Health workforce development and retention in Guinea: a policy analysis post-Ebola

BACKGROUND

The state of the Guinean health workforce is one of the country's bottlenecks in advancing health outcomes. The impact of the 2014-2015 Ebola virus disease outbreak and resulting international attention has provided a policy window to invest in the workforce and reform the health system. This research constitutes a baseline study on the health workforce situation, professional education, and retention policies in Guinea. The study was conducted to inform capacity development as part of a scientific collaboration between Belgian and Guinean health institutes aiming to strengthen public health systems and health workforce development. It provides initial recommendations to the Guinean government and key actors.

METHODOLOGY

The conceptual framework for this study is inspired by Gilson and Walt's health policy triangle. The research consists of a mixed-methods approach with documents and data collected at the national, regional, and district levels between October 2016 and March 2017. Interviews were conducted with 57 resource persons from the Ministry of Health, other ministries, district health authorities, health centers and hospitals, health training institutions, health workers, community leaders, NGO representatives, and development partners. Quantitative data included figures obtained from seven health professionals' schools in each administrative region of Guinea. A quantitative analysis was conducted to determine the professional graduate trends by year and type of personnel. This provided for a picture of the pool of professional graduates available in the regions in relation to the actual employment possibilities in rural areas. The districts of Forecariah and Yomou were chosen as the main study sites.

RESULTS

Limited recruitment and a relative overproduction of medical doctors and nurse assistants have led to unemployment of health personnel. There was a mismatch between the number of civil servants administratively deployed and those actually present at their health posts. Participants argued for decentralization of health workforce management and financing. Collaboration between government actors and development partners is required to anticipate problems with the policy implementation of new health workers' deployment in rural areas. Further privatization of health education has to meet health needs and labor market dynamics.

School status and its associations among children with epilepsy in the Republic of Guinea

BACKGROUND

In low-income countries (LICs), there are multiple barriers for children with epilepsy (CWE) to attend school. We examined potentially modifiable associations with poor school performance in CWE in the West African Republic of Guinea.

METHODS

Children with epilepsy of school age were recruited using public announcements and a clinical register of people with epilepsy at the Ignace Deen Hospital in Conakry in 2018. A team of Guinean and U.S. neurologists and neurologists-in-training interviewed each CWE and parent for his/her epilepsy history, household finances, educational attainment level, and perceived stigma using the Stigma Scale of Epilepsy (SSE). Each child was also tested using the Wechsler Nonverbal Scale of Ability (WNV). Low school performance was defined as either not attending school or being held back a grade level at least once. Potential predictors of low school performance were analyzed.

FINDINGS

Of 128 CWE (mean age: 11.6 years, 48.4% female), 11.7% (n = 15) never attended school, 23.3% (n = 30) dropped out, and 64.8% (n = 83) were currently enrolled. Of CWE attending school, 46.9% (n = 39) were held back a grade level. Overall, 54 children were defined as low performers (LPs) (42%). ;Greater than 100 lifetime seizures (odds ratio (OR) = 8.81; 95% confidence interval (CI) = 2.51, 37.4; p = 0.001) and lower total WNV score (OR = 0.954; 95% CI = 0.926, 0.977; p < 0.001) were significantly associated with poor school performance in separate models, when controlling for potential confounders. Given the strong relationship between seizure freedom and school performance, we estimated that 38 additional CWE (33.6%) could become high performers (HPs) if all CWE were adequately treated to achieve the lifetime seizure category of <10 seizures and could be cognitively intact again. Models examining SSE and household wealth quintile were not significantly associated with school performance.

CONCLUSIONS

Higher lifetime seizures and lower WNV score were significantly associated with low school performance in CWE in Guinea. In spite of our conservative definition of high school performance (attending without failing) and risk of referral bias at an academic center where patients were allowed to self-refer, we demonstrate that seizure control in this setting could increase the number of CWE who could attend and stay in school.

