Ebola: a holistic approach is required to achieve effective management and control

A One Health Approach to Reducing Livestock Disease Prevalence in Developing Countries: Advances, Challenges, and Prospects

Challenges in livestock production in developing countries are often linked to a high disease prevalence and may be related to poor husbandry, feeding, and nutrition practices, as well as to inadequate access to preventive veterinary care. Structural barriers including chronic poverty, gender roles, inadequate supply chains, and limitations in surveillance infrastructure further complicate progress. Despite many challenges, the livestock sector substantially contributes to agricultural GDP, and reducing livestock disease prevalence is a goal for many countries. One Health initiatives that work across disciplines and sectors to reduce livestock diseases are underway around the world and use integrated approaches that consider the connections between humans, animals, and their shared environments. The growing recognition of the role livestock play in sustainability and livelihoods, as well as their involvement in zoonotic disease transmission and global health security, has highlighted the need for disease reduction strategies as described in this review.

Assessment of healthcare workers' knowledge and attitude on Ebola virus disease in Somalia: a multicenter nationwide survey

BACKGROUND

In September 2022, a new Ebola outbreak was reported in Uganda, East Africa, and 142 confirmed cases, including 19 Healthcare workers (HCWs) reported. Ebola is not endemic in Somalia, but the country is at a reasonable risk of the virus being introduced due to the direct connection with daily flights from Uganda without border health control and prevention activities. Therefore, evaluating HCWs' Knowledge and attitude is crucial since this is the first time being evaluated in Somalia. The study's objective is to evaluate the HCWs' Knowledge and attitude toward the Ebola virus disease in Somalia.

METHOD

An online self-administrated cross-sectional survey was conducted among HCWs (n = 1103) in all six federal member states of Somalia using a validated, reliable, well-structured questionnaire. Data we analyzed using descriptive statistics and Logistic regression were used to determine sociodemographic characteristics associated with poor Knowledge and negative attitude.

RESULT

Over one-third (37.3%) of HCWs had poor Knowledge; the mean knowledge score was 7.97 SD ± 2.15. Almost 40.1% of the HCWs had a negative attitude; the mean attitude was 27.81 SD ± 8.06. Low-income HCWs (AOR = 2.06, 95%CI:1.01-4.19), Married HCWs (AOR = 1.39, 95%CI: 1.110-1.963), Midwives (AOR = 2.76, 95%CI: 1.74-4.39), Lab technicians (AOR = 2.43, 95%CI: 1.43-4.14), HCWs work in Jubaland state of Somalia (AOR = 3.69, 95%CI: 2.39-5.70), Galmudug state (AOR = 8.50, 95%CI: 4.59-15.77), Hirshabelle state (AOR = 3.18, 95%CI: 2.15-4.71) were more likely to have poor Knowledge compared to their counterparts. HCWs who work in Hirshabelle state (AOR = 5.44,95%CI: 3.58-8.27), Jubaland state (AOR = 8.47, 95%CI: 4.69-15.29), and Galmudug state (AOR = 4.43, 95%CI: 3.03-6.48) was more likely to have a negative attitude than those working in the Banadir region administration.

CONCLUSION

Most Somali healthcare workers showed good Knowledge and a positive attitude toward the Ebola virus. The implementation to enhance Knowledge and attitude must specifically focus on low-income HCWs, Midwives, Lab technicalities, and those who work in Hirshabelle, Jubaland, and Galmudug states of Somalia.

Co-created community contracts support biosecurity changes in a region where African swine fever is endemic – Part II: Implementation of biosecurity measures

Smallholder subsistence pig production is common in Uganda and African swine fever (ASF) is endemic in the country, with its spread driven by human activities along the smallholder value chain. Previous research in the study area has revealed that many stakeholders are aware of how ASF is spread, its prevention and control, and have a generally positive attitude towards biosecurity. Despite this, even basic biosecurity is largely lacking. Costs, as well as a lack of adaptation to the local context, culture and traditions have been identified as factors hindering biosecurity implementation. Community engagement and local ownership of disease problems are increasingly recognised as important for improving disease prevention and control. The objective of this study was to investigate the capacity of participatory action at community level with broad inclusion of stakeholders to improve biosecurity in the smallholder pig value chain. Specific attention was paid to participants' perceptions and experiences of implementing the biosecurity measures included in their co-created community contracts. The study was conducted in Northern Uganda in villages purposively selected on the basis of previous occurrences of ASF. In each village, farmers and traders were also purposively selected. At a first meeting, basic information about ASF was shared and participants presented with a list of biosecurity measures adapted for farmers and traders respectively. Participants discussed each measure in farmer and trader subgroups, decided on the measures to implement for one year, and signed a community contract to this effect. The following year, interviews were again undertaken and implementation support given. Interview data were coded and thematically analysed. Each subgroup chose a minimum of three and a maximum of nine measures, with wide variations between villages in their selection of measures. At the follow-ups, none of the subgroups had fully implemented what had been agreed in their contract, but all had changed some of their biosecurity routines. Some frequently recommended biosecurity measures, such as not borrowing breeding boars, were not considered feasible. Relatively simple and cheap biosecurity measures were rejected for reasons of cost, highlighting the participants' general level of poverty and the relevance of poverty as a specific factor governing disease control results. The participatory methodology allowing for discussions, co-creation and the option to refuse measures seemed to facilitate the implementation of measures that had initially been thought to be controversial. The broad community approach was deemed to be positive for strengthening community identity, cooperation and implementation.

