrhoea

Human Human

Severe Acute Watery Watery Acute Severe

Acute Flaccid Paralysis Flaccid Acute

Acute Bloody Diarrhoea Diarrhoea Bloody Acute

Animal bites (Suspected (Suspected bites Animal No. of Health District District No. Health of Counties 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 0 0 0 0 0 0 0 0 0 0 Bong 9 9 0 0 0 0 0 0 2 0 0 0 1 0 0 0 0 3 0 0 0 0 0 0 0 0 Gbarpolu 5 5 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 1 0 0 0 0 0 3 0 0 0 4 0 0 0 1 0 0 0 0 0 0 0 0 0 Grand Cape Mount 5 5 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 Gedeh 6 6 0 0 2 0 0 0 0 0 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 Grand Kru 5 5 0 0 1 0 0 0 0 0 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 Lofa 6 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Margibi 4 4 0 0 1 0 0 0 2 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 Maryland 6 6 0 0 1 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 Montserrado 7 7 0 0 0 0 0 0 5 0 0 0 18 0 0 0 1 3 0 0 3 0 0 0 0 0 Nimba 6 6 0 0 0 0 0 7 0 6 0 2 0 1 0 0 0 0 0 0 0 0 0 0 0 Rivercess 6 6 0 0 3 0 0 0 3 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 River Gee 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 Sinoe 10 10 0 1 0 0 0 0 0 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 Total Weekly 93 92 1 0 9 0 0 0 23 0 6 0 50 0 1 0 3 6 0 0 3 0 1 0 0 1

Cumulative 6 0 20 0 9 0 145 0 13 2 170 0 6 0 24 51 1 0 1 9 0 0 1 Reported 5 Cumulative Laboratory 0 0 2 0 0 0 0 0 0 0 31 0 0 0 0 0 0 0 0 0 0 0 Confirmed

D = Dead Editorial Team - NPHIL: Roseline N. George; Advertus N. Mianah – Surveillance Coordinator/DIDE; Irene Pewu – Epidemiologist/DIDE; Sumo Nuwolo, Godwina B. Williams, Lasee W. Colee, T. A = Alive Lafayette Hall, Sumor Lomax Flomo & Samuel Zayzay – Disease Investigators/DIDE; Trokon O. Yeabah – Data Manager/DIDE; Partners: WHO & US CDC Kwuakuan D.M. Yealue, Jeremy Sesay

National Public Health Institute of Liberia (NPHIL)

OUR MISSION To prevent and control public health threats by promoting healthy outcomes and serving as a source of knowledge and expertise.

GOALS Contribute to the development and sustainability of the public health workforce Develop, enhance, and expand the surveillance and response platform Develop and strengthen the laboratory system and public health diagnostics Develop, enhance, and expand process and structures to protect environmental and occupation health Expand, conduct, and coordinate public health and medical research to inform Liberian public health policies Ensure sustainable financing and operations of the NPHIL

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: +231 886 937386/777442444 Website: www.nationalphil.org

Ralph W. Jetoh, MD Deputy Director Infectious Disease and Epidemiology Division National Public Health Insttute of Liberia Republic of Liberia Email: [email protected] Phone: +231 886526388/777372655 Website: www.nationalphil.org