Estimating the number of secondary Ebola cases resulting from an unsafe burial and risk factors for transmission during the West Africa Ebola epidemic

"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.

Performance of a safe and dignified burial intervention during an Ebola epidemic in the eastern Democratic Republic of the Congo, 2018-2019

BACKGROUND

A protracted Ebola Virus Disease (EVD) epidemic in the eastern Ituri, North and South Kivu provinces of the Democratic Republic of Congo (DRC) caused 3470 confirmed and probable cases between July 2018 and April 2020. During the epidemic, the International Federation of Red Cross and Red Crescent Societies (IFRC) supported the DRC Red Cross and other local actors to offer safe and dignified burials (SDB) for suspected and confirmed EVD cases, so as to reduce transmission associated with infectious dead bodies. We conducted a retrospective cohort study of the SDB service's performance in order to inform future applications of this intervention.

METHODS

We analysed data on individual SDB responses to quantify performance based on key indicators and against pre-specified service standards. Specifically, we defined SDB timeliness as response within 24 h and success as all components of the service being implemented. Combining the database with other information sources, we also fit generalised linear mixed binomial models to explore factors associated with unsuccessful SDB.

RESULTS

Out of 14,624 requests for SDB, 99% were responded to, 89% within 24 h. Overall, 61% of SDBs were successful, somewhat below target (80%), with failures clustered during a high-insecurity period. Factors associated with increased odds of unsuccessful SDB included reported community and/or family nonacceptance, insecurity and suspensions of the EVD response, low health facility coverage and high coverage of radio and telephony. Burials supported by mobile Civil Protection (local authorities) and/or static, community-based 'harm reduction' teams were associated with lower odds of failure.

CONCLUSIONS

A large-scale, timely and moderately performant SDB service proved feasible during the challenging eastern DRC EVD response. Burial teams that are managed by community actors and operate locally, and supported rather than owned by the Red Cross or other humanitarian organisations, are a promising modality of delivering this pillar of EVD control.

Inequitable access to Ebola vaccines and the resurgence of Ebola in Africa: A state of arts review

The Ebola virus, a member of the filoviridae family of viruses, is responsible for causing Ebola Virus Disease (EVD) with a case fatality rate as high as 50%. The largest EVD outbreak was recorded in West Africa from March 2013 to June 2016, leading to over 28 000 cases and 11 000 deaths. It affected several countries, including Nigeria, Senegal, Guinea, Liberia, and Sierra Leone. Until then, EVD was predominantly reported in remote villages in central and west Africa close to tropical rainforests. Human mobility, behavioral and cultural norms, the use of bushmeat, burial customs, preference for traditional remedies and treatments, and resistance to health interventions are just a few of the social factors that considerably aid and amplify the risk of transmission. The scale and persistence of recent ebola outbreaks, as well as the risk of widespread global transmission and its ability for bioterrorism, have led to a rethinking of public health strategies to curb the disease, such as the expedition of Ebola vaccine production. However, as vaccine production lags in the subcontinent, among other challenges, the risk of another ebola outbreak is likely and feared by public health authorities in the region. This review describes the inequality of vaccine production in Africa and the resurgence of EVD, emphasizing the significance of health equality.

Host–Pathogen Interactions Influencing Zoonotic Spillover Potential and Transmission in Humans

Emerging infectious diseases of zoonotic origin are an ever-increasing public health risk and economic burden. The factors that determine if and when an animal virus is able to spill over into the human population with sufficient success to achieve ongoing transmission in humans are complex and dynamic. We are currently unable to fully predict which pathogens may appear in humans, where and with what impact. In this review, we highlight current knowledge of the key host–pathogen interactions known to influence zoonotic spillover potential and transmission in humans, with a particular focus on two important human viruses of zoonotic origin, the Nipah virus and the Ebola virus. Namely, key factors determining spillover potential include cellular and tissue tropism, as well as the virulence and pathogenic characteristics of the pathogen and the capacity of the pathogen to adapt and evolve within a novel host environment. We also detail our emerging understanding of the importance of steric hindrance of host cell factors by viral proteins using a “flytrap”-type mechanism of protein amyloidogenesis that could be crucial in developing future antiviral therapies against emerging pathogens. Finally, we discuss strategies to prepare for and to reduce the frequency of zoonotic spillover occurrences in order to minimize the risk of new outbreaks.