Co-created community contracts support biosecurity changes in a region where African swine fever is endemic - Part I: The methodology

In Northern Uganda more people live in poverty than elsewhere in the country. Small-scale pig-keeping is common and African swine fever (ASF) is endemic, spreading along the smallholder value chain. Biosecurity measures remain the only way to prevent and control the spread of ASF in this context. Previous research in the study area has shown that many stakeholders are aware of ASF, how it is spread and methods for prevention and control, but biosecurity implementation remains limited. Participatory approaches have been suggested in order to increase community engagement in relation to animal disease control, ensuring that disease prevention or control actions are guided by local people's priorities and the promotion of local ownership of disease control. The objective of this study was to investigate the capacity of participatory action at community level with a broad inclusion of stakeholders to initiate change and greater stakeholder ownership to improve biosecurity in the smallholder pig value chain. Specific attention was paid to the feasibility of co-created community contracts for this purpose. The study was carried out in Northern Uganda in six purposively selected villages and included both farmers and traders. Centred on co-created community contracts on biosecurity, the study comprised repeated group discussions, semi-structured and structured group and individual interviews, as well as field observations. At the first meeting, participants were presented with suggested biosecurity measures adapted for farmers and traders respectively. Participants discussed each measure, agreed which ones to implement for one year, and co-created a community contract to this effect. During the study period, repeated interviews were undertaken and implementation support was provided. Interview data was coded and thematically analysed. Great diversity was observed between communities with regard to which and how many measures were selected, illustrating heterogeneity in the possibilities of biosecurity implementation and the complexity of livelihood challenges. The methodology appeared to be effective at instigating change, with all the communities changing some of their biosecurity behaviour during the study period. The intensified communication and cooperation around pigs in the communities reinforced the sense of group identity and the capacity-building offered at the first meeting supported implementation and appeared to be more important than the physical contract. Participants reported feeling empowered and described how they shared their knowledge, educated their peers and acted as catalysts for wider biosecurity change in their communities. These are promising results and indicate a positive attitude to both the agreed measures and the methodology.

Modelling the impact of some control strategies on the transmission dynamics of Ebola virus in human-bat population: An optimal control analysis

Qualitative research and comprehensive public awareness to nip the transmission of Ebola virus in the bud before it becomes a global threat is fast becoming imperative especially now that the Gambia Ebola virus is mutated. It is therefore necessary to consider and investigate a vector-host transmission model for possible control strategy of this deadly disease. Hence, in this study, we presented a novel and feasible human-bat (host-vector) S h E h I h R h i s R h n i - S b E b I b model which foretells the spread and severity of the Ebola virus from bats to humans to investigate the combined effects of three control strategies viz: (1) allowing specialized and designated agencies to bury deceased from Ebola infection without relatives touching or curdling the remains as usually practiced in most part of Africa as last respect for their departed love ones ( k 1 ), (2) systematic and deliberate depopulation of bats in the metropolis (through persecution with pesticide exposure, pre capturing, chemical timber treatment for roosts destruction) to discourage hunting them for food by virtue of their proximity ( k 2 ) and (3) immediate treatment of infected individuals in isolation ( k 3 ). We established, among others, the endemic equilibrium, disease-free equilibrium, global and local stability, non-negativity, and boundedness of the model to prove the epidemiological feasibility of the model. The reality of the presence of optimal control remarkably influences the dynamics of transmission of the virus and simulated results also confirm the great effect of the combination of the control strategies k 1 , k 2 and k 3 in flattening the curve of Ebola transmission (fig 1 - fig 8). Health workers and policy makers are better informed with fundamental precautions that could help eradicate Ebola from the populace.

International training of pharmacists and fitness to practice in Nigeria: Emergent issues and novel insights

INTRODUCTION

Pharmacy education and practice vary significantly in different parts of the world. Research into higher education has long concentrated on determining standards and defining the quality of teaching. This study aimed at assessing the suitability of foreign trained pharmacy graduates to practice pharmacy in Nigeria.