Estimating undetected Ebola spillovers

The preparedness of health systems to detect, treat, and prevent onward transmission of Ebola virus disease (EVD) is central to mitigating future outbreaks. Early detection of outbreaks is critical to timely response, but estimating detection rates is difficult because unreported spillover events and outbreaks do not generate data. Using three independent datasets available on the distributions of secondary infections during EVD outbreaks across West Africa, in a single district (Western Area) of Sierra Leone, and in the city of Conakry, Guinea, we simulated realistic outbreak size distributions and compared them to reported outbreak sizes. These three empirical distributions lead to estimates for the proportion of detected spillover events and small outbreaks of 26% (range 8-40%, based on the full outbreak data), 48% (range 39-62%, based on the Sierra Leone data), and 17% (range 11-24%, based on the Guinea data). We conclude that at least half of all spillover events have failed to be reported since EVD was first recognized. We also estimate the probability of detecting outbreaks of different sizes, which is likely less than 10% for single-case spillover events. Comparing models of the observation process also suggests the probability of detecting an outbreak is not simply the cumulative probability of independently detecting any one individual. Rather, we find that any individual's probability of detection is highly dependent upon the size of the cluster of cases. These findings highlight the importance of primary health care and local case management to detect and contain undetected early stage outbreaks at source.

Prevalence, management and ethnobotanical investigation of hypertension in two Guinean urban districts

ETHNOPHARMACOLOGICAL RELEVANCE

Hypertension is an important public health challenge in low- and middle-income countries, and in many African countries including Guinea medicinal plants are still widely used for its treatment.

MATERIALS AND METHODS

The objective of this study was to determine the prevalence of hypertension in two Guinean urban districts (Pounthioun and Dowsare), to describe its management and to collect information on traditional herbal remedies. A total of 316 participants entered the study, 28.2% (89/316) men and 71.8% (227/316) women. Of these, 181 were from Dowsare (50 men and 131 women) and 135 from Pounthioun (39 men and 96 women). The mean age of subjects was 40.8 ± 14.0 years (range18 - 88years), while the majority of subjects (63.3% or 200/316) were 45-74 years old.

RESULTS

The overall prevalence of hypertension was 44.9% (142/316): 46.4% (84/181) from Dowsare and 43.0% (58/135) from Pounthioun. Ethnobotanical investigations among hypertensive patients led to the collection of 15 plant species, among which Hymenocardia acida leaves and Uapaca togoensis stem bark were the most cited. Phytochemical investigation of these two plant species led to the isolation and identification of isovitexin and isoorientin from H. acida, and betulinic acid and lupeol from U. togoensis.

CONCLUSION

The presence of these constituents in Hymenocardia acida leaves and Uapaca togoensis stem bark may at least in part support their traditional use against hypertension in Guinea.

Evaluation of the maternal deaths surveillance and response system at the health district level in Guinea in 2017 through digital communication tools

BACKGROUND

Reducing maternal mortality still remains a major challenge in low-income countries. This study aims to explore how digital communication tools can be used to evaluate the maternal deaths surveillance and response (MDSR) system at the health district level in Guinea.

METHODS

A descriptive cross-sectional study was conducted, using an innovative digital approach called District.Team, from April to September 2017. This study targeted all 38 district medical officers in Guinea. In addition to district medical officers, the participation of health actors from regional and central levels were also expected in the online discussion forum. Data collected through the questionnaire were mixed and those from the online discussion forum were entirely qualitative.

RESULTS

In total, 23 (61%) district medical officers (DMOs) participated in the study. Out of health districts (87%) which had updated guidelines and standards for the MDSR, 4 (20%) did not apply the content. In two health districts (8.7%), not all health facilities had maternal deaths notification forms. Three districts (13%) did not have maternal death review committees. In 2016, only half (50.2%) of reported maternal deaths were reviewed. The main recommendation formulated was related to quality of care. Other needs were also highlighted including continuous training of health care providers on emergency obstetric and neonatal care. Less than half (45%) of the review committee's recommendations were implemented. Six health districts (26.1%) did not have a response plan to reported maternal deaths and no district annual report on the MDSR was published in 2016. The weaknesses identified were, among others, insufficiency of human resources and lack of financial resources. Fifty-eight messages related to MDSR weaknesses and improvement solutions were posted in the online discussion forum by 28 participants (23 DMOs and 5 health actors from regional and central levels).

