Community Trust and the Ebola Endgame

Ebola lessons: Did prior epidemic experience protect against the spread of COVID-19 in Sierra Leone?

The COVID-19 pandemic has prompted a re-examination of public health preparedness with an emphasis on lessons learned following the West African Ebola epidemic. However, much of this work focuses on technological solutions rather than social learning. Drawing upon anthropological work, this paper examines how Sierra Leoneans prepared for COVID-19 through a lens of "embodied epidemic memory." Findings reveal that while people felt more empowered to respond to COVID-19 due to their past experiences, traumatic memories from the Ebola outbreak also sparked logics of fear and avoidance, driven by mistrust toward the state and its healthcare system. As a result, people avoided healthcare facilities, and rumors concerning government corruption threatened mitigation efforts. While local populations should be better leveraged for their existing epidemic expertise, greater attention is needed to the "higher hanging fruit" of preparedness: restoring trust in the government's ability to respond to epidemics.

Perceptions, attitudes, and willingness of healthcare and frontline workers to participate in an Ebola vaccine trial in Uganda

BACKGROUND

Understanding the knowledge, perception and attitudes towards Ebola vaccines is an important factor in ensuring future use of these vaccines. A qualitative methods study embedded in an Ebola vaccine immunogenicity and safety trial (NCT04028349) was conducted to explore the knowledge and perceptions of healthcare (HCWs) and frontline workers (FLWs), about Ebola vaccines and their willingness to participate or recommend participation in Uganda.

METHOD

We carried out focus group discussions and semi-structured interviews before and after vaccination, with 70 HCWs and FLWs who consented to participate in the trial, and in the qualitative component, from August to September 2019. Data were analysed using thematic content analysis.

RESULTS

Respondents showed good knowledge about Ebola and the vaccines in general, and had wide access to information through several channels, including the study team. On prevention, particular attention was given to effective communication within health facilities. Misconceptions were mainly around route of transmission, animal origin and types of vaccines. Previous fears were based on rumours circulating in the community, mainly about the presence of the virus in the vaccine, side effects and intention to harm (e.g. by "the whites"), ultimately insisting on transparency, trust and involvement of local leaders. Acceptability of participation was motivated by the need to protect self and others, and the willingness to advance research. Majority were willing to recommend participation to their community.

CONCLUSIONS

Overall, information sharing leads to a better understanding and acceptance of vaccine trials and a positive vaccination experience can be a deciding factor in the acceptance of others. Particular attention should be paid to involving the community in addressing misconceptions and fears, while ensuring that participants have access to vaccination sites in terms of transport, and that they are properly accommodated at the study site including staying for a reasonable period of time.

Dimension reduction in higher-order contagious phenomena

We investigate epidemic spreading in a deterministic susceptible-infected-susceptible model on uncorrelated heterogeneous networks with higher-order interactions. We provide a recipe for the construction of one-dimensional reduced model (resilience function) of the N-dimensional susceptible-infected-susceptible dynamics in the presence of higher-order interactions. Utilizing this reduction process, we are able to capture the microscopic and macroscopic behavior of infectious networks. We find that the microscopic state of nodes (fraction of stable healthy individual of each node) inversely scales with their degree, and it becomes diminished due to the presence of higher-order interactions. In this case, we analytically obtain that the macroscopic state of the system (fraction of infectious or healthy population) undergoes abrupt transition. Additionally, we quantify the network's resilience, i.e., how the topological changes affect the stable infected population. Finally, we provide an alternative framework of dimension reduction based on the spectral analysis of the network, which can identify the critical onset of the disease in the presence or absence of higher-order interactions. Both reduction methods can be extended for a large class of dynamical models.

The lasting influence of Ebola: a qualitative study of community-level behaviors, trust, and perceptions three years after the 2014-16 Ebola epidemic in Liberia

The majority of disease transmission during the 2014-16 West Africa Ebola epidemic was driven by community-based behaviors that proved difficult to change in a social paradigm of misinformation, denial, and deep-seated distrust of government representatives and institutions. In Liberia, perceptions and beliefs about Ebola during and since the epidemic can provide insights useful to public health strategies aimed at improving community preparedness. In this 2018 study, we conducted nine focus groups with Liberians from three communities who experienced Ebola differently, to evaluate behaviors, attitudes, and trust during and after the epidemic. Focus group participants reported that some behaviors adopted during Ebola have persisted (e.g. handwashing and caretaking practices), while others have reverted (e.g. physical proximity and funeral customs); and reported ongoing distrust of the government and denial of the Ebola epidemic. These findings suggest that a lack of trust in the biomedical paradigm and government health institutions persists in Liberia. Future public health information campaigns may benefit from community engagement addressed at understanding beliefs and sources of trust and mistrust in the community to effect behavior change and improve community-level epidemic preparedness.

Flattening the curve: voluntary association participation and the 2013-16 West Africa Ebola epidemic

To what extent does voluntary association participation correlate with reduced Ebola duration in districts of Guinea, Liberia, and Sierra Leone during the epidemic in West Africa in 2013-16? This study, the first cross-national quantitative analysis of Ebola outcomes across these countries, answers this question by investigating how social capital influences epidemic outcomes. Ebola virus disease struck along the borders of three countries with similar levels of human development as well as cultural practices, yet resulted in different outcomes. This study examines the role of social trust, political trust, voluntary association participation, religious organisation membership, and community meeting attendance in explaining international policy failure to reduce Ebola outcomes. Overall, in districts with a culture of raising issues and participating in voluntary and religious organisations, Ebola duration rates were lower. These findings have implications not only for health crisis response, but also for disaster response and the provision of international aid to civil society.

How has Guinea learnt from the response to outbreaks? A learning health system analysis

INTRODUCTION

Learning is a key attribute of a resilient health system and, therefore, is central to health system strengthening. The main objective of this study was to analyse how Guinea's health system has learnt from the response to outbreaks between 2014 and 2021.

METHODS

We used a retrospective longitudinal single embedded case study design, applying the framework conceptualised by Sheikh and Abimbola for analysing learning health systems. Data were collected employing a mixed methods systematic review carried out in March 2022 and an online survey conducted in April 2022.

RESULTS

The 70 reports included in the evidence synthesis were about the 2014-2016 Ebola virus disease (EVD), Measles, Lassa Fever, COVID-19, 2021 EVD and Marburg virus disease. The main lessons were from 2014 to 2016 EVD and included: early community engagement in the response, social mobilisation, prioritising investment in health personnel, early involvement of anthropologists, developing health infrastructure and equipment and ensuring crisis communication. They were learnt through information (research and experts' opinions), action/practice and double-loop and were progressively incorporated in the response to future outbreaks through deliberation, single-loop, double-loop and triple-loop learning. However, advanced learning aspects (learning through action, double-loop and triple-loop) were limited within the health system. Nevertheless, the health system successfully controlled COVID-19, the 2021 EVD and Marburg virus disease. Survey respondents' commonly reported that enablers were the creation of the national agency for health security and support from development partners. Barriers included cultural and political issues and lack of funding. Common recommendations included establishing a knowledge management unit within the Ministry of Health with representatives at regional and district levels, investing in human capacities and improving the governance and management system.