METHODS

Paper-based self-completion questionnaires were administered to participants that registered for a certification programme organised for foreign-trained pharmacy graduates. Descriptive and inferential statistical analyses were undertaking using Statistical Package for Social Sciences version 25.

RESULTS

A total of 83 respondents participated in the study. More than half (53.0%) were females and two-thirds (66.3%) of the study participants were aged 21 to 25. A little above one-third (37.3%) of the study participants studied in Asia, and about three-quarters (73%) had a bachelor of pharmacy qualification. Also, approximately one-quarter (23.21%) of the study participants indicated that pharmacovigilance was not included in their respective curricula, and a similar proportion (23.8%) were of the opinion that there were gaps in their respective curricula. Other aspects of pharmacy where respondents lacked knowledge included clinical pharmacy and dispensing. Similarly, some of the study participants indicated that they had little or no training and experience with respect to issues relating to tropical diseases.

CONCLUSIONS

This study has provided some insights into gaps that exist in foreign training of pharmacists, especially as it pertains to fitness of purpose to practice in Nigeria. Although further research is indicated, these findings provide emergent evidence which can underpin reforms by relevant regulatory and policy entities.

Misconceptions and Rumors about Ebola Virus Disease in Sub-Saharan Africa: A Systematic Review

We sought to summarize knowledge, misconceptions, beliefs, and practices about Ebola that might impede the control of Ebola outbreaks in Africa. We searched Medline, EMBASE, CINAHL, and Google Scholar (through May 2019) for publications reporting on knowledge, attitudes, and practices (KAP) related to Ebola in Africa. In total, 14 of 433 articles were included. Knowledge was evaluated in all 14 articles, and they all highlighted that there are misconceptions and risk behaviors during an Ebola outbreak. Some communities believed that Ebola spreads through the air, mosquito bites, malice from foreign doctors, witchcraft, and houseflies. Because patients believe that Ebola was caused by witchcraft, they sought help from traditional healers. Some people believed that Ebola could be prevented by bathing with salt or hot water. Burial practices where people touch Ebola-infected corpses were common, especially among Muslims. Discriminatory attitudes towards Ebola survivors or their families were also prevalent. Some Ebola survivors were not accepted back in their communities; the possibility of being ostracized from their neighborhoods was high and Ebola survivors had to lead a difficult social life. Most communities affected by Ebola need more comprehensive knowledge on Ebola. Efforts are needed to address misconceptions and risk behaviors surrounding Ebola for future outbreak preparedness in Africa.

Analysis of individual-level data from 2018-2020 Ebola outbreak in Democratic Republic of the Congo

The 2018-2020 Ebola virus disease epidemic in Democratic Republic of the Congo (DRC) resulted in 3481 cases (probable and confirmed) and 2299 deaths. In this paper, we use a novel statistical method to analyze the individual-level incidence and hospitalization data on DRC Ebola victims. Our analysis suggests that an increase in the rate of quarantine and isolation that has shortened the infectiousness period by approximately one day during the epidemic's third and final wave was likely responsible for the eventual containment of the outbreak. The analysis further reveals that the total effective population size or the average number of individuals at risk for the disease exposure in three epidemic waves over the period of 24 months was around 16,000-a much smaller number than previously estimated and likely an evidence of at least partial protection of the population at risk through ring vaccination and contact tracing as well as adherence to strict quarantine and isolation policies.

Estimating Risk of Introduction of Ebola Virus Disease from the Democratic Republic of Congo to Tanzania: A Qualitative Assessment

Between April 2018 and November 2020, the Democratic Republic of Congo (DRC) experienced its 11th Ebola virus disease (EVD) outbreak. Tanzania's cross-border interactions with DRC through regular visitors, traders, and refugees are of concern, given the potential for further spread to neighboring countries. This study aimed to estimate the risk of introducing EVD to Tanzania from DRC. National data for flights, boats, and car transport schedules from DRC to Tanzania covering the period of May 2018 to June 2019 were analyzed to describe population movement via land, port, and air travel and coupled with available surveillance data to model the risk of EVD entry. The land border crossing was considered the most frequently used means of travel and the most likely pathway of introducing EVD from DRC to Tanzania. High probabilities of introducing EVD from DRC to Tanzania through the assessed pathways were associated with the viability of the pathogen and low detection capacity at the ports of entry. This study provides important information regarding the elements contributing to the risk associated with the introduction of EBV in Tanzania. It also indicates that infected humans arriving via land are the most likely pathway of EBV entry, and therefore, mitigation strategies including land border surveillance should be strengthened.