CONCLUSION

Digital tools can be used to assess the functioning of a system like maternal deaths surveillance and response. Moreover, the findings of the evaluation conducted will help stakeholders (starting from the health districts themselves) to design strategies and interventions for an effective MDSR.

Survey of Ebola Viruses in Frugivorous and Insectivorous Bats in Guinea, Cameroon, and the Democratic Republic of the Congo, 2015-2017

To clarify the role of bats in the ecology of Ebola viruses, we assessed the prevalence of Ebola virus antibodies in a large-scale sample of bats collected during 2015–2017 from countries in Africa that have had previous Ebola outbreaks (Guinea, the Democratic Republic of the Congo) or are at high risk for outbreaks (Cameroon). We analyzed 4,022 blood samples of bats from >12 frugivorous and 27 insectivorous species; 2–37 (0.05%–0.92%) bats were seropositive for Zaire and 0–30 (0%–0.75%) bats for Sudan Ebola viruses. We observed Ebola virus antibodies in 1 insectivorous bat genus and 6 frugivorous bat species. Certain bat species widespread across Africa had serologic evidence of Zaire and Sudan Ebola viruses. No viral RNA was detected in the subset of samples tested (n = 665). Ongoing surveillance of bats and other potential animal reservoirs are required to predict and prepare for future outbreaks.

Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone

BACKGROUND

The role of community health workers (CHWs) in the West Africa Ebola outbreak has been highlighted to advocate for increasing numbers of CHWs globally to build resilience, strengthen health systems, and provide emergency response capacity. However, the roles CHWs played, the challenges they faced, and their effectiveness during the outbreak are not well documented. This study assessed the impact of Ebola on community-based maternal, newborn, and child health (MNCH) services, documented the contribution of CHWs and other community-based actors to the Ebola response, and identified lessons learned to strengthen resilience in future emergencies.

METHODS

This mixed methods study was conducted in Guinea, Liberia, and Sierra Leone, with data collected in four Ebola-affected districts of each country. Qualitative data were collected through in-depth interviews and focus group discussions with stakeholders at national, district, and community levels. Quantitative program data were used to assess trends in delivery of community-based MNCH services.

RESULTS

There was a sharp decline in MNCH service provision due to weak service delivery, confusion over policy, and the overwhelming nature of the outbreak. However, many CHWs remained active in their communities and were willing to continue providing services. When CHWs received clear directives and were supported, service provision rebounded. Although CHWs faced mistrust and hostility from community members because of their linkages to health facilities, the relationship between CHWs and communities proved resilient over time, and CHWs were more effectively able to carry out Ebola-related activities than outsiders. Traditional birth attendants, community health committees, community leaders, and traditional healers also played important roles, despite a lack of formal engagement or support. Service delivery weaknesses, especially related to supply chain and supervision, limited the effectiveness of community health services before, during, and after the outbreak.

CONCLUSIONS

CHWs and other community-level actors played important roles during the Ebola outbreak. However, maintenance of primary care services and the Ebola response were hampered because community actors were engaged late in the response and did not receive sufficient support. In the future, communities should be placed at the forefront of emergency preparedness and response plans and they must be adequately supported to strengthen service delivery.

[Stigmatisation of mental illness by medical students in Conakry, Guinea]

INTRODUCTION

Stigmatisation of mental illness constitutes a major problem in the development of mental healthcare programs, especially when it originates from health professionals themselves. The aim of this research is to investigate possible attitudes of stigmatisation among first and final year medical students registered at the University of Conakry faculty of medicine in Guinea-Conakry (West Africa).

METHODS

Focus group discussions identified students' attitudes and perceptions in relation to mental illness, their explanatory models, their opinions concerning traditional and modern therapeutic practices with regard to mental illness, and their interest to possibly incorporate psychiatry in their future medical practice.