CONCLUSION

Our study highlights the importance of learning. The health system performed well and achieved encouraging and better outbreak response outcomes over time with learning that occurred.

Ending tuberculosis in a post-COVID-19 world: a person-centred, equity-oriented approach

The COVID-19 pandemic has disrupted systems of care for infectious diseases-including tuberculosis-and has exposed pervasive inequities that have long marred efforts to combat these diseases. The resulting health disparities often intersect at the individual and community levels in ways that heighten vulnerability to tuberculosis. Effective responses to tuberculosis (and other infectious diseases) must respond to these realities. Unfortunately, current tuberculosis programmes are generally not designed from the perspectives of affected individuals and fail to address structural determinants of health disparities. We describe a person-centred, equity-oriented response that would identify and focus on communities affected by disparities, tailor interventions to the mechanisms by which disparities worsen tuberculosis, and address upstream determinants of those disparities. We detail four key elements of the approach (data collection, programme design, implementation, and sustainability). We then illustrate how organisations at multiple levels might partner and adapt current practices to incorporate these elements. Such an approach could generate more substantial, sustainable, and equitable reductions in tuberculosis burden at the community level, highlighting the urgency of restructuring post-COVID-19 health systems in a more person-centred, equity-oriented way.

Public trust, policing, and the COVID-19 pandemic: Evidence from an electoral authoritarian regime

We examine how trust shapes compliance with public health restrictions during the COVID- 19 pandemic in Uganda. We use an endorsement experiment embedded in a mobile phone survey to show that messages from government officials generate more support for public health restrictions than messages from religious authorities, traditional leaders, or international NGOs. We further show that compliance with these restrictions is strongly positively correlated with trust in government, but only weakly correlated with trust in local authorities or other citizens. We use measures of trust from both before and during the pandemic to rule out the possibility that trust is a function of the pandemic itself. The relationship between trust and compliance is especially strong for the Ministry of Health and-more surprisingly-the police. We conclude that trust is crucial for encouraging compliance but note that it may be difficult to sustain, particularly in settings where governments and police forces have reputations for repression.

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.

Association of Lower Exposure Risk With Paucisymptomatic/Asymptomatic Infection, Less Severe Disease, and Unrecognized Ebola Virus Disease: A Seroepidemiological Study

Background

It remains unclear if there is a dose-dependent relationship between exposure risk to Ebola virus (EBOV) and severity of illness.

Methods

From September 2016 to July 2017, we conducted a cross-sectional, community-based study of Ebola virus disease (EVD) cases and household contacts of several transmission chains in Kono District, Sierra Leone. We analyzed 154 quarantined households, comprising both reported EVD cases and their close contacts. We used epidemiological surveys and blood samples to define severity of illness as no infection, pauci-/asymptomatic infection, unrecognized EVD, reported EVD cases who survived, or reported EVD decedents. We determine seropositivity with the Filovirus Animal Nonclinical Group EBOV glycoprotein immunoglobulin G antibody test. We defined levels of exposure risk from 8 questions and considered contact with body fluid as maximum exposure risk.

Results

Our analysis included 76 reported EVD cases (both decedents and survivors) and 421 close contacts. Among these contacts, 40 were seropositive (22 paucisymptomatic and 18 unrecognized EVD), accounting for 34% of the total 116 EBOV infections. Higher exposure risks were associated with having had EBOV infection (maximum risk: adjusted odds ratio [AOR], 12.1 [95% confidence interval {CI}, 5.8-25.4; trend test: P < .001) and more severe illness (maximum risk: AOR, 25.2 [95% CI, 6.2-102.4]; trend test: P < .001).

Conclusions

This community-based study of EVD cases and contacts provides epidemiological evidence of a dose-dependent relationship between exposure risk and severity of illness, which may partially explain why pauci-/asymptomatic EBOV infection, less severe disease, and unrecognized EVD occurs.

The Salience of Trust to the Client-Provider Relationship in Post-Ebola Guinea: Findings From a Qualitative Study

This qualitative study in post-Ebola Guinea showed that trust was a salient construct for clients making health care-seeking decisions in a postemergency setting. This analysis argues for global health programs to build trust between clients and the health system by addressing underlying domains of trust as defined by the clients themselves.

Lack of trust in the health care system can serve as a barrier to service utilization, especially in pandemic and postemergency settings. Although previous research has identified domains of trust that contribute to individuals’ trust in the health system, little research exists from low- and middle-income countries, particularly during and after infectious disease outbreaks. The current study—conducted to inform activities for a post-Ebola program—explored perceptions and experiences of health care provision in post-Ebola Guinea, with particular attention to trust. Researchers conducted in-depth interviews with health workers (n=15) and mothers of young children (n=29) along with 12 focus group discussions with grandmothers of young children and 12 with male heads of household. The study occurred in Basse Guinée and Guinée Forestière—2 areas hardest hit by Ebola. Respondents identified a breach of trust during the epidemic, with several domains emerging as relevant for renewed trust and care-seeking practices. At the core of a trusting client-provider relationship was the inherent belief that providers had an intrinsic duty to treat clients well. From there, perceived provider competence, the hospitality at the facility, provider empathy, transparency about costs, and commitment to confidentiality emerged as relevant influences on participant trust in providers. Community members and providers expressed similar viewpoints regarding trust and discussed the role of open communication and community mobilization in rebuilding trust. Study findings informed a variety of program activities, including the development of campaign messages and interpersonal communication trainings for health workers. This study provides valuable insight about some underlying components of trust that can provide key leverage points to rebuild trust and promote care seeking in postemergency settings. This insight is informing program activities in the current Ebola response in Guinea and could be useful in other crises, such as the global coronavirus disease (COVID-19) pandemic.

Findings and Implications From an Evaluation of the Gold Star Campaign in Post-Ebola Guinea: The Role of Gender and Education

During public health crises, such as an Ebola epidemic, people may lose trust in local health facilities. Short-duration mass media campaigns can improve attitudes about the quality of health facilities for men and women and can play an important role in encouraging future health service utilization.

In post-Ebola Guinea, the Health Communication Capacity Collaborative (HC3) project worked to rebuild trust in the health system and increase the utilization of reproductive, maternal, neonatal, and child health services. Core to HC3 Guinea was the promotion of quality local health centers through the Gold Star campaign (2016–2017). The current study aimed to determine the relationship between campaign exposure and attitudes/intentions regarding local health centers, to inform communication efforts in future epidemics. Between June–July 2017, HC3 Guinea conducted a telephone survey with men (n=1,000) and women (n=2,000) aged 18–49 years. Multivariate regression analyses estimated the association between campaign exposure and attitudinal/intention outcomes for the overall sample as well as for gender- and education-stratified samples.