Ethical and sociocultural challenges in managing dead bodies during epidemics and natural disasters

Background

Catastrophic natural disasters and epidemics claim thousands of lives and have severe and lasting consequences, accompanied by human suffering. The Ebola epidemic of 2014–2016 and the current COVID-19 pandemic have revealed some of the practical and ethical complexities relating to the management of dead bodies. While frontline staff are tasked with saving lives, managing the bodies of those who die remains an under-resourced and overlooked issue, with numerous ethical and practical problems globally.

Methods

This scoping review of literature examines the management of dead bodies during epidemics and natural disasters. 82 articles were reviewed, of which only a small number were empirical studies focusing on ethical or sociocultural issues that emerge in the management of dead bodies.

Results

We have identified a wide range of ethical and sociocultural challenges, such as ensuring dignity for the deceased while protecting the living, honouring the cultural and religious rituals surrounding death, alleviating the suffering that accompanies grieving for the survivors and mitigating inequalities of resource allocation. It was revealed that several ethical and sociocultural issues arise at all stages of body management: notification, retrieving, identification, storage and burial of dead bodies.

Conclusion

While practical issues with managing dead bodies have been discussed in the global health literature and the ethical and sociocultural facets of handling the dead have been recognised, they are nonetheless not given adequate attention. Further research is needed to ensure care for the dead in epidemics and that natural disasters are informed by ethical best practice.

Perceptions of pastoralist problems: A participatory study on animal management, disease spectrum and animal health priorities of small ruminant pastoralists in Georgia

Small ruminants support the livelihoods of millions of poor pastoralist and sedentary households around the world. While pastoralists are generally not amongst the poorest in terms of assets, they are frequently marginalised in terms of their access to political power, health and education. This study was undertaken among pastoralist households keeping small ruminants in four regions of the country of Georgia. Small ruminants are an important cultural, social and economic asset in Georgia and are mainly managed in a transhumant pastoralist system. Georgia suffered its first, and so far only outbreak of peste des petits ruminants (PPR) in 2016. This qualitative interview study was designed to acquire contextual understanding of local small ruminant husbandry and the livelihood situations of the participating pastoralists, and to detect historical, unreported PPR outbreaks. Focus group discussions comprising participatory epidemiology tools and other forms of interviews were used to explore small ruminant management, disease spectrum and management, and animal health priorities. The participants had experienced a wide variety of animal health constraints, with intestinal worms, braxy, piroplasmosis, pasture-related problems, predators and lameness emerging as priorities. No historic, unreported PPR outbreak was detected in this study, and PPR was not a priority for participants. Instead, the day-to-day reality of animal health for the pastoralists was characterised by co-infections of mainly endemic pathogens, and problems related to other challenges such as access to land, feed and genetic resources. The rationale behind the participants' prioritisation of animal health problems was supported by the need to pay extra attention to animals in order to avoid risk factors, keep animals healthy and minimise the negative impact of diseases or management problems; the various epidemiological and clinical parameters of the prioritised diseases; the economic impact of the specific problems and the zoonotic potential of diseases and predation. Even within regions, and within seemingly socially and culturally homogenous groups, there were important local differences in the problems faced by pastoralists that affect their livestock management. This study underlines the importance of a contextualised understanding of the local disease panorama and complexities in the livelihood situations of rural people when designing actions to improve animal health in general or, more specifically, passive surveillance as well as prevention or control measures. Finally, it is concluded that to achieve such an understanding, there is a need for participatory, scoping-style studies that specifically acknowledge diversity and power relations.

Managing the COVID-19 emergency: A coordination framework to enhance response practices and actions

The global outbreak of the coronavirus pneumonia (COVID-19) showed how epidemics today can spread very rapidly, with potentially ruinous impact on economies and societies. Whereas medical research is crucial to define effective treatment protocols, technology innovation and social research can contribute by defining effective approaches to emergency management, especially to optimize the complex dynamics arising within actors and systems during the outbreak. The purpose of this article is to define a framework for modeling activities, actors and resources coordination in the epidemic management scenario, and to reflect on its use to enhance response practices and actions. We identify 25 types of resources and 8 activities involved in the management of epidemic, and study 29 "flow", "fit", and "share" dependencies among those resources and activities, along with purposeful management criteria. Next, we use a coordination framework to conceptualize an emergency management system encompassing practices and response actions. This study has the potential to impact a broad audience, and can opens avenues for follow up works at the intersection between technology and innovation management and societal challenges. The outcomes can have immediate applicability to an ongoing societal problem, as well as be generalized for application in future (possible although undesired) events.