RESULTS

Many students explicitly regret the stigmatisation of mental health patients, but nevertheless share the general population's prevailing attitudes of discrimination. The dominant stereotype of mental illness is that of madness, although final year medical students describe a more diverse spectrum of mental health problems. There is strong adherence to secular occult explanations of mental illness and advocacy for traditional medicine in addressing these illnesses, including among final year medical students.

DISCUSSION

No student would opt for psychiatry as a specialisation, although some expressed interest in integrating psychiatry into their future medical practice. However, this research indicates that stigmatising attitudes are not cut in stone. Under the impetus of specific teaching programmes, attitudes can evolve to create room for tolerance and compassion.

Implications of the Ebola virus disease outbreak in Guinea: Qualitative findings to inform future health and nutrition-related responses

INTRODUCTION

Due to the close relationship between EVD and nutrition, the humanitarian community implemented various nutrition-specific and -sensitive interventions to stem the Ebola Virus Disease (EVD) outbreak in West Africa. Little, however, is known about stakeholder and community members' perspectives toward this response in Guinea. Therefore, we aimed to firstly understand how EVD may have influenced the nutrition situation; and secondly to assess the perceived acceptability and effectiveness of the nutrition response.

MATERIALS AND METHODS

Using 27 in-depth interviews conducted in April-May 2016, this descriptive, qualitative study had three iterative phases in an emergent design. Phase 1 explored the perceptions of 11 high-level policy and management staff. Phase 2 assessed the views of 16 community members, survivors, and front-line workers. Phase 3 compared the qualitative findings to relevant nutrition indicators from secondary data for final interpretations. A systematic, team-based coding approach using Dedoose software identified key themes during textual analysis.

RESULTS

Overall, several plausible pathways through an interrelated network of bio-social factors help describe EVD impacts on the nutrition situation of Guinea. At a basic level, complex social dimensions of health, response unpreparedness, and market disruptions were perceived to be major determinants affecting the nutrition situation, especially among IYC. At an underlying level, household food security was negatively impacted, along with weakened care-seeking practices, IYC feeding practices, and coping strategies. Consequently, treatment coverage for childhood illnesses and IYC diets were negatively impacted during the outbreak. In hindsight, most participants had positive perceptions toward the overall EVD response, but described salient considerations for improving upon this nutrition response during future outbreaks.

DISCUSSION

This study highlighted the complex web of inter-related factors through which EVD was perceived to impact the nutrition situation in Guinea. Considering the multi-level social and behavioral dimensions of health and nutrition is critical for effectively responding to infectious disease outbreaks.

Sensitivity and Specificity of Suspected Case Definition Used during West Africa Ebola Epidemic

Rapid early detection and control of Ebola virus disease (EVD) is contingent on accurate case definitions. Using an epidemic surveillance dataset from Guinea, we analyzed an EVD case definition developed by the World Health Organization (WHO) and used in Guinea. We used the surveillance dataset (March-October 2014; n = 2,847 persons) to identify patients who satisfied or did not satisfy case definition criteria. Laboratory confirmation determined cases from noncases, and we calculated sensitivity, specificity and predictive values. The sensitivity of the defintion was 68.9%, and the specificity of the definition was 49.6%. The presence of epidemiologic risk factors (i.e., recent contact with a known or suspected EVD case-patient) had the highest sensitivity (74.7%), and unexplained deaths had the highest specificity (92.8%). Results for case definition analyses were statistically significant (p<0.05 by χ² test). Multiple components of the EVD case definition used in Guinea contributed to improved overall sensitivity and specificity.

Adherence to Ebola-specific malaria case management guidelines at health facilities in Guinea during the West African Ebola epidemic

BACKGROUND

Malaria case management in the context of the 2014-2016 West African Ebola virus disease (EVD) epidemic was complicated by a similar initial clinical presentation of the two diseases. In September 2014, the World Health Organization (WHO) released recommendations titled, "Guidance on temporary malaria control measures in Ebola-affected countries", which aimed at reducing the risk of EVD transmission and improving malaria outcomes. This guidance recommended malaria diagnostic testing of fever cases only if adequate personal protective equipment (PPE) was available, defined as examination gloves, face shield, disposable gown, boots, and head cover; otherwise presumptive anti-malarial treatment was recommended. The extent to which health workers adhered to these guidelines in affected countries has not been assessed.