Epidemiology of Ebolaviruses from an Etiological Perspective

Since the inception of the ebolavirus in 1976, 32 outbreaks have resulted in nearly 15,350 deaths in more than ten countries of the African continent. In the last decade, the largest (2013-2016) and second largest (2018-2020) ebolavirus outbreaks have occurred in West Africa (mainly Guinea, Liberia, and Sierra Leone) and the Democratic Republic of the Congo, respectively. The 2013-2016 outbreak indicated an alarming geographical spread of the virus and was the first to qualify as an epidemic. Hence, it is imperative to halt ebolavirus progression and develop effective countermeasures. Despite several research efforts, ebolaviruses' natural hosts and secondary reservoirs still elude the scientific world. The primary source responsible for infecting the index case is also unknown for most outbreaks. In this review, we summarize the history of ebolavirus outbreaks with a focus on etiology, natural hosts, zoonotic reservoirs, and transmission mechanisms. We also discuss the reasons why the African continent is the most affected region and identify steps to contain this virus.

Predicting the combined effects of case isolation, safe funeral practices, and contact tracing during Ebola virus disease outbreaks

BACKGROUND

The recent outbreaks of Ebola virus disease (EVD) in Uganda and the Marburg virus disease (MVD) in Ghana reflect a persisting threat of Filoviridae to the global health community. Characteristic of Filoviridae are not just their high case fatality rates, but also that corpses are highly contagious and prone to cause infections in the absence of appropriate precautions. Vaccines against the most virulent Ebolavirus species, the Zaire ebolavirus (ZEBOV) are approved. However, there exists no approved vaccine or treatment against the Sudan ebolavirus (SUDV) which causes the current outbreak of EVD. Hence, the control of the outbreak relies on case isolation, safe funeral practices, and contact tracing. So far, the effectiveness of these control measures was studied only separately by epidemiological models, while the impact of their interaction is unclear.

METHODS AND FINDINGS

To sustain decision making in public health-emergency management, we introduce a predictive model to study the interaction of case isolation, safe funeral practices, and contact tracing. The model is a complex extension of an SEIR-type model, and serves as an epidemic preparedness tool. The model considers different phases of the EVD infections, the possibility of infections being treated in isolation (if appropriately diagnosed), in hospital (if not properly diagnosed), or at home (if the infected do not present to hospital for whatever reason). It is assumed that the corpses of those who died in isolation are buried with proper safety measures, while those who die outside isolation might be buried unsafely, such that transmission can occur during the funeral. Furthermore, the contacts of individuals in isolation will be traced. Based on parameter estimates from the scientific literature, the model suggests that proper diagnosis and hence isolation of cases has the highest impact in reducing the size of the outbreak. However, the combination of case isolation and safe funeral practices alone are insufficient to fully contain the epidemic under plausible parameters. This changes if these measures are combined with contact tracing. In addition, shortening the time to successfully trace back contacts contribute substantially to contain the outbreak.

CONCLUSIONS

In the absence of an approved vaccine and treatment, EVD management by proper and fast diagnostics in combination with epidemic awareness are fundamental. Awareness will particularly facilitate contact tracing and safe funeral practices. Moreover, proper and fast diagnostics are a major determinant of case isolation. The model introduced here is not just applicable to EVD, but also to other viral hemorrhagic fevers such as the MVD or the Lassa fever.

A systematic survey of adults' health-protective behavior use during early COVID-19 pandemic in Canada, Germany, United Kingdom, and the United States, and vaccination hesitancy and status eight months later

Adoption of health-protective behaviors, including social distancing measures, are a mainstay of mitigating pandemics, so it is important to understand the characteristics associated with those who use them or not. We aimed to delineate local and personal factors associated with self-reported use of health-protective behaviors (HPB) in response to COVID-19, among adults across 4 economically developed countries. We conducted an exploratory, cross-sectional, representative, on-line survey of adults in Canada, Germany, U.K., or the U.S. during the COVID-19 pandemic (June-July, 2020) with two and eight month follow-ups. All countries were experiencing the initial waves of the COVID-19 pandemic. We obtained N=6,990 participants, who reported 20 specific health-protective behaviors (dependent measure), along with locally mandated health measures, individual characteristics and psychological scales. Using health-protective behaviors (HPB-Quartile score) was significantly associated with 28 of 35 variables studied. In stepwise logistic regression, 21 variables predicted 23.51% of the variance in HPB-Q scores (p <.000). The strongest predictors were locally mandated protective measures, immature defense mechanisms, COVID-fears, age, moving due to COVID-19, domestic violence, and perceived emotional support from significant others. HPB-Q predicted vaccination hesitancy/willingness (OR=4.61, CI-95%: 2.66-8.00) and adoption 8 months later. During the early pandemic, HPB use was most strongly associated with locally mandated measures, followed by psychiatric, demographic, and other personal factors. Considering these empirically derived characteristics may improve public health approaches to optimize HPB and vaccination adoption, mitigating SAR-CoV-2 transmission. Findings may also inform public health responses to future epidemics/pandemics.