Survey results indicated that more than 30% of the sample recalled either the campaign (32.5%) or logo (37.6%). Statistically significant associations existed between exposure and various attitudinal outcomes. For example, regardless of gender/level of education, campaign recall was strongly associated with agreeing that the local health center improved in the last 6 months. Given that the campaign itself was short in duration, it is encouraging that attitudes changed with campaign exposure. Although a greater percentage of women than men held positive attitudes about health facilities, men seemed more influenced by campaign exposure.

The current study provides evidence that mass media campaigns can help rebuild trust in health care facilities after an epidemic. Study findings also stress the value of conducting stratified analyses by important demographic characteristics (e.g., gender, education). Stratified analyses can help identify meaningful differences and better tailor health promotion activities and achieve greater success. The recent recurrence of Ebola in Guinea has resulted in renewed discussions about ways to incorporate these evaluation findings into current programming, including exploring ways to address gender considerations in message design and overall program strategy.

Community trust of government and non-governmental organizations during the 2014-16 Ebola epidemic in Liberia

The West African Ebola Virus Disease epidemic of 2014-16 cost more than 11,000 lives. Interventions targeting key behaviors to curb transmission, such as safe funeral practices and reporting and isolating the ill, were initially unsuccessful in a climate of fear, mistrust, and denial. Building trust was eventually recognized as essential to epidemic response and prioritized, and trust was seen to improve toward the end of the epidemic as incidence fell. However, little is understood about how and why trust changed during Ebola, what factors were most influential to community trust, and how different institutions might have been perceived under different levels of exposure to the outbreak. In this large-N household survey conducted in Liberia in 2018, we measured self-reported trust over time retrospectively in three different communities with different exposures to Ebola. We found trust was consistently higher for non-governmental organizations than for the government of Liberia across all time periods. Trust reportedly decreased significantly from the start to the peak of the epidemic in the study site of highest Ebola incidence. This finding, in combination with a negative association found between knowing someone infected and trust of both iNGOs and the government, indicates the experience of Ebola may have itself caused a decline of trust in the community. These results suggest that national governments should aim to establish trust when engaging communities to change behavior during epidemics. Further research on the relationship between trust and epidemics may serve to improve epidemic response efficacy and behavior uptake.

Optimal test-kit-based intervention strategy of epidemic spreading in heterogeneous complex networks

We propose a deterministic compartmental model of infectious disease that considers the test kits as an important ingredient for the suppression and mitigation of epidemics. A rigorous simulation (with an analytical argument) is provided to reveal the effective reduction of the final outbreak size and the peak of infection as a function of basic reproduction number in a single patch. Furthermore, to study the impact of long and short-distance human migration among the patches, we consider heterogeneous networks where the linear diffusive connectivity is determined by the network link structure. We numerically confirm that implementation of test kits in a fraction of nodes (patches) having larger degrees or betweenness centralities can reduce the peak of infection (as well as the final outbreak size) significantly. A next-generation matrix-based analytical treatment is provided to find out the critical transmission probability in the entire network for the onset of epidemics. Finally, the optimal intervention strategy is validated in two real networks: the global airport network and the transportation network of Kolkata, India.

Partisanship, health behavior, and policy attitudes in the early stages of the COVID-19 pandemic

Objective

To study the U.S. public’s health behaviors, attitudes, and policy opinions about COVID-19 in the earliest weeks of the national health crisis (March 20–23, 2020).

Method

We designed and fielded an original representative survey of 3,000 American adults between March 20–23, 2020 to collect data on a battery of 38 health-related behaviors, government policy preferences on COVID-19 response and worries about the pandemic. We test for partisan differences COVID-19 related policy attitudes and behaviors, measured in three different ways: party affiliation, intended 2020 Presidential vote, and self-placed ideological positioning. Our multivariate approach adjusts for a wide range of individual demographic and geographic characteristics that might confound the relationship between partisanship and health behaviors, attitudes, and preferences.

Results

We find that partisanship—measured as party identification, support for President Trump, or left-right ideological positioning—explains differences in Americans across a wide range of health behaviors and policy preferences. We find no consistent evidence that controlling for individual news consumption, the local policy environment, and local pandemic-related deaths erases the observed partisan differences in health behaviors, beliefs, and attitudes. In further analyses, we use a LASSO regression approach to select predictors, and find that a partisanship indicator is the most commonly selected predictor across the 38 dependent variables that we study.

Conclusion

Our analysis of individual self-reported behavior, attitudes, and policy preferences in response to COVID-19 reveals that partisanship played a central role in shaping individual responses in the earliest months of the COVID-19 pandemic. These results indicate that partisan differences in responding to a national public health emergency were entrenched from the earliest days of the pandemic.

Trust and transparency in times of crisis: Results from an online survey during the first wave (April 2020) of the COVID-19 epidemic in the UK

Background

The success of a government’s COVID-19 control strategy relies on public trust and broad acceptance of response measures. We investigated public perceptions of the UK government’s COVID-19 response, focusing on the relationship between trust and perceived transparency, during the first wave (April 2020) of the COVID-19 pandemic in the United Kingdom.

Methods

Anonymous survey data were collected (2020-04-06 to 2020-04-22) from 9,322 respondents, aged 20+ using an online questionnaire shared primarily through Facebook. We took an embedded-mixed-methods approach to data analysis. Missing data were imputed via multiple imputation. Binomial & multinomial logistic regression were used to detect associations between demographic characteristics and perceptions or opinions of the UK government’s response to COVID-19. Structural topic modelling (STM), qualitative thematic coding of sub-sets of responses were then used to perform a thematic analysis of topics that were of interest to key demographic groups.

Results

Most respondents (95.1%) supported government enforcement of behaviour change. While 52.1% of respondents thought the government was making good decisions, differences were apparent across demographic groups, for example respondents from Scotland had lower odds of responding positively than respondents in London. Higher educational levels saw decreasing odds of having a positive opinion of the government response and decreasing household income associated with decreasing positive opinion. Of respondents who thought the government was not making good decisions 60% believed the economy was being prioritised over people and their health. Positive views on government decision-making were associated with positive views on government transparency about the COVID-19 response. Qualitative analysis about perceptions of government transparency highlighted five key themes: (1) the justification of opacity due to the condition of crisis, (2) generalised mistrust of politics, (3) concerns about the role of scientific evidence, (4) quality of government communication and (5) questions about political decision-making processes.

Conclusion

Our study suggests that trust is not homogenous across communities, and that generalised mistrust, concerns about the transparent use and communication of evidence and insights into decision-making processes can affect perceptions of the government’s pandemic response. We recommend targeted community engagement, tailored to the experiences of different groups and a new focus on accountability and openness around how decisions are made in the response to the UK COVID-19 pandemic.