METHODS

A cross-sectional survey was conducted in 118 health units in Guinea in November 2014 to produce a representative and probabilistic sample of health facilities and patients. Adherence to the EVD-specific malaria case management guidelines during the height of the EVD epidemic was assessed. Associations between case management practices and possible determinants were calculated using multivariate logistic regression, controlling for expected confounders and the complex sample design.

RESULTS

Most (78%) facilities reported availability of examination gloves, but adequate PPE was available at only 27% of facilities. Only 28% of febrile patients received correct malaria case management per the WHO temporary malaria case management guidelines. The most common error was diagnostic testing in the absence of adequate PPE (45% of febrile patients), followed by no presumptive treatment in the absence of adequate PPE (14%). Having had a report of an EVD case at a health facility and health worker-reported participation in EVD-specific malaria trainings were associated with lower odds of diagnostic testing and higher odds of presumptive treatment.

CONCLUSIONS

Adherence to guidance on malaria case management in EVD-affected countries was low at the height of the EVD epidemic in Guinea, and there was substantial malaria diagnostic testing in the absence of adequate PPE, which could have contributed to increased EVD transmission in the healthcare setting. Conversely, low presumptive treatment when diagnostic tests were not performed may have led to additional morbidity and mortality among malaria positive patients. National malaria control programs may consider preparing contingency plans for future implementation of temporary changes to malaria case management guidelines to facilitate uptake by health workers. Additional training on standard and transmission-based precautions should help health workers understand how to protect themselves in the face of emerging and unknown pathogens.

Baseline trachoma prevalence in Guinea: Results of national trachoma mapping in 31 health districts

Background

Based on previous studies, historical records and risk factors, trachoma was suspected to be endemic in 31 health districts (HDs) in Guinea. To facilitate planning for the elimination of trachoma as a public health problem, national trachoma surveys were conducted between 2011 and 2016 to determine the prevalence of trachomatous inflammation—follicular (TF) and trachomatous trichiasis (TT) in all 31 endemic HDs.

Methodology/Principal findings

A total of 27 cross-sectional surveys were conducted, each using two-stage cluster sampling (one survey in 2011 covered five HDs). Children aged 1–9 years and adults aged ≥15 years were examined for TF and TT, respectively, using the World Health Organization (WHO) simplified grading system. Indicators of household access to water, sanitation and hygiene (WASH) were also collected. A total of 100,051 people from 13,725 households of 556 clusters were examined, of whom 44,899 were male and 55,152 were female. 44,209 children aged 1–9-years and 48,745 adults aged ≥15 years were examined. The adjusted prevalence of TF varied between 1.0% (95%CI: 0.6–1.5%) to 41.8% (95%CI: 39.4–44.2%), while the adjusted prevalence of TT ranged from 0.0% (95%CI: 0.0–0.2%) to 2.8% (95%CI: 2.3–3.5%) in the 27 surveys. In all, 18 HDs had a TF prevalence ≥5% in children aged 1–9 years and 21 HDs had a TT prevalence ≥0.2% in adults aged ≥15 years. There were an estimated 32,737 (95% CI: 19,986–57,811) individuals with TT living in surveyed HDs at the time of surveys.

Conclusions/Significance

Trachoma is a public health problem in Guinea. 18 HDs required intervention with at least one round of mass drug administration and an estimated 32,737 persons required TT surgery in the country. The results provided clear evidence for Guinea to plan for national trachoma elimination.

Trachoma is the leading infectious cause of blindness worldwide. The World Health Organization (WHO) recommends that endemic countries implement the SAFE strategy (surgery for trichiasis, antibiotic treatment, facial cleanliness and environmental improvement) to achieve trachoma elimination by the year 2020. Trachoma was suspected to be endemic in Guinea in 31 health districts except those in and around the capital Conakry, based on historical records and previous studies. To facilitate planning for the elimination of trachoma as a public health problem, Guinea conducted 27 separate trachoma surveys between 2011 and 2016 to determine the prevalence of trachomatous inflammation—follicular (TF) and trachomatous trichiasis (TT) in these 31 health districts. The results showed 18 health districts requiring intervention with at least one round of mass drug administration and an estimated 32,737 persons requiring TT surgery in the country. These data provided clear evidence for Guinea to plan for national trachoma elimination.

