Household Transmission of Ebola Virus: Risks and Preventive Factors, Freetown, Sierra Leone, 2015

"If I die for touching him, let me die": a rapid ethnographic assessment of cultural practices and Ebola transmission in high-risk border regions of Tanzania

BACKGROUND

Ebola Virus Disease (EVD) is a rare but contagious disease caused by Ebola Virus (EBOV). The first Ebola outbreaks were reported in the Democratic Republic of Congo (DRC) before subsequent reported cases in Western and East African countries, including Uganda, which borders Tanzania. Proximity to EVD-infected countries raises the prospect of cross-border transmission, raising alarm in Tanzania. This study aimed to explore the cultural practices likely to prevent or escalate EVD transmission in the event of its outbreak in the country.

METHODS

This rapid ethnographic assessment employed observation, interviews, and focus group discussions to collect data from people with diverse characteristics in five regions of Tanzania Mainland namely, Kagera, Kigoma, Mwanza and Songwe regions and Zanzibar Island. The qualitative data was then subjected to thematic analysis.

FINDINGS

Cultural practices may escalate the transmission of EVD and hinder its prevention and control. These cultural practices include caring sick people at home, confirmation of death, mourning, and body preparation for burial. Communal life, ceremonies, and social gatherings were other aspects observed to have the potential for compounding EVD transmission and hindering its containment in case of an outbreak.

CONCLUSION

Cultural practices may escalate EVD transmission as identified in the study settings. As such, Risk Communication and Community Engagement (RCCE) activities should be interventionist in transforming cultural practices that may escalate the spread of EVD as part of preparedness, prevention, and control efforts in the event of an outbreak.

The potential risk components and prevention measures of the Ebola virus disease outbreak in Liberia: An in-depth interview with the health workers and stakeholders

Background

The Ebola virus, a highly infectious and deadly pathogen, has posed a significant public health threat in West Africa for several decades. Liberia is one of the most severely affected countries. Healthcare personnel, including nurses, are on the front lines of patient care, and their perspectives are invaluable in understanding the challenges that arise during outbreaks, especially in implementing prevention measures.

Objective

This study aimed to explore the potential risk components and prevention measures of the Ebola virus disease (EVD).

Methods

This study used an exploratory descriptive qualitative design. Five stakeholders, ten doctors and five nurses who had suffered from EVD during the outbreak in Liberia participated in semi-structured interviews to provide their experience and comprehensive perspectives on EVD. Data were collected from February 2022-August 2023. NVivo 12 plus was used for inductive thematic analysis.

Results

Six themes and several subthemes emerged: 1) transmission modes (body contact, body fluid, sexual intercourse, traditional burial), 2) funeral attendance (traditional practices and crowded gatherings), 3) community-led prevention (promoting good hygiene practices, increasing awareness, contact tracing, and surveillance), 4) Ebola virus vaccine (false sense of security, potential side effects, and limited data), 5) challenges in implementing prevention measures (inadequate health infrastructures, difficulty of tracing infected people, lack of resources, and cultural-social barriers), 6) Liberia's health systems (a weak, underfunded, fragile health infrastructure, lack of health facilities and shortage of health workers).

Conclusion

Several potential risk components contributing to the EVD outbreak should be a public concern. Strengthening the current healthcare system supported by local community and international aid providers (multidisciplinary teams) is needed to anticipate behavioral problems and to improve the efficacy of the prevention measures appropriate to the conditions in Liberia. Accordingly, the nurses' compliance with the recommended prevention practices is necessary.

Ebola virus disease in children: epidemiology, pathogenesis, management, and prevention

Ebola disease is a severe disease with extremely high case-fatality rates ranging from 28-100%. Observations made during the 2013-2016 West African epidemic improved our understanding of the clinical course of Ebola disease and accelerated the study of therapeutic and preventative strategies. The epidemic also highlighted the unique challenges associated with providing optimal care for children during Ebola disease outbreaks. In this review, we outline current understanding of Ebola disease epidemiology, pathogenesis, management, and prevention, highlighting data pertinent to the care of children. IMPACT: In this review, we summarize recent advancements in our understanding of Ebola disease epidemiology, clinical presentation, and therapeutic and preventative strategies. We highlight recent data pertinent to the care of children and pregnant women and identify research gaps for this important emerging viral infection in children.