Using Community Feedback to Guide the COVID-19 Response in Sub-Saharan Africa: Red Cross and Red Crescent Approach and Lessons Learned from Ebola

Risk communication and community engagement are critical elements of epidemic response. Despite progress made in this area, few examples of regional feedback mechanisms in Africa provide information on community concerns and perceptions in real time. To enable humanitarian responders to move beyond disseminating messages, work in partnership with communities, listen to their ideas, identify community-led solutions, and support implementation of solutions systems need to be in place for documenting, analyzing, and acting on community feedback. This article describes how the International Federation of Red Cross and Red Crescent Societies and its national societies in sub-Saharan Africa have worked to establish and strengthen systems to ensure local intelligence and community insights inform operational decision making. As part of the COVID-19 response, a system was set up to collect, compile, and analyze unstructured community feedback from across the region. We describe how this system was set up based on a system piloted in the response to Ebola in the Democratic Republic of the Congo, which tools were adapted and shared across the region, and how the information gathered was used to shape and adapt the response of the Red Cross and Red Crescent Societies and the broader humanitarian response.

Community engagement for health system resilience: evidence from Liberia's Ebola epidemic

The importance of community engagement (CE) for health system resilience is established in theoretical and empirical literature. The practical dimensions of how to operationalize theory and implement its principles have been less explored, especially within low-resource crisis settings. It is therefore unclear how CE is drawn upon and how, if at all, it facilitates health system resilience in times of health system crises. To address this critical gap, we adapt and apply existing theoretical CE frameworks to analyse qualitative data from 92 in-depth interviews and 16 focus group discussions collected with health system stakeholders in Liberia in the aftermath of the 2014-15 Ebola outbreak. Health system stakeholders indicated that CE was a crucial contributing factor in addressing the Ebola epidemic in Liberia. Multiple forms of CE were used during the outbreak; however, only some forms were perceived as meaningful, such as the formation of community-based surveillance teams. To achieve meaningful CE, participants recommended that communities be treated as active participants in-as opposed to passive recipients of-health response efforts and that communication platforms for CE be established ahead of a crisis. Participant responses highlight that meaningful CE led to improved communication with and increased trust in health authorities and programming. This facilitated health system response efforts, leading to a fortuitous cycle of increased trust, improved communication and continued meaningful CE-all necessary conditions for health system resilience. This study refines our understanding of CE and demonstrates the ways in which meaningful CE and trust work together in mutually reinforcing and beneficial ways. These findings provide empirical evidence on which to base policies and programmes aimed at improving health system resilience in low-resource settings to more effectively respond to health system crises.

Period prevalence and identification challenges of viral haemorrhagic fever suspect cases in a tertiary referral hospital in Guinea: a cross-sectional, retrospective study of triage and emergency room patient profiles

Background

A functioning Viral Haemorrhagic Fever (VHF) surveillance system in countries at risk for outbreaks can reduce early transmission in case of an outbreak. Surveillance performance depends on the application of suspect case definitions in daily clinical practice. Recommended suspect case criteria during outbreaks are designed for high sensitivity and include general symptoms, pyrexia, haemorrhage, epidemiological link and unexplained death in patients. Non-outbreak criteria are narrower, relying on the persistence of fever and the presence of haemorrhagic signs.

Methods

This study ascertains VHF suspect case prevalence based on outbreak and non-outbreak criteria in a Guinean regional hospital for a period of three months. The study further describes clinical trajectories of patients who meet non-outbreak VHF suspect case criteria in order to discuss challenges in their identification. We used cross-sectional data collection at triage and emergency room to record demographic and clinical data of all admitted patients during the study period. For the follow-up study with description of diagnostic trajectories of VHF suspect cases, we used retrospective chart review.

Results

The most common symptoms of all patients upon admission were fever, tiredness/weakness and abdominal pain. 686 patients met EVD outbreak criteria, ten adult patients and two paediatric patients met study-specific non-outbreak VHF suspect case criteria. None of the suspect cases was treated as VHF suspect case and none tested positive for malaria upon admission. Their most frequent discharge diagnosis was unspecific gastrointestinal infection. The most common diagnostic measures were haemoglobin level and glycaemia for both adults and for children; of the requested examinations for hospitalized suspect cases, 36% were not executed or obtained. Half of those patients self-discharged against medical advice.

Conclusions

Our study shows that the number of VHF suspect cases may vary greatly depending on which suspect case criteria are applied. Identification of VHF suspect cases seems challenging in clinical practice. We suggest that this may be due to the low use of laboratory diagnostics to support certain diagnoses and the non-application of VHF suspect case definitions in clinical practice. Future VHF suspect case management should aim to tackle such challenges in comparable hospital settings.

Health system governance in strengthening International Health Regulations (IHR) compliance in Myanmar

The International Health Regulations 2005 (IHR) is a legally binding framework which requires 196 WHO Member States to take actions to prevent, protect against, control and provide public health response to the international spread of disease. Improving IHR compliance provides grounds for better health system strengthening, which is key to moving countries closer towards Universal Health Coverage. Multisectoral, collaborative working within and across sectors is fundamental to improving IHR (2005) compliance, and for that, governance is the best lever of the health system. This paper highlights the importance of the relationship between governance and IHR in the context of Sustainable Development Goals (SDGs) which follow the fundamental principle of interdependence; SDGs interlink with one another. We consider governance (SDG 16) and how it influences the IHR capacity of SDG 3 (health and well-being for all at all ages). This paper considers the successes of the Myanmar Ministry of Health and Sports thus far in improving IHR compliance and highlights that an even greater focus on health system governance would lead to more sustainable outcomes. Nurturing an institutional culture with enforced rules, which are conducive for improved accountability through inclusive participation would further improve Myanmar IHR strengthening efforts. Without those principles of good governance, the developed IHR capacities cannot be sustained or owned by Myanmar people. This has now become even more urgent given the current COVID-19 pandemic.

The Role of News Consumption and Trust in Public Health Leadership in Shaping COVID-19 Knowledge and Prejudice

The novelty of COVID-19 has created unique challenges to successful public health efforts because it has required the public to quickly learn and formulate knowledge and attitudes about the virus as information becomes available. The need to stay apprised of new information has also created a critical role for mass media and public institutions in shaping the public’s knowledge of, attitudes about, and responses to the unfolding pandemic. In this study, we examine how media consumption and reliance on specific institutions for information shapes three critical outcomes associated with public health epidemics: the accumulation of knowledge and the endorsement of misinformation about COVID-19, and prejudicial responses to the virus. We surveyed 1,141 adults residing across the United States in March 2020. Using multivariate regression and t-tests, we found that participants had greater knowledge, were less likely to endorse misinformation, and reported less bias toward Asian Americans when they had higher trust in the CDC and lower trust in President Trump. Reliance on certain news formats and sources was also associated with knowledge, misinformation, and prejudice. Our findings suggest that trust and news consumption can pose critical barriers to health literacy and foster negative prejudicial responses that further undermine public health efforts surrounding the COVID-19 pandemic.