With or without a Vaccine-A Review of Complementary and Alternative Approaches to Managing African Swine Fever in Resource-Constrained Smallholder Settings

The spectacular recent spread of African swine fever (ASF) in Eastern Europe and Asia has been strongly associated, as it is in the endemic areas in Africa, with free-ranging pig populations and low-biosecurity backyard pig farming. Managing the disease in wild boar populations and in circumstances where the disease in domestic pigs is largely driven by poverty is particularly challenging and may remain so even in the presence of effective vaccines. The only option currently available to prevent ASF is strict biosecurity. Among small-scale pig farmers biosecurity measures are often considered unaffordable or impossible to implement. However, as outbreaks of ASF are also unaffordable, the adoption of basic biosecurity measures is imperative to achieve control and prevent losses. Biosecurity measures can be adapted to fit smallholder contexts, culture and costs. A longer-term approach that could prove valuable particularly for free-ranging pig populations would be exploitation of innate resistance to the virus, which is fully effective in wild African suids and has been observed in some domestic pig populations in areas of prolonged endemicity. We explore available options for preventing ASF in terms of feasibility, practicality and affordability among domestic pig populations that are at greatest risk of exposure to ASF.

The Importance of Developing Rigorous Social Science Methods for Community Engagement and Behavior Change During Outbreak Response

Despite growing international attention, the anthropological and socio-behavioral elements of epidemics continue to be understudied and under resourced and lag behind the traditional outbreak response infrastructure. As seen in the current 2019 coronavirus disease (COVID-19) pandemic, the importance of socio-behavioral elements in understanding transmission and facilitating control of many outbreak-prone pathogens, this is problematic. Beyond the recent strengthening of global outbreak response capacities and global health security measures, a greater focus on the socio-behavioral components of outbreak response is required. We add to the current discussion by briefly highlighting the importance of socio-behavior in the Ebola virus disease (EVD) response, and describe vital areas of future development, including methods for community engagement and validated frameworks for behavioral modeling and change in outbreak settings.

Computational Drug Design against Ebola Virus Targeting Viral Matrix Protein VP30

Ebola viral disease (EVD) is a deadly infectious hemorrhagic viral fever caused by the Ebola virus with a high mortality rate. Until date, there is no effective drug or vaccination available to combat this condition. This study focuses on designing an effective antiviral drug for Ebola viral disease targeting viral protein 30 (VP30) of Ebola virus, highly required for transcription initiation. The lead molecules were screened for Lipinski rule of five, ADMET study following which molecular docking and bioactivity prediction was carried out. The compounds with the least binding energy were analyzed using interaction software. The results revealed that 6-Hydroxyluteolin and (-)-Arctigenin represent active lead compounds that inhibit the activity of VP30 protein and exhibits efficient pharmacokinetics. Both these compounds are plant-derived flavonoids and possess no known adverse effects on human health. In addition, they bind strongly to the predicted binding site centered on Lys180, suggesting that these two lead molecules can be imperative in designing a potential drug for EVD.

Molecular detection of dengue virus in patients suspected of Ebola virus disease in Ghana

Dengue fever is known to be one of the most common arthropod-borne viral infectious diseases of public health importance. The disease is now endemic in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, Southeast Asia and the Western Pacific with an estimated two fifths of the world's population being at risk. The notable endemic viral hemorrhagic fevers (VHFs) found in West Africa, including yellow fever, Lassa fever, Rift Valley fever, dengue fever and until recently Ebola have been responsible for most outbreaks with fatal consequences. These VHFs usually produce unclear acute febrile illness, especially in the acute phase of infection. In this study we detected the presence of 2 different serotypes (DENV-2 and DENV-3) of Dengue virus in 4 sera of 150 patients clinically suspected of Ebola virus disease during the Ebola Virus Disease (EVD) outbreak in West Africa with the use of serological and molecular test assays. Sequence data was successfully generated for DENV-3 and phylogenetic analysis of the envelope gene showed that the DENV-3 sequences had close homology with DENV-3 sequences from Senegal and India. This study documents molecular evidence of an indigenous Dengue fever viral infection in Ghana and therefore necessitates the need to have an efficient surveillance system to rapidly detect and control the dissemination of the different serotypes in the population which has the potential to cause outbreaks of dengue hemorrhagic fevers.

Strategies in Ebola virus disease (EVD) diagnostics at the point of care

Ebola virus disease (EVD) is a devastating, highly infectious illness with a high mortality rate. The disease is endemic to regions of Central and West Africa, where there is limited laboratory infrastructure and trained staff. The recent 2014 West African EVD outbreak has been unprecedented in case numbers and fatalities, and has proven that such regional outbreaks can become a potential threat to global public health, as it became the source for the subsequent transmission events in Spain and the USA. The urgent need for rapid and affordable means of detecting Ebola is crucial to control the spread of EVD and prevent devastating fatalities. Current diagnostic techniques include molecular diagnostics and other serological and antigen detection assays; which can be time-consuming, laboratory-based, often require trained personnel and specialized equipment. In this review, we discuss the various Ebola detection techniques currently in use, and highlight the potential future directions pertinent to the development and adoption of novel point-of-care diagnostic tools. Finally, a case is made for the need to develop novel microfluidic technologies and versatile rapid detection platforms for early detection of EVD.