Evaluation of Community Perceptions and Prevention Practices Related to Ebola Virus as Part of Outbreak Preparedness in Uganda, 2020

Targeted risk communication and community engagement strategies to raise Ebola virus disease awareness and knowledge, particularly in setting where risk of infection is perceived to be low, may not be sufficient to motivate people to adopt protective behaviors and prevention practices.

Introduction:

During the 2018–2020 Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo, risk communication and community engagement (RCCE) were prioritized in geographic areas in Uganda considered at high risk of introduction of EVD. To inform EVD preparedness in Uganda, we evaluated community perceptions and prevention practices related to EVD in 6 districts in Uganda.

Methods:

In March 2020, we conducted a population-based survey in 6 purposively selected districts in Uganda using multistage cluster sampling. We examined differences between districts classified as high- versus low risk for EVD in terms of their message exposure from RCCE; risk perception; and EVD knowledge, attitudes, and prevention practices.

Results:

A total of 3,485 respondents were interviewed (91% response rate). EVD message exposure was more common in the high- versus low-risk districts. EVD risk perceptions were low overall but greater in the high- versus low-risk districts. Comprehensive knowledge was significantly greater in the high- versus low-risk districts (adjusted prevalence ratio [aPR] 1.61, 95% confidence interval [CI]=1.35, 1.93). Respondents' engagement in all 3 EVD prevention practices (frequent handwashing with soap, avoiding physical contact with suspected Ebola patients, and avoiding burials involving contact with a corpse) was very low (4%). However, respondents with comprehensive knowledge were more likely to engage in all 3 EVD prevention practices compared to respondents without comprehensive knowledge (aPR 1.87, 95% CI=1.08, 3.25).

Conclusion:

Our findings suggest that while RCCE efforts as part of EVD outbreak preparedness may have contributed to higher EVD knowledge in the targeted high-risk districts, uptake of prevention behaviors was similarly low across districts. In a non-outbreak setting, implementing targeted RCCE strategies may not be sufficient to motivate people to adopt protective behaviors in the absence of a high threshold of perceived threat such as in an active outbreak.

A Review of Infectious Diseases Associated with Religious and Nonreligious Rituals

Rituals are an integral part of human life but a wide range of rituals (both religious and non-religious), from self-flagellation to blood brotherhood to ritual sprinkling of holy water, have been associated with transmission of infections. These infections include angiostrongyliasis, anthrax, brucellosis, cholera, COVID-19, cutaneous larva migrans, Ebola, hepatitis viruses, herpes simplex virus, HIV, human T-cell leukemia virus (HTLV), kuru, Mycobacterium bovis, Naegleria fowleri meningoencephalitis, orf, rift valley fever, and sporotrichosis. Education and community engagement are important cornerstones in mitigating infectious risks associated with rituals.

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

Background

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

Methods

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

Results

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

Conclusion

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

Funeral Processes During the COVID-19 Pandemic: Perceptions Among Islamic Religious Leaders in Indonesia

Controversies surrounding the handling of corpses have been amplified during the present COVID-19 pandemic. According to Indonesian scholars, certain perspectives driving these controversies inhibit the implementation of health protocols issued by the government. This study comprehensively explores the diverse perceptions and responses of religious leaders regarding COVID-19 funeral management. Participants comprised six scholars from major Islamic religious organizations, two community leaders, and two families representing COVID-19 patients. Furthermore, content analysis was used to analyze the data. The results showed that the religious leaders, all men aged over 50 years, supported the health directives designed to reduce high transmission risk. However, there were substantial disparities in corpse preparation processes, potentially due to organizational beliefs around burial rites. Some religious leaders aligned their protocols with their religious beliefs. Conversely, families of the deceased insisted that the approved protocol for handling corpses went against their religious and cultural values. Therefore, promotion of protocols and coordination among the government, religious leaders, and the community are needed to decrease the misperceptions and misinformation surrounding the new COVID-19 funeral protocols.

Health seeking behavior after the 2013-16 Ebola epidemic: Lassa fever as a metric of persistent changes in Kenema District, Sierra Leone

BACKGROUND

The West African Ebola epidemic of 2013-2016 killed nearly 4,000 Sierra Leoneans and devastated health infrastructure across West Africa. Changes in health seeking behavior (HSB) during the outbreak resulted in dramatic underreporting and substantial declines in hospital presentations to public health facilities, resulting in an estimated tens of thousands of additional maternal, infant, and adult deaths per year. Sierra Leone's Kenema District, a major Ebola hotspot, is also endemic for Lassa fever (LF), another often-fatal hemorrhagic disease. Here we assess the impact of the West African Ebola epidemic on health seeking behaviors with respect to presentations to the Kenema Government Hospital (KGH) Lassa Ward, which serves as the primary health care referral center for suspected Lassa fever cases in the Eastern Province of Sierra Leone.