Optimizing Pandemic Preparedness and Response Through Health Information Systems: Lessons Learned From Ebola to COVID-19

Strengthening health systems and maintaining essential service delivery during health emergencies response is critical for early detection and diagnosis, prompt treatment, and effective control of pandemics, including the novel coronavirus disease 2019 (COVID-19). Health information systems (HIS) developed during recent Ebola outbreaks in West Africa and the Democratic Republic of the Congo (DRC) provided opportunities to collect, analyze, and distribute data to inform both day-to-day and long-term policy decisions on outbreak preparedness. As COVID-19 continues to sweep across the globe, HIS and related technological advancements remain vital for effective and sustained data sharing, contact tracing, mapping and monitoring, community risk sensitization and engagement, preventive education, and timely preparedness and response activities. In reviewing literature of how HIS could have further supported mitigation of these Ebola outbreaks and the ongoing COVID-19 pandemic, 3 key areas were identified: governance and coordination, health systems infrastructure and resources, and community engagement. In this concept study, we outline scalable HIS lessons from recent Ebola outbreaks and early COVID-19 responses along these 3 domains, synthesizing recommendations to offer clear, evidence-based approaches on how to leverage HIS to strengthen the current pandemic response and foster community health systems resilience moving forward.

Contested legitimacy for anthropologists involved in medical humanitarian action: experiences from the 2014-2016 West Africa Ebola epidemic

The growing involvement of anthropologists in medical humanitarian response efforts has laid bare the moral and ethical consequences that emerge from humanitarian action. Anthropologists are well placed to examine the social, political, cultural and economic dimensions that influence the spread of diseases, and the ways in which to respond to epidemics. Anthropologists are also, with care, able to turn a critical lens on medical humanitarian response. However, there remains some resistance to involving anthropologists in response activities in the field. Drawing on interviews with anthropologists and humanitarian workers involved in the 2014-2016 West African Ebola epidemic, this paper reveals the complex roles taken on by anthropologists in the field and reveals how anthropologists faced questions of legitimacy vis-à-vis communities and responders in their roles in response activities, which focused on acting as 'firefighters' and 'cultural brokers' as well as legitimacy as academic researchers. Whilst these anthropologists were able to conduct research alongside these activities, or draw on anthropological knowledge to inform response activities, questions also arose about the legitimacy of these roles for anthropological academia. We conclude that the process of gaining legitimacy from all these different constituencies is particular to anthropologists and reveals the role of 'giving voice' to communities alongside critiquing medical humanitarianism. Whilst these anthropologists have strengthened the argument for the involvement of anthropologists in epidemic response this anthropological engagement with medical humanitarianism has revealed theoretical considerations more broadly for the discipline, as highlighted through engagement in other fields, especially in human rights and global health.

Forty-two years of responding to Ebola virus outbreaks in Sub-Saharan Africa: a review

Introduction

Ebola virus disease (EVD) is one of the deadliest haemorrhagic fevers affecting humans and non-human primates. Thirty-four outbreaks have been reported in Africa since it was first recognised in 1976. This review analysed 42 years of EVD outbreaks and identified various challenges and opportunities for its control and prevention in Sub-Saharan Africa.

Methods

A literature search of relevant articles on EVD was done in PubMed, Web of Science and Google Scholar electronic databases. Articles published from 1976 to 2019 were reviewed to document reports of EVD outbreaks in Sub-Saharan Africa. Data extraction focused on the year of outbreak, geographical spread, virus strain involved, number of cases and deaths, case fatality, and outbreak management. Analyses of trends in case fatality were performed by calculating ORs between times.

Results

In the past four decades, a total of 34 EVD outbreaks affecting 34 356 cases and causing 14 823 deaths were reported in 11 countries in Sub-Saharan Africa. The overall case fatality rate (95% CI) was 66% (62 to 71) and did not change substantially over time (OR in 2019 vs 1976=1.6 (95% CI 1.5 to 1.8), p<0.001). The results of this review indicate that challenges to control EVD outbreaks are related to epidemiological, sociocultural and health system factors.

Conclusions

Sub-Saharan Africa continues to face considerable challenges in EVD control, whereby there are no significant changes in case fatality rates observed during the past four decades. Socioeconomic and cultural processes need to be critically considered to shape the community behaviours that lead to exposure to EVD outbreaks. Areas that need to be addressed to prevent future EVD outbreaks include a broad-based, one-health approach, effective communication, social mobilisation, and strengthening of the health systems.

Factors influencing participation in an Ebola vaccine trial among front-line workers in Guinea

BACKGROUND

Alongside the clinical aspects of the immunogenicity and safety trial of an Ebola vaccine deployed among front-line workers, a qualitative study was conducted to describe motivations behind individuals' decisions to participate - or not to participate - in the study.

METHODS

In July and August 2015, focus group discussions and semi-structured individual interviews were conducted in Conakry, Guinea. Individuals were eligible for the qualitative study if they met the inclusion criteria of the immunogenicity and safety study irrespective of their participation. Surveys were also conducted among several institution and department heads of staff included in the study as well as vaccine trial staff members. Discussion and interview transcripts were analyzed using content thematic analysis.

RESULTS

Interviews and focus groups were conducted among 110 persons, of whom about two-thirds (67%) participated in the vaccine trial. There was at least one group interview conducted at each participating trial site, along with numerous formal and informal interviews and conversations through the enrollment period. Participants were often motivated by a desire to save and protect themselves and others, contribute to scientific progress, or lead by example. Non-participants expressed concerns regarding the risk and costs of participation, particularly the fear of unknown side effects following vaccination, and distrust or fear of stigmatization.

CONCLUSIONS

Despite the unique nature of the 2014-2015 Ebola outbreak, front-line workers employed much of the same logic when choosing to participate as in other clinical trials in similar settings. Special consideration should be given to addressing perceived inequity, misunderstanding, and mistrust among the target populations in future trials. Clinical trial registry number: This trial is registered with the Pan African Clinical Trials Registry, number PACTR201503001057193.

Overcoming distrust to deliver universal health coverage: lessons from Ebola

Liana Woskie and Mosoka Fallah use the Ebola outbreak in Liberia to better understand the role and consequences of distrust in health systems and how it affects universal health coverage

Health system preparedness for emerging infectious diseases: A synthesis of the literature

This review reflects on what the literature to date has taught us about how health systems of low- and middle-income countries (LMICs) respond to emerging infectious disease (EID) outbreaks. These findings are then applied to propose a conceptual framework characterising an EID prepared health system. A narrative synthesis approach was adopted to explore the key elements of LMIC health systems during an EID outbreak. Overarching themes ('core health system constructs') and sub-themes ('elements') relevant to EID preparedness were extracted from 49 peer-reviewed articles. The resulting conceptual framework recognised six core constructs: four focused on material resources and structures (i.e. system 'hardware'), including (i) Surveillance, (ii) Infrastructure and medical supplies, (iii) Workforce, and (iv) Communication mechanisms; and two focused on human and institutional relationships, values and norms (i.e. system 'software'), including (i) Governance, and (ii) Trust. The article reinforces the interconnectedness of the traditional health system building blocks to EID detection, prevention and response, and highlights the critical role of system 'software' (i.e. governance and trust) in enabling LMIC health systems to achieve and maintain EID preparedness. The review provides recommendations for refining a set of indicators for an 'optimised' health system EID preparedness tool to aid health system strengthening efforts.