Occupational Exposures to Ebola Virus in Ebola Treatment Center, Conakry, Guinea

We report 77 cases of occupational exposures for 57 healthcare workers at the Ebola Treatment Center in Conakry, Guinea, during the Ebola virus disease outbreak in 2014−2015. Despite the high incidence of 3.5 occupational exposures/healthcare worker/year, only 18% of workers were at high risk for transmission, and no infections occurred.

Infection prevention and control training and capacity building during the Ebola epidemic in Guinea

Background

During the 2014–2016 Ebola epidemic in West Africa, a key epidemiological feature was disease transmission within healthcare facilities, indicating a need for infection prevention and control (IPC) training and support.

Methods

IPC training was provided to frontline healthcare workers (HCW) in healthcare facilities that were not Ebola treatment units, as well as to IPC trainers and IPC supervisors placed in healthcare facilities. Trainings included both didactic and hands-on components, and were assessed using pre-tests, post-tests and practical evaluations. We calculated median percent increase in knowledge.

Results

From October–December 2014, 20 IPC courses trained 1,625 Guineans: 1,521 HCW, 55 IPC trainers, and 49 IPC supervisors. Median test scores increased 40% (interquartile range [IQR]: 19–86%) among HCW, 15% (IQR: 8–33%) among IPC trainers, and 21% (IQR: 15–30%) among IPC supervisors (all P<0.0001) to post-test scores of 83%, 93%, and 93%, respectively.

Conclusions

IPC training resulted in clear improvements in knowledge and was feasible in a public health emergency setting. This method of IPC training addressed a high demand among HCW. Valuable lessons were learned to facilitate expansion of IPC training to other prefectures; this model may be considered when responding to other large outbreaks.

The Ebola-effect in Guinea 2014-15: Tangled trends of malaria care in children under-five

Introduction

The 2014–15 Ebola outbreak in West Africa was disruptive for the general health services in the affected countries. This study assessed the impact of the outbreak on the reported number and management of malaria in children under-five in rural Guinea.

Materials and methods

A retrospective cross-sectional study was conducted in nineteen health centres in two rural, malaria-endemic health districts, one at the epicentre of the outbreak (Guéckédou) and one (Koubia) spared by Ebola. Routine surveillance data at health facility level were compared over similar periods of high malaria transmission in both districts before, during and after the outbreak.

Results

There were significant declines in the number of visits during the Ebola outbreak (3,700) in Guéckédou compared to before (4,616) and after it (4,195), while this trend remained more stable within the three periods for Koubia. Differences were nonetheless significant in both districts (p<0.001). In 2014, during the peak of the outbreak, the overall number of malaria cases treated exceeded the number of confirmed malaria cases in Guéckédou. There were decreases in antimalarial treatment provision in August and November 2014. In contrast, during 2015 and 2016, the proportion of malaria positive cases and those treated were closely aligned. During the peak of the Ebola outbreak, there was a significant decrease in oral antimalarial drug administration, which corresponded to an increase in injectable antimalarial treatments. Stock-outs in rapid diagnostic tests were evident and prolonged in Guéckédou during the outbreak, while more limited in Koubia.

Conclusion

The Ebola outbreak of 2014–15 in Guinea had a significant impact on the admission and management of malaria in children under-five. This study identifies potential challenges in the delivery of care for those at highest risk for malaria mortality during an Ebola outbreak and the need to improve preparedness strategies pre-Ebola and health systems recovery post-Ebola.

Ebola Virus Imported from Guinea to Senegal, 2014

In March 2014, the World Health Organization declared an outbreak of Ebola virus disease in Guinea. In August 2014, a case caused by virus imported from Guinea occurred in Senegal, most likely resulting from nonsecure funerals and travel. Preparedness and surveillance in Senegal probably prevented secondary cases.