Contrasting academic and lay press print coverage of the 2013-2016 Ebola Virus Disease outbreak

Under a traditional paradigm, only those with the expected background knowledge consume academic literature. The lay press, as well as government and non-government agencies, play a complementary role of extracting findings of high interest or importance and translating them for general viewing. The need for accurate reporting and public advising is paramount when attempting to tackle epidemic outbreaks through behavior change. Yet, public trust in media outlets is at a historic low. The Crisis and Emergency Risk Communication (CERC) model for media reporting on public health emergencies was established in 2005 and has subsequently been used to analyze media reporting on outbreaks of influenza and measles as well as smoking habits and medication compliance. However, no media analysis had yet been performed on the 2013–2016 Ebola Virus Disease (EVD) outbreak. This study compared the EVD information relayed by lay press sources with general review articles in the academic literature through a mixed-methods analysis. These findings suggest that comprehensive review articles could not serve as a source to clarify and contextualize the uncertainties around the EVD outbreak, perhaps due to adherence to technical accuracy at the expense of clarity within the context of outbreak conditions. This finding does not imply inferiority of the academic literature, nor does it draw direct causation between confusion in review articles and public misunderstanding. Given the erosion of the barriers siloing academia, combined with the demands of today’s fast-paced media environment, contemporary researchers should realize that no study is outside the public forum and to therefore consider shifting the paradigm to take personal responsibility in the process of accurately translating their scientific words into public policy actions to best serve as a source of clarity.

The link between the West African Ebola outbreak and health systems in Guinea, Liberia and Sierra Leone: a systematic review

BACKGROUND

An Ebola outbreak started in December 2013 in Guinea and spread to Liberia and Sierra Leone in 2014. The health systems in place in the three countries lacked the infrastructure and the preparation to respond to the outbreak quickly and the World Health Organisation (WHO) declared a public health emergency of international concern on August 8 2014.

OBJECTIVE

The aim of this study was to determine the effects of health systems' organisation and performance on the West African Ebola outbreak in Guinea, Liberia and Sierra Leone and lessons learned. The WHO health system building blocks were used to evaluate the performance of the health systems in these countries.

METHODS

A systematic review of articles published from inception until July 2015 was conducted following the PRISMA guidelines. Electronic databases including Medline, Embase, Global Health, and the Cochrane library were searched for relevant literature. Grey literature was also searched through Google Scholar and Scopus. Articles were exported and selected based on a set of inclusion and exclusion criteria. Data was then extracted into a spreadsheet and a descriptive analysis was performed. Each study was critically appraised using the Crowe Critical Appraisal Tool. The review was supplemented with expert interviews where participants were identified from reference lists and using the snowball method.

FINDINGS

Thirteen articles were included in the study and six experts from different organisations were interviewed. Findings were analysed based on the WHO health system building blocks. Shortage of health workforce had an important effect on the control of Ebola but also suffered the most from the outbreak. This was followed by information and research, medical products and technologies, health financing and leadership and governance. Poor surveillance and lack of proper communication also contributed to the outbreak. Lack of available funds jeopardised payments and purchase of essential resources and medicines. Leadership and governance had least findings but an overarching consensus that they would have helped prompt response, adequate coordination and management of resources.

CONCLUSION

Ensuring an adequate and efficient health workforce is of the utmost importance to ensure a strong health system and a quick response to new outbreaks. Adequate service delivery results from a collective success of the other blocks. Health financing and its management is crucial to ensure availability of medical products, fund payments to staff and purchase necessary equipment. However, leadership and governance needs to be rigorously explored on their main defects to control the outbreak.

The emerging threat of pre-extensively drug-resistant tuberculosis in West Africa: preparing for large-scale tuberculosis research and drug resistance surveillance

BACKGROUND

Drug-resistant tuberculosis (TB) is a global public health problem. Adequate management requires baseline drug-resistance prevalence data. In West Africa, due to a poor laboratory infrastructure and inadequate capacity, such data are scarce. Therefore, the true extent of drug-resistant TB was hitherto undetermined. In 2008, a new research network, the West African Network of Excellence for Tuberculosis, AIDS and Malaria (WANETAM), was founded, comprising nine study sites from eight West African countries (Burkina Faso, The Gambia, Ghana, Guinea-Bissau, Mali, Nigeria, Senegal and Togo). The goal was to establish Good Clinical Laboratory Practice (GCLP) principles and build capacity in standardised smear microscopy and mycobacterial culture across partnering laboratories to generate the first comprehensive West African drug-resistance data.