Indirect rule redux: the political economy of diamond mining and its relation to the Ebola outbreak in Kono District, Sierra Leone

This article explores the relationship between the 2014-2016 Ebola outbreak and the political economy of diamond mining in Kono District, Sierra Leone. The authors argue that foreign companies have recycled colonial strategies of indirect rule to facilitate the illicit flow of resources out of Sierra Leone. Drawing on field research conducted during the outbreak and in its aftermath, they show how this 'indirect rule redux' undermines democratic governance and the development of revenue-generation institutions. Finally, they consider the linkages between indirect rule and the Ebola outbreak, vis-à-vis the consequences of the region's intentionally underdeveloped health care infrastructure and the scaffolding of outbreak containment onto the paramount chieftaincy system.

Ebola virus disease-related stigma among survivors declined in Liberia over an 18-month, post-outbreak period: An observational cohort study

BACKGROUND

While qualitative assessments of Ebola virus disease (EVD)-related stigma have been undertaken among survivors and the general public, quantitative tools and assessment targeting survivors have been lacking.

METHODS AND FINDINGS

Beginning in June 2015, EVD survivors from seven Liberian counties, where most of the country's EVD cases occurred, were eligible to enroll in a longitudinal cohort. Seven stigma questions were adapted from the People Living with HIV Stigma Index and asked to EVD survivors over the age of 12 at initial visit (median 358 days post-EVD) and 18 months later. Primary outcome was a 7-item EVD-related stigma index. Explanatory variables included age, gender, educational level, pregnancy status, post-EVD hospitalization, referred to medical care and EVD source. Proportional odds logistic regression models and generalized linear mixed-effects models were used to assess stigma at initial visit and over time. The stigma questions were administered to 859 EVD survivors at initial visit and 741 (86%) survivors at follow-up. While 63% of survivors reported any stigma at initial visit, only 5% reported any stigma at follow-up. Over the 18-month period, there was a significant decrease in stigma among EVD survivors (Adjusted Odds Ratio [AOR], 0.02; 95% Confidence Interval [CI], 0.01-0.04). At initial visit, having primary, junior high or vocational education, and being referred to medical care was associated with higher odds of stigma (educational level: AOR, 1.82; 95%CI, 1.27-2.62; referred: AOR, 1.50; 95%CI, 1.16-1.94). Compared to ages of 20-29, those who had ages of 12-19 or 50+ experienced lower odds of stigma (12-19: AOR, 0.32; 95%CI, 0.21-0.48; 50+: AOR, 0.58 95%CI, 0.37-0.91).

CONCLUSIONS

Our data suggest that EVD-related stigma was much lower more than a year after active Ebola transmission ended in Liberia. Among survivors who screened negative for stigma, additional probing may be considered based on age, education, and referral to care.

Global health security and universal health coverage: from a marriage of convenience to a strategic, effective partnership

Global health security and universal health coverage have been frequently considered as "two sides of the same coin". Yet, greater analysis is required as to whether and where these two ideals converge, and what important differences exist. A consequence of ignoring their individual characteristics is to distort global and local health priorities in an effort to streamline policymaking and funding activities. This paper examines the areas of convergence and divergence between global health security and universal health coverage, both conceptually and empirically. We consider analytical concepts of risk and human rights as fundamental to both goals, but also identify differences in priorities between the two ideals. We support the argument that the process of health system strengthening provides the most promising mechanism of benefiting both goals.

Beyond the crisis: did the Ebola epidemic improve resilience of Liberia's health system?

Resilience was widely identified as a critical attribute for strong health systems following the 2014-15 West Africa Ebola epidemic. In Liberia, Sierra Leone and Guinea, struggles to control the disease and suspension of the operation of many health services demonstrated that health systems must plan for resilience long before a crisis. However, the operational elements of resilience and ways that a crisis experience can shape resilience are not well described in the literature. To understand how a health system adapts to crisis and how the priorities of different health system actors influence this response we conducted interviews with global, national, and local respondents in Liberia between July and September 2015 (n = 108), several months after the country was first declared Ebola-free. We found that health system resilience functions prioritized by global and national actors improved to a greater extent than those valued by community leaders and local health actors over the course of the epidemic. Although the Ebola epidemic stimulated some positive adaptations in Liberia's health system, building a truly resilient health system will require longer-term investments and sustained attention long beyond the crisis.

The Response to and Impact of the Ebola Epidemic: Towards an Agenda for Interdisciplinary Research

Background: The 2013-2016 Ebola virus disease (EVD) epidemic in West Africa was the largest in history and resulted in a huge public health burden and significant social and economic impact in those countries most affected. Its size, duration and geographical spread presents important opportunities for research than might help national and global health and social care systems to better prepare for and respond to future outbreaks. This paper examines research needs and research priorities from the perspective of those who directly experienced the EVD epidemic in Guinea.

Methods: The paper reports the findings from a research scoping exercise conducted in Guinea in 2017. This exercise explored the need for health and social care research, and identified research gaps, from the perspectives of different groups. Interviews were carried out with key stakeholders such as representatives of the Ministry of Health, non-governmental organizations (NGOs), academic and health service researchers and members of research ethics committees (N=15); health practitioners (N=12) and community representatives (N=11). Discussion groups were conducted with male and female EVD survivors (N=24) from two distinct communities.

Results: This research scoping exercise identified seven key questions for further research. An important research priority that emerged during this study was the need to carry out a comprehensive analysis of the wider social, economic and political impact of the epidemic on the country, communities and survivors. The social and cultural dynamics of the epidemic and the local, national and international response to it need to be better understood. Many survivors and their relatives continue to experience stigma and social isolation and have a number of complex unmet needs. It is important to understand what sort of support they need, and how that might best be provided. A better understanding of the virus and the long-term health and social implications for survivors and non-infected survivors is also needed.

Conclusion: This study identified a need and priority for interdisciplinary research focusing on the long-term sociocultural, economic and health impact of the EVD epidemic. Experiences of survivors and other non-infected members of the community still need to be explored but in this broader context.

Developing a Buruli ulcer community of practice in Bankim, Cameroon: A model for Buruli ulcer outreach in Africa

Background

In the Cameroon, previous efforts to identify Buruli ulcer (BU) through the mobilization of community health workers (CHWs) yielded poor results. In this paper, we describe the successful creation of a BU community of practice (BUCOP) in Bankim, Cameroon composed of hospital staff, former patients, CHWs, and traditional healers.

Methods and principle findings

All seven stages of a well-defined formative research process were conducted during three phases of research carried out by a team of social scientists working closely with Bankim hospital staff. Phase one ethnographic research generated interventions tested in a phase two proof of concept study followed by a three- year pilot project. In phase three the pilot project was evaluated. An outcome evaluation documented a significant rise in BU detection, especially category I cases, and a shift in case referral. Trained CHW and traditional healers initially referred most suspected cases of BU to Bankim hospital. Over time, household members exposed to an innovative and culturally sensitive outreach education program referred the greatest number of suspected cases. Laboratory confirmation of suspected BU cases referred by community stakeholders was above 30%. An impact and process evaluation found that sustained collaboration between health staff, CHWs, and traditional healers had been achieved. CHWs came to play a more active role in organizing BU outreach activities, which increased their social status. Traditional healers found they gained more from collaboration than they lost from referral.