Ebola virus disease: A review for the emergency medicine clinician

INTRODUCTION

Ebolavirus, the causative agent of Ebola virus disease (EVD) has been responsible for sporadic outbreaks mainly in sub-Saharan Africa since 1976. EVD is associated with high risk of transmission, especially to healthcare workers during patient care.

OBJECTIVE

The purpose of this review is to provide a concise review of EVD presentation, diagnosis, and management for emergency clinicians.

DISCUSSION

EVD is spread through direct contact, including blood, bodily fluids or contact with a contaminated object. Patients may present with non-specific symptoms such as fevers, myalgias, vomiting, or diarrhea that overlap with other viral illnesses, but rash, bruising, and bleeding may also occur. Laboratory analysis may reveal transaminitis, coagulopathy, and disseminated intravascular coagulation. The average clinical course is approximately 8-10 days with an average case fatality rate of 50%. The mainstay of treatment is supportive care, with two U.S. Food and Drug Administration-approved monoclonal antibody treatments (Ebanga and Inmazeb). Survivors of the disease may have a complicated recovery, marked by long-term symptoms.

CONCLUSION

EVD is a potentially deadly condition that can present with a wide range of signs and symptoms. Emergency clinicians must be aware of the presentation, evaluation, and management to optimize the care of these patients.

Marburg virus disease: the paradox of Nigeria's preparedness and priority effects in co-epidemics

BACKGROUND

The recent outbreaks of Marburg virus disease (MVD) in Guinea and Ghana have become a major public health concern not only to the West African sub-region but a threat to global health.

MAIN BODY OF THE ABSTRACT

Given the poorly elucidated ecological and epidemiological dynamics of the Marburg virus, it would be imprudent to preclude the possibility of another pandemic if urgent efforts are not put in place. However, the prior emergence and impact of COVID-19 and other co-occurring epidemics may add 'noise' to the epidemiological dynamics and public health interventions that may be required in the advent of a MVD outbreak in Nigeria.

SHORT CONCLUSION

Paying attention to the lessons learned from previous (and current) multiple epidemics including Avian Influenza, Yellow fever, Ebola virus disease, Monkeypox, Lassa fever, and COVID-19 could help avoid a potentially devastating public health catastrophe in Nigeria.

Social Network Analysis of Ebola Virus Disease During the 2014 Outbreak in Sukudu, Sierra Leone

Background

Transmission by unreported cases has been proposed as a reason for the 2013-2016 Ebola virus (EBOV) epidemic decline in West Africa, but studies that test this hypothesis are lacking. We examined a transmission chain within social networks in Sukudu village to assess spread and transmission burnout.

Methods

Network data were collected in 2 phases: (1) serological and contact information from Ebola cases (n = 48, including unreported); and (2) interviews (n = 148), including Ebola survivors (n = 13), to identify key social interactions. Social links to the transmission chain were used to calculate cumulative incidence proportion as the number of EBOV-infected people in the network divided by total network size.

Results

The sample included 148 participants and 1522 contacts, comprising 10 social networks: 3 had strong links (>50% of cases) to the transmission chain: household sharing (largely kinship), leisure time, and talking about important things (both largely non-kin). Overall cumulative incidence for these networks was 37 of 311 (12%). Unreported cases did not have higher network centrality than reported cases.

Conclusions

Although this study did not find evidence that explained epidemic decline in Sukudu, it excluded potential reasons (eg, unreported cases, herd immunity) and identified 3 social interactions in EBOV transmission.

Risk factors for Ebola virus disease among household care providers, Sierra Leone, 2015

BACKGROUND

Household contacts who provide care to an Ebola virus disease (EVD) case have a 3-fold higher risk of EVD compared with contacts who do not provide care.