METHODS

Following GCLP and laboratory training sessions, TB isolates were collected at sentinel referral sites between 2009-2013 and tested for first- and second-line drug resistance.

RESULTS

From the analysis of 974 isolates, an unexpectedly high prevalence of multi-drug-resistant (MDR) strains was found in new (6 %) and retreatment patients (35 %) across all sentinel sites, with the highest prevalence amongst retreatment patients in Bamako, Mali (59 %) and the two Nigerian sites in Ibadan and Lagos (39 % and 66 %). In Lagos, MDR is already spreading actively amongst 32 % of new patients. Pre-extensively drug-resistant (pre-XDR) isolates are present in all sites, with Ghana showing the highest proportion (35 % of MDR). In Ghana and Togo, pre-XDR isolates are circulating amongst new patients.

CONCLUSIONS

West African drug-resistance prevalence poses a previously underestimated, yet serious public health threat, and our estimates obtained differ significantly from previous World Health Organisation (WHO) estimates. Therefore, our data are reshaping current concepts and are essential in informing WHO and public health strategists to implement urgently needed surveillance and control interventions in West Africa.

Analysis of Ebola virus polymerase domains to find strain-specific differences and to gain insight on their pathogenicity

Ebola virus, a member of the family Filoviridae has caused immense morbidity and mortality in recent times, especially in West Africa. The infection characterized by chills, fever, diarrhea, and myalgia can progress to hemorrhage and death. Hence, it is a high priority area to better understand its biology in order to expedite vaccine development pipelines. In this regard, this study analyzes the domains in RNA polymerase of fifteen publicly-available Ebola isolates belonging to three strains (Zaire, Sudan and Reston). The protein FASTA sequences of the isolates belonging Zaire, Sudan and Reston strains were extracted from UniProt database and submitted to the interactive web tool SMART for the polymerase domain profiles. Subsequent in silico investigation furnished interesting results that sure can contribute to the understanding of Ebola pathogenesis. The key findings and patterns have been presented, and based on them hypotheses have been formulated for further empirical validation.

Lessons of Risk Communication and Health Promotion - West Africa and United States

During the response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC addressed the disease on two fronts: in the epidemic epicenter of West Africa and at home in the United States. Different needs drove the demand for information in these two regions. The severity of the epidemic was reflected not only in lives lost but also in the amount of fear, misinformation, and stigma that it generated worldwide. CDC helped increase awareness, promoted actions to stop the spread of Ebola, and coordinated CDC communication efforts with multiple international and domestic partners. CDC, with input from partners, vastly increased the number of Ebola communication materials for groups with different needs, levels of health literacy, and cultural preferences. CDC deployed health communicators to West Africa to support ministries of health in developing and disseminating clear, science-based messages and promoting science-based behavioral interventions. Partnerships in West Africa with local radio, television, and cell phone businesses made possible the dissemination of messages appropriate for maximum effect. CDC and its partners communicated evolving science and risk in a culturally appropriate way to motivate persons to adapt their behavior and prevent infection with and spread of Ebola virus. Acknowledging what is and is not known is key to effective risk communication, and CDC worked with partners to integrate health promotion and behavioral and cultural knowledge into the response to increase awareness of the actual risk for Ebola and to promote protective actions and specific steps to stop its spread. The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

Treating Ebola patients: a 'bottom up' approach using generic statins and angiotensin receptor blockers

The international community has responded to the Ebola outbreak in West Africa with a 'top down' approach. This has contributed to outbreak control, but has done much less to reduce the high mortality rate in individual patients. Ebola patients experience a breakdown in endothelial barrier integrity that leads to massive fluid losses and vascular collapse. Statins and angiotensin receptor blockers (ARBs) maintain or restore endothelial barrier integrity. Local physicians in Sierra Leone have treated approximately 100 consecutive Ebola patients with atorvastatin and irbesartan, and all but two inadequately treated patients have survived. The results of this experience have not been released and they need to be reviewed and validated. Unlike other treatments that target the Ebola virus itself, this 'bottom up' approach to treatment represents a paradigm shift by targeting the host response to infection. Treatment with these safe, inexpensive generic agents could be implemented readily throughout West Africa.

The Role of the Polio Program Infrastructure in Response to Ebola Virus Disease Outbreak in Nigeria 2014

BACKGROUND

The current West African outbreak of the Ebola virus disease (EVD) began in Guinea in December 2013 and rapidly spread to Liberia and Sierra Leone. On 20 July 2014, a sick individual flew into Lagos, Nigeria, from Monrovia, Liberia, setting off an outbreak in Lagos and later in Port Harcourt city. The government of Nigeria, supported by the World Health Organization and other partners, mounted a response to the outbreak relying on the polio program experiences and infrastructure. On 20 October 2014, the country was declared free of EVD.