Conclusion/ Significance

Setting up lines of communication, and promoting collaboration and trust between community stakeholders and health staff is essential to the control of neglected tropical diseases. It is also essential to health system strengthening and emerging disease preparedness. The BUCOP model described in this paper holds great promise for bringing communities together to solve pressing health problems in a culturally sensitive manner.

Buruli ulcer (BU) is a neglected tropical disease primarily found in West Africa largely effecting the rural poor. BU has a known cause and cure, but an unknown route of transmission and a poorly understood incubation period. If not treated early and in a timely manner, BU often progresses to an advanced state requiring surgery and prolonged wound care. In the Cameroon, previous efforts to mobilize community health workers and educate community members to identify cases of BU yielded poor results. In this paper, we describe steps undertaken to create a successful BU community of practice (BUCOP) composed of community stakeholders working in concert with clinic staff. The success of the BUCOP was measured in terms of numbers of suspected BU cases referred and confirmed, a decline in treatment drop out, and sustained collaboration among stakeholders both during and following the pilot project. Pilot project success is attributed to an innovative and culturally sensitive approach to BU outreach education, increased levels of patient assistance, and mutual respect among BUCOP members for what each stakeholder contributed to BU detection, treatment, psychosocial support, and spiritual protection.

Food Insecurity as a Risk Factor for Outcomes Related to Ebola Virus Disease in Kono District, Sierra Leone: A Cross-Sectional Study

Studies have shown that people suffering from food insecurity are at higher risk for infectious and noncommunicable diseases and have poorer health outcomes. No study, however, has examined the association between food insecurity and outcomes related to Ebola virus disease (EVD). We conducted a cross-sectional study in two Ebola-affected communities in Kono district, Sierra Leone, from November 2015 to September 2016. We enrolled persons who were determined to have been exposed to Ebola virus. We assessed the association of food insecurity, using an adapted version of the Household Food Insecurity Access Scale, a nine-item scale well validated across Africa, with having been diagnosed with EVD and having died of EVD, using logistic regression models with cluster-adjusted standard errors. We interviewed 326 persons who were exposed to Ebola virus; 61 (19%) were diagnosed with EVD and 45/61 (74%) died. We found high levels (87%) of food insecurity, but there was no association between food insecurity and having been diagnosed with EVD. Among EVD cases, those who were food insecure had 18.3 times the adjusted odds of death than those who were food secure (P = 0.03). This is the first study to demonstrate a potential relationship between food insecurity and having died of EVD, although larger prospective studies are needed to confirm these findings.

Ecologic Features of Plague Outbreak Areas, Democratic Republic of the Congo, 2004-2014

During 2004-2014, the Democratic Republic of the Congo (DRC) declared 54% of plague cases worldwide. Using national data, we characterized the epidemiology of human plague in DRC for this period. All 4,630 suspected human plague cases and 349 deaths recorded in DRC came from Orientale Province. Pneumonic plague cases (8.8% of total) occurred during 2 major outbreaks in mining camps in the equatorial forest, and some limited outbreaks occurred in the Ituri highlands. Epidemics originated in 5 health zones clustered in Ituri, where sporadic bubonic cases were recorded throughout every year. Classification and regression tree characterized this cluster by the dominance of ecosystem 40 (mountain tropical climate). In conclusion, a small, stable, endemic focus of plague in the highlands of the Ituri tropical region persisted, acting as a source of outbreaks in DRC.

Social Mobilization and Community Engagement Central to the Ebola Response in West Africa: Lessons for Future Public Health Emergencies

Key lessons for the crucial components of social mobilization and community engagement in this context:

Invest in trusted local community members to facilitate community entrance and engagement.

Use key communication networks and channels with wide reach and relevance to the community, such as radio in low-resource settings or faith-based organizations.

Invest in strategic partnerships to tap relevant capacities and resources.

Support a network of communication professionals who can deploy rapidly for lengthy periods.

Balance centralized mechanisms to promote consistency and quality with decentralized programming for flexibility and adaptation to local needs.

Evolve communication approaches and messaging over time with the changing outbreak patterns, e.g., from halting disease transmission to integration and support of survivors.

Establish clear communication indicators and analyze and share data in real time.

Following the World Health Organization (WHO) declaration of a Public Health Emergency of International Concern regarding the Ebola outbreak in West Africa in July 2014, UNICEF was asked to co-lead, in coordination with WHO and the ministries of health of affected countries, the communication and social mobilization component—which UNICEF refers to as communication for development (C4D)—of the Ebola response. For the first time in an emergency setting, C4D was formally incorporated into each country's national response, alongside more typical components such as supplies and logistics, surveillance, and clinical care. This article describes the lessons learned about social mobilization and community engagement in the emergency response to the Ebola outbreak, with a particular focus on UNICEF's C4D work in Guinea, Liberia, and Sierra Leone. The lessons emerged through an assessment conducted by UNICEF using 4 methods: a literature review of key documents, meeting reports, and other articles; structured discussions conducted in June 2015 and October 2015 with UNICEF and civil society experts; an electronic survey, launched in October and November 2015, with staff from government, the UN, or any partner organization who worked on Ebola (N = 53); and key informant interviews (N = 5). After triangulating the findings from all data sources, we distilled lessons under 7 major domains: (1) strategy and decentralization: develop a comprehensive C4D strategy with communities at the center and decentralized programming to facilitate flexibility and adaptation to the local context; (2) coordination: establish C4D leadership with the necessary authority to coordinate between partners and enforce use of standard operating procedures as a central coordination and quality assurance tool; (3) entering and engaging communities: invest in key communication channels (such as radio) and trusted local community members; (4) messaging: adapt messages and strategies continually as patterns of the epidemic change over time; (5) partnerships: invest in strategic partnerships with community, religious leaders, journalists, radio stations, and partner organizations; (6) capacity building: support a network of local and international professionals with capacity for C4D who can be deployed rapidly; (7) data and performance monitoring: establish clear C4D process and impact indicators and strive for real-time data analysis and rapid feedback to communities and authorities to inform decision making. Ultimately, communication, community engagement, and social mobilization need to be formally placed within the global humanitarian response architecture with proper funding to effectively support future public health emergencies, which are as much a social as a health phenomenon.

Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone

An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the country's most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIH's experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.