METHODOLOGY/PRINCIPAL FINDINGS

Presentation frequencies for suspected Lassa fever presenting to KGH or one of its referral centers from 2011-2019 were analyzed to consider the potential impact of the West African Ebola epidemic on presentation patterns. There was a significant decline in suspected LF cases presenting to KGH following the epidemic, and a lower percentage of subjects were admitted to the KGH Lassa Ward following the epidemic. To assess general HSB, a questionnaire was developed and administered to 200 residents from 8 villages in Kenema District. Among 194 completed interviews, 151 (78%) of respondents stated they felt hospitals were safer post-epidemic with no significant differences noted among subjects according to religious background, age, gender, or education. However, 37 (19%) subjects reported decreased attendance at hospitals since the epidemic, which suggests that trust in the healthcare system has not fully rebounded. Cost was identified as a major deterrent to seeking healthcare.

CONCLUSIONS/SIGNIFICANCE

Analysis of patient demographic data suggests that fewer individuals sought care for Lassa fever and other febrile illnesses in Kenema District after the West African Ebola epidemic. Re-establishing trust in health care services will require efforts beyond rebuilding infrastructure and require concerted efforts to rebuild the trust of local residents who may be wary of seeking healthcare post epidemic.

Exclusivity of Cultural Practices Within Emerging Disease Outbreak Responses in Developing Nations Leads to Detrimental Outcomes

A number of organizations provide aid and medical care to areas affected by emerging infectious disease outbreaks. This process oftentimes involves organizations traveling to developing areas and coordinating efforts on-site of the initial outbreak. Yet, the longevity and death toll of specific recent outbreaks and inability to effectively control them lead to unnecessary deaths and an unconstructive use of resources. While virtually all organizations justifiably point toward limited resources as an explanatory mechanism, this in itself does not excuse poor utilization of resources. Specifically, organizations systematically do not factor cultural practices into their disease responses. This is demonstrated in analyzing components of responses during 3 recent outbreaks occurring at different times and on different continents: Ebola in 2014 and 2019, and Zika in 2016. While systemic trends in these differential environments demonstrate the extent of the problem, fortunately, scientific innovations, collaboration with local individuals and leadership, and especially establishment of cross-cultural dialogue and response flexibility with the eventual development of effective behavioral change communication can help curb or mitigate this issue in the future.

Integrated digital system for community engagement and community-based surveillance during the 2014-2016 Ebola outbreak in Sierra Leone: lessons for future health emergencies

Community engagement and community-based surveillance are essential components of responding to infectious disease outbreaks, but real-time data reporting remains a challenge. In the 2014-2016 Ebola outbreak in Sierra Leone, the Social Mobilisation Action Consortium was formed to scale-up structured, data-driven community engagement. The consortium became operational across all 14 districts and supported an expansive network of 2500 community mobilisers, 6000 faith leaders and 42 partner radio stations. The benefit of a more agile digital reporting system became apparent within few months of implementing paper-based reporting given the need to rapidly use the data to inform the fast-evolving epidemic. In this paper, we aim to document the design, deployment and implementation of a digital reporting system used in six high transmission districts. We highlight lessons learnt from our experience in scaling up the digital reporting system during an unprecedented public health crisis. The lessons learnt from our experience in Sierra Leone have important implications for designing and implementing similar digital reporting systems for community engagement and community-based surveillance during public health emergencies.

[Anthropology of Infectious Death]

How do funeral rituals adapt when death is of infectious origin, or when death occurs in an epidemic context? What changes are needed? What anthropological fundamentals are altered, diverted or reversed? We will see, in the following anthropological and historical examples, how the community of the living deals with its fears and metaphysical demands vis-à-vis the community of the deceased, dealing with codes and beliefs. In short, how parallel rituals have been established to satisfy both parties.

Barriers and facilitators to reporting deaths following Ebola surveillance in Sierra Leone: implications for sustainable mortality surveillance based on an exploratory qualitative assessment

OBJECTIVES

To understand the barriers contributing to the more than threefold decline in the number of deaths (of all causes) reported to a national toll free telephone line (1-1-7) after the 2014-2016 Ebola outbreak ended in Sierra Leone and explore opportunities for improving routine death reporting as part of a nationwide mortality surveillance system.

DESIGN

An exploratory qualitative assessment comprising 32 in-depth interviews (16 in Kenema district and 16 in Western Area). All interviews were audio-recorded, transcribed and analysed using qualitative content analysis to identify themes.

SETTING

Participants were selected from urban and rural communities in two districts that experienced varying levels of Ebola cases during the outbreak. All interviews were conducted in August 2017 in the post-Ebola-outbreak context in Sierra Leone when the Sierra Leone Ministry of Health and Sanitation was continuing to mandate reporting of all deaths.

PARTICIPANTS

Family members of deceased persons