METHODS

We enrolled persons with confirmed EVD from December 2014 to April 2015 in Freetown, Sierra Leone, and their household contacts. Index cases and contacts were interviewed, and contacts were followed for 21 days to identify secondary cases. Epidemiological data were analysed to describe household care and to identify risk factors for developing EVD.

RESULTS

Of 838 contacts in 147 households, 156 (17%) self-reported providing care to the index case; 56 households had no care provider, 52 a single care provider and 39 multiple care providers. The median care provider age was 29 years, 68% were female and 32% were the index case's spouse. Care providers were more likely to report physical contact, contact with body fluids or sharing clothing, bed linens or utensils with an index case, compared with non-care providers (P <0.01). EVD risk among non-care providers was greater when the number of care providers in the household increased (odds ratio: 1.61; 95% confidence interval: 1.1, 2.4). In multivariable analysis, factors associated with care provider EVD risk included no piped water access and absence of index case fever, and protective factors included age <20 years and avoiding the index case.

CONCLUSIONS

Limiting the number of care providers in a household could reduce the risk of EVD transmission to both care providers and non-care providers. Strategies to protect care providers from EVD exposure are needed.

"A Divine Infection": A Systematic Review on the Roles of Religious Communities During the Early Stage of COVID-19

The objective of this systematic review was to summarize the roles that religious communities played during the early stage of COVID-19 pandemic. Seven databases were searched and a total of 58 articles in English published between February 2020 and July 2020 were included in evidence synthesis. The findings of the literature showed diverse influences of religion as a double-edged sword in the context of COVID-19 pandemic. Religious communities have played detrimental and/or beneficial roles as a response to COVID-19 pandemic. A collaborative approach among religious communities, health science, and government is critical to combat COVID-19 crisis and future pandemics/epidemics.

Using secondary cases to characterize the severity of an emerging or re-emerging infection

The methods to ascertain cases of an emerging infectious disease are typically biased toward cases with more severe disease, which can bias the average infection-severity profile. Here, we conducted a systematic review to extract information on disease severity among index cases and secondary cases identified by contact tracing of index cases for COVID-19. We identified 38 studies to extract information on measures of clinical severity. The proportion of index cases with fever was 43% higher than for secondary cases. The proportion of symptomatic, hospitalized, and fatal illnesses among index cases were 12%, 126%, and 179% higher than for secondary cases, respectively. We developed a statistical model to utilize the severity difference, and estimate 55% of index cases were missed in Wuhan, China. Information on disease severity in secondary cases should be less susceptible to ascertainment bias and could inform estimates of disease severity and the proportion of missed index cases.

Mobility, exposure, and epidemiological timelines of COVID-19 infections in China outside Hubei province

The 2019 coronavirus disease (COVID-19) is pseudonymously linked to more than 100 million cases in the world as of January 2021. High-quality data are needed but lacking in the understanding of and fighting against COVID-19. We provide a complete and updating hand-coded line-list dataset containing detailed information of the cases in China and outside the epicenter in Hubei province. The data are extracted from public disclosures by local health authorities, starting from January 19. This dataset contains a very rich set of features for the characterization of COVID-19's epidemiological properties, including individual cases' demographic information, travel history, potential virus exposure scenario, contacts with known infections, and timelines of symptom onset, quarantine, infection confirmation, and hospitalization. These cases can be considered the baseline COVID-19 transmissibility under extreme mitigation measures, and therefore, a reference for comparative scientific investigation and public policymaking.