METHODS

We examined the organization and operations of the response to the 2014 EVD outbreak in Nigeria and how experiences and support from the country's polio program infrastructure accelerated the outbreak response.

RESULTS

The deputy incident manager of the National Polio Emergency Operations Centre was appointed the incident manager of the Ebola Emergency Operations Centre (EEOC), the body that coordinated and directed the response to the EVD outbreak in the country. A total of 892 contacts were followed up, and blood specimens were collected from 61 persons with suspected EVD and tested in designated laboratories. Of these, 19 (31%) were positive for Ebola, and 11 (58%) of the case patients were healthcare workers. The overall case-fatality rate was 40%. EVD sensitization and training were conducted during the outbreak and for 2 months after the outbreak ended. The World Health Organization deployed its surveillance and logistics personnel from non-Ebola-infected states to support response activities in Lagos and Rivers states.

CONCLUSIONS

The support from the polio program infrastructure, particularly the coordination mechanism adopted (the EEOC), the availability of skilled personnel in the polio program, and lessons learned from managing the polio eradication program greatly contributed to the speedy containment of the 2014 EVD outbreak in Nigeria.

Simulation-guided phase 3 trial design to evaluate vaccine effectiveness to prevent Ebola virus disease infection: Statistical considerations, design rationale, and challenges

Starting in December 2013, West Africa was overwhelmed with the deadliest outbreak of Ebola virus known to date, resulting in more than 27,500 cases and 11,000 deaths. In response to the epidemic, development of a heterologous prime-boost vaccine regimen was accelerated and involved preparation of a phase 3 effectiveness study. While individually randomized controlled trials are widely acknowledged as the gold standard for demonstrating the efficacy of a candidate vaccine, there was considerable debate on the ethical appropriateness of these designs in the context of an epidemic. A suitable phase 3 trial must convincingly ensure unbiased evaluation with sufficient statistical power. In addition, efficient evaluation of a vaccine candidate is required so that an effective vaccine can be immediately disseminated. This manuscript aims to present the statistical and modeling considerations, design rationale and challenges encountered due to the emergent, epidemic setting that led to the selection of a cluster-randomized phase 3 study design under field conditions.

Antiviral Vaccines: Challenges and Advances

Vaccination is the most effective means of preventing and controlling viral infections. The eradication of smallpox and the significant progress made toward polio eradication are clear examples of the great impact of antiviral vaccines. However, viral infections remain a major public health threat and a significant cause of death. Most of the antiviral vaccines introduced over the past century were empirically developed. Poliomyelitis, measles, mumps, and rubella are examples of diseases that are now largely controlled thanks to these empirically developed vaccines. However, there is a growing list of viral pathogens against which effective vaccines are yet to be developed. Recent technological advances will potentially provide us with new platforms that could be harnessed to develop vaccines against emerging and reemerging viral pathogens.

Prognostic Analysis of Patients with Ebola Virus Disease

Background

The Ebola virus causes an acute, serious illness which is often fatal if untreated. However, factors affecting the survival of the disease remain unclear. Here, we investigated the prognostic factors of Ebola virus disease (EVD) through various statistical models.

Methodology/Principal Findings

Sixty three laboratory-confirmed EVD patients with relatively complete clinical profiles were included in the study. All the patients were recruited at Jui Government Hospital, Sierra Leone between October 1st, 2014 and January 18th, 2015. We first investigated whether a single clinical presentation would be correlated with the survival of EVD. Log-rank test demonstrated that patients with viral load higher than 10⁶ copies/ml presented significantly shorter survival time than those whose viral load were lower than 10⁶ copies/ml (P = 0.005). Also, using Pearson chi-square test, we identified that chest pain, coma, and viral load (>10⁶ copies/ml) were significantly associated with poor survival of EVD patients. Furthermore, we evaluated the effect of multiple variables on the survival of EVD by Cox proportional hazards model. Interestingly, results revealed that patient’s age, symptom of confusion, and viral load were the significantly associated with the survival of EVD cases (P = 0.017, P = 0.002, and P = 0.027, respectively).

Conclusions/Significance

These results suggest that age, chest pain, coma, confusion and viral load are associated with the prognosis of EVD, in which viral load could be one of the most important factors for the survival of the disease.

The current outbreak of Ebola virus disease (EVD) in West Africa is the largest and most complex Ebola outbreak since the virus was first discovered in 1976. Factors affecting the survival of the disease remain unclear. Here, we investigated the prognostic factors of EBV from 63 cases with relatively complete clinical profiles in Sierra Leone. Using different statistical models, we found that age, chest pain, coma, confusion and viral load were associated with the prognosis of EVD, in which viral load could be one of the most important factors for the survival of the disease.