Sending the Right Message: Wild Game and the West Africa Ebola Outbreak

The unprecedented scale of the Ebola epidemic in West Africa in 2014-15 caught the world by surprise. Zaire Ebolavirus had not previously been documented in Guinea, Sierra Leone, or Liberia. However, since this strain of filovirus was first identified in 1976, scientists have been studying the disease and its origins. They have identified forest-dwelling animals that carry the virus, and some that die from it, but have yet to isolate how it is transmitted from animals to humans. During the height of the Ebola outbreak in West Africa, some public health messages addressed the link among Ebola, wild animals, and humans. This article analyzes 3 of those health messages and identifies information that is inconsistent with scientific research. Two additional examples illustrate more accurate public health messages. Until there is greater certainty about the nature of the transmission chain, future public health campaigns may be improved by timing, placement, images, and wording that provide the most accurate information to the most appropriate audience.

Assessment of poliovirus antibody seroprevalence in polio high risk areas of West Africa

We conducted a serological survey of anti-polio antibodies in polio high-risk areas of Mali, Guinea and Cote d'Ivoire to assess risk of future poliovirus outbreaks. Random community sampling of children 6-11 and 36-48 months-old was conducted; neutralizing antibodies against poliovirus were detected using microneutralization assay. We analysed 1059/1064 (99.5%) of enrolled children. Seroprevalence to poliovirus type 1 (PV1) across all age groups and locations ranged between 92 and 100%, for PV2 it was 77-100%, and 89-95% for PV3. PV2 seroprevalence in the younger age group in Guinea and Cote d'Ivoire was <80%. History of <4 polio vaccine doses and acute malnutrition were associated with seronegativity (OR = 2.1 CI95% = 1.5-3.1, OR = 1.8 CI95% = 1.1-3.3 respectively). The risk of poliovirus outbreak following importation is low because of high population immunity to PV1, however, due to large cohort of PV2 seronegative children any future detection of vaccine-derived poliovirus type 2 requires urgent response to arrest rapid spread.

Post-Ebola Measles Outbreak in Lola, Guinea, January-June 2015(1)

During public health crises such as the recent outbreaks of Ebola virus disease in West Africa, breakdowns in public health systems can lead to epidemics of vaccine-preventable diseases. We report here on an outbreak of measles in the prefecture of Lola, Guinea, which started in January 2015.

Unusual Ebola Virus Chain of Transmission, Conakry, Guinea, 2014-2015

In October 2015, a new case of Ebola virus disease in Guinea was detected. Case investigation, serology, and whole-genome sequencing indicated possible transmission of the virus from an Ebola virus disease survivor to another person and then to the case-patient reported here. This transmission chain over 11 months suggests slow Ebola virus evolution.

Emergence of Vaccine-Derived Polioviruses during Ebola Virus Disease Outbreak, Guinea, 2014-2015

During the 2014-2015 outbreak of Ebola virus disease in Guinea, 13 type 2 circulating vaccine-derived polioviruses (cVDPVs) were isolated from 6 polio patients and 7 healthy contacts. To clarify the genetic properties of cVDPVs and their emergence, we combined epidemiologic and virologic data for polio cases in Guinea. Deviation of public health resources to the Ebola outbreak disrupted polio vaccination programs and surveillance activities, which fueled the spread of neurovirulent VDPVs in an area of low vaccination coverage and immunity. Genetic properties of cVDPVs were consistent with their capacity to cause paralytic disease in humans and capacity for sustained person-to-person transmission. Circulation ceased when coverage of oral polio vaccine increased. A polio outbreak in the context of the Ebola virus disease outbreak highlights the need to consider risks for polio emergence and spread during complex emergencies and urges awareness of the challenges in polio surveillance, vaccination, and diagnosis.

Characteristics of the musculoskeletal symptoms observed among survivors of Ebola virus disease in the Postebogui cohort in Guinea

Objective

Previous studies show that arthralgia is the most common symptom experienced by Ebola virus disease (EVD) survivors. Nevertheless, specific analyses of rheumatological sequelea are still lacking.