Estimating and interpreting secondary attack risk: Binomial considered biased

The household secondary attack risk (SAR), often called the secondary attack rate or secondary infection risk, is the probability of infectious contact from an infectious household member A to a given household member B, where we define infectious contact to be a contact sufficient to infect B if he or she is susceptible. Estimation of the SAR is an important part of understanding and controlling the transmission of infectious diseases. In practice, it is most often estimated using binomial models such as logistic regression, which implicitly attribute all secondary infections in a household to the primary case. In the simplest case, the number of secondary infections in a household with m susceptibles and a single primary case is modeled as a binomial(m, p) random variable where p is the SAR. Although it has long been understood that transmission within households is not binomial, it is thought that multiple generations of transmission can be neglected safely when p is small. We use probability generating functions and simulations to show that this is a mistake. The proportion of susceptible household members infected can be substantially larger than the SAR even when p is small. As a result, binomial estimates of the SAR are biased upward and their confidence intervals have poor coverage probabilities even if adjusted for clustering. Accurate point and interval estimates of the SAR can be obtained using longitudinal chain binomial models or pairwise survival analysis, which account for multiple generations of transmission within households, the ongoing risk of infection from outside the household, and incomplete follow-up. We illustrate the practical implications of these results in an analysis of household surveillance data collected by the Los Angeles County Department of Public Health during the 2009 influenza A (H1N1) pandemic.

The household secondary attack risk (SAR), often called the secondary attack rate or secondary infection risk, is the probability of infectious contact from an infectious household member A to a given household member B, where we define infectious contact to be a contact sufficient to infect B if he or she is susceptible. The most common statistical models used to estimate the SAR are binomial models such as logistic regression, which implicitly assume that all secondary infections in a household are infected by the primary case. Here, we use analytical calculations and simulations to show that estimation of the SAR must account for multiple generations of transmission within households. As an example, we show that binomial models and statistical models that account for multiple generations of within-household transmission reach different conclusions about the household SAR for 2009 influenza A (H1N1) in Los Angeles County, with the latter models fitting the data better. In an epidemic, accurate estimation of the SAR allows rigorous evaluation of the effectiveness of public health interventions such as social distancing, prophylaxis or treatment, and vaccination.

Ebola Patient Virus Cycle Threshold and Risk of Household Transmission of Ebola Virus

BACKGROUND

Identifying risk factors for household transmission of Ebola virus (EBOV) is important to guide preventive measures during Ebola outbreaks.

METHODS

We enrolled all confirmed persons with EBOV disease who were the first case patient in a household from December 2014 to April 2015 in Freetown, Sierra Leone, and their household contacts. Index patients and contacts were interviewed, and contacts were followed up for 21 days to identify secondary cases. Epidemiologic data were linked to EBOV real-time reverse-transcription polymerase chain reaction cycle threshold (Ct) data from initial diagnostic specimens obtained from enrolled index case patients.

RESULTS

Ct data were available for 106 (71%) of 150 enrolled index patients. Of the Ct results, 85 (80%) were from blood specimens from live patients and 21 (20%) from oral swab specimens from deceased patients. The median Ct values for blood and swab specimens were 21.0 and 24.0, respectively (P = .007). In multivariable analysis, a Ct value from blood specimens in the lowest quintile was an independent predictor of both increased risk of household transmission (P = .009) and higher secondary attack rate among household contacts (P = .03), after adjustment for epidemiologic factors.

CONCLUSIONS

Our findings suggest the potential to use Ct values from acute EBOV diagnostic specimens for index patients as an early predictor of high-risk households and high-risk groups of contacts to help prioritize EBOV disease investigation and control efforts.

Faith and Global Health Practice in Ebola and HIV Emergencies

We examined the relationship between religion and health by highlighting the influences of religion on the response to the 2014 to 2016 Ebola outbreak and the global HIV epidemic. We recounted the influences of religion on burial practices developed as an infection control measure during the Ebola outbreak in West Africa. We also explored the influence of religion on community outreach and health education. We examined faith-based responses to the global HIV/AIDS pandemic, noting that religion conflicted with public health responses to HIV (e.g., justification for HIV-related stigma) or aligned with public health as a force for improved HIV responses (e.g., providing HIV services or providing social capital and cohesion to support advocacy efforts). We further discussed the similarities and differences between the influence of religion during the HIV/AIDS pandemic and the 2014 to 2016 Ebola outbreak. We then described lessons learned from Ebola and HIV/AIDS to better inform collaboration with religious actors.