Ethnomedical and ethnobotanical investigations on the response capacities of Guinean traditional health practioners in the management of outbreaks of infectious diseases: The case of the Ebola virus epidemic

ETHNOPHARMACOLOGICAL RELEVANCE

The recent outbreak of Ebola virus infections has mostly remained confined to the West African countries Guinea-Conakry, Sierra-Leone and Liberia. Due to intense national and international mobilizations, a significant reduction in Ebola virus transmission has been recorded. While international efforts focus on new vaccines, medicines and diagnostics, no coherent national or international approach exists to integrate the potential of the traditional health practitioners (THPs) in the management of infectious diseases epidemics. Nevertheless, the first contact of most of the Ebola infected patients is with the THPs since the symptoms are similar to those of common traditionally treated diseases or symptoms such as malaria, hemorrhagic syndrome, typhoid or other gastrointestinal diseases, fever and vomiting.

MATERIALS AND METHODS

In an ethnomedical survey conducted in the 4 main Guinean regions contacts were established with a total of 113 THPs. The socio-demographic characteristics, the professional status and the traditional perception of Ebola Virus Disease (EVD) were recorded.

RESULTS

The traditional treatment of the main symptoms was based on 47 vegetal recipes which were focused on the treatment of diarrhea (22 recipes), fever (22 recipes), vomiting (2 recipes), external antiseptic (2 recipes), hemorrhagic syndrome (2 recipes), convulsion and dysentery (one recipe each). An ethnobotanical survey led to the collection of 54 plant species from which 44 identified belonging to 26 families. The most represented families were Euphorbiaceae, Caesalpiniaceae and Rubiaceae. Literature data on the twelve most cited plant species tends to corroborate their traditional use and to highlight their pharmacological potential.

CONCLUSIONS

It is worth to document all available knowledge on the traditional management of EVD-like symptoms in order to evaluate systematically the anti-Ebola potential of Guinean plant species.

Social and cultural factors behind community resistance during an Ebola outbreak in a village of the Guinean Forest region, February 2015: a field experience

BACKGROUND

During the Ebola outbreak in Guinea, community resistance obstructed case investigation and response. We investigated a cluster of Ebola cases that were hiding in the forest, refusing external help, to identify sociocultural determinants related to community resistance.

METHODS

Participant observation, interviews and focus group discussions were carried out.

RESULTS

Most villagers feared the Ebola treatment centre (ETC) as there was the belief that people were killed in ETCs for organ trade. Four survivors accompanied back to the village from the ETC shared their experiences and reassured their neighbours. Subsequently, community compliance with contact tracing improved, leading to the timely detection of cases.

CONCLUSIONS

Engaging Ebola virus disease survivors improved community compliance. Understanding the sociocultural context and community perceptions may improve community engagement and prevent Ebola virus transmission.

The Ebola Vaccine Team B: a model for promoting the rapid development of medical countermeasures for emerging infectious disease threats

In support of accelerated development of Ebola vaccines from preclinical research to clinical trials, in November, 2014, the Wellcome Trust and the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota established the Wellcome Trust-CIDRAP Ebola Vaccine Team B initiative. This ongoing initiative includes experts with global experience in various phases of bringing new vaccines to market, such as funding, research and development, manufacturing, determination of safety and efficacy, regulatory approval, and vaccination delivery. It also includes experts in community engagement strategies and ethical issues germane to vaccination policies, including eight African scientists with direct experience in developing and implementing vaccination policies in Africa. Ebola Vaccine Team B members have worked on a range of vaccination programmes, such as polio eradication (Africa and globally), development of meningococcal A disease vaccination campaigns in Africa, and malaria and HIV/AIDS vaccine research. We also provide perspective on how this experience can inform future situations where urgent development of vaccines is needed, and we comment on the role that an independent, expert group such as Team B can have in support of national and international public health authorities toward addressing a public health crisis.

Ebola virus disease in the Democratic Republic of the Congo, 1976-2014

The Democratic Republic of the Congo has experienced the most outbreaks of Ebola virus disease since the virus' discovery in 1976. This article provides for the first time a description and a line list for all outbreaks in this country, comprising 996 cases. Compared to patients over 15 years old, the odds of dying were significantly lower in patients aged 5 to 15 and higher in children under five (with 100% mortality in those under 2 years old). The odds of dying increased by 11% per day that a patient was not hospitalised. Outbreaks with an initially high reproduction number, R (>3), were rapidly brought under control, whilst outbreaks with a lower initial R caused longer and generally larger outbreaks. These findings can inform the choice of target age groups for interventions and highlight the importance of both reducing the delay between symptom onset and hospitalisation and rapid national and international response.

DOI:http://dx.doi.org/10.7554/eLife.09015.001

Ebola virus disease commonly causes symptoms such as high fever, vomiting, and diarrhoea. It may also cause muscle pain, headaches, and bleeding, and often leads to death.

There have been seven outbreaks of Ebola virus disease in the Democratic Republic of the Congo (DRC) since 1976. The DRC is the country that has had the most outbreaks of this disease in the world. The most recent outbreak in the DRC was in 2014; this was separate from the outbreak that started in West Africa in the same year. Rosello, Mossoko et al. have now compiled the data from all seven of the outbreaks in the DRC into a single dataset, which covers almost 1000 patients.

Analysing this data revealed that people between 25 and 64 years of age were most likely to be infected by the Ebola virus, possibly because most healthcare workers fall into this category. Age also affected how likely a patient was to die, with those aged under 5 and over 15 more likely to die than those aged between 5 and 15. Delaying going to hospital once symptoms had started, even by one day, also increased the likelihood of death.

Rosello, Mossoko et al. also examined the Ebola virus effective reproduction number, which indicates how many people, on average, an infected person passes the virus on to. Outbreaks that initially featured viruses with a reproduction number larger than three tended to be stemmed quickly. However, when the reproduction number was lower, national and international organisations were slower to respond to the signs of the outbreak, leading to outbreaks that lasted longer.

Further research is needed to understand why the likelihood of death is different for different age groups and to investigate the effect of the different routes of transmission of the virus on interventions such as vaccination.

DOI:http://dx.doi.org/10.7554/eLife.09015.002

Ebola Virus Disease--Sierra Leone and Guinea, August 2015

The Ebola virus disease (Ebola) outbreak in West Africa began in late 2013 in Guinea (1) and spread unchecked during early 2014. By mid-2014, it had become the first Ebola epidemic ever documented. Transmission was occurring in multiple districts of Guinea, Liberia, and Sierra Leone, and for the first time, in capital cities (2). On August 8, 2014, the World Health Organization (WHO) declared the outbreak to be a Public Health Emergency of International Concern (3). Ministries of Health, with assistance from multinational collaborators, have reduced Ebola transmission, and the number of cases is now declining. While Liberia has not reported a case since July 12, 2015, transmission has continued in Guinea and Sierra Leone, although the numbers of cases reported are at the lowest point in a year. In August 2015, Guinea and Sierra Leone reported 10 and four confirmed cases, respectively, compared with a peak of 526 (Guinea) and 1,997 (Sierra Leone) in November 2014. This report details the current situation in Guinea and Sierra Leone, outlines strategies to interrupt transmission, and highlights the need to maintain public health response capacity and vigilance for new cases at this critical time to end the outbreak.