Methods

The Postebogui study is a prospective, multicentre cohort aiming to evaluate the long-term outcomes of EVD survivors infected during the 2014-15 outbreak in Guinea. Of the 216 participants enrolled in the study in October 2015, 44 patients with arthralgia/myalgia underwent a physical examination by a rheumatologist (the Eborheum cohort). Data were collected using a standardized questionnaire.

Results

In the Eborheum cohort, 61% of patients were female, the median age was 31.1 years, and the median time from Ebola Treatment Centre discharge was 8.8 months. Pain manifestation started after Ebola infection in all but one patient. Patients had mainly both mechanical and inflammatory pain (45%) and low back pain (77%). All patients reported pain in at least one peripheral joint. Pain in large joints was more frequently reported than in small joints (73 vs 41%). Oligo- and polyarticular presentations were similar, with symmetrical pain distribution. Furthermore, 36 patients had at least one painful 18-tender point count, most of whom reported extensive pain (n = 19) and symmetrical distribution (91%). Diagnoses were mainly non-specific musculoskeletal disorders (59%) and mechanical back pain (52%). No polyarthritis was observed. We found a higher percentage of depressed patients compared with the remaining Postebogui group (42 vs 11%; P < 0.001).

Conclusion

Results from the study come from the first complete rheumatological examination of a cohort of EVD survivors, nearly 9 months after Ebola Treatment Centre discharge. Importantly, we found that patients with arthralgia/myalgia included in the Eborheum cohort were more likely to experience depression than survivors not reporting these symptoms, highlighting the impact of pain symptoms among survivors.

Ebola 2014: Setting up a port health screening programme at an international train station

An outbreak of Ebola virus disease (EVD) began in Guinea in December 2013 and was declared a Public Health Emergency of International Concern by the World Health Organization in August 2014. In October, the UK government tasked Public Health England (PHE) to set up EVD screening at key ports. The key aim of port-of-entry screening was to identify passengers coming from areas with high risk of EVD, and give them advice to raise their awareness of symptoms and what actions to take. Direct flights from Sierra Leone, Guinea or Liberia had all been cancelled, so intelligence on passenger numbers and routes was used to identify the most commonly used routes from the affected countries into the UK. One of these was St Pancras International train station. Screening had never previously been implemented at a UK train station so had to be set up from scratch. Key to the success of this was excellent multi-agency working between PHE, the UK Border Force, Eurostar, Network Rail and the Cabinet Office. This paper gives an overview of the activation of EVD screening at St Pancras International and the subsequent decommissioning.

[The origin of Ebola: Biomedical approach versus popular interpretations in Macenta, Guinea]

In December 2013, a two-year-old child died from viral haemorrhagic fever in Méliandou village in the South-East of Guinea, and constituted the likely index case of a major epidemic. When the virus was formally identified as Ebola, epidemiologists started to investigate the chains of transmission, while local people were trying to make sense out of these deaths. The epidemic control measures taken by national and international health agencies were soon faced by strong reluctance and a sometimes aggressive attitude of the affected communities. Preliminary ethnographic observations were carried out by ST in Macenta (Forest region) during an assignment (October-November 2014) for the Global Outbreak and Alert Response Network (GOARN) of the World Health Organization. ST carried out participative observation, informal conversations and in-depth interviews to identify the rumours and their sources, understand the local population's perception and knowledge about the history and origin of the Ebola outbreak in Guinea. Epidemiologists involved in the outbreak response attributed the first Ebola deaths in the Forest region to the transmission of a virus by contact with fluids of patients, but other Guinean citizens believed these deaths were caused by the breach of a taboo. The epidemiological and popular explanations, mainly evolving in parallel, but sometimes overlapping, are driven by different explanatory models, a biomedical model and a traditional-religious model. The outbreak response must be flexible and must systematically document popular discourse(s), rumours, codes, practices, knowledge and opinions related to the outbreak and use this information to shape and adapt its control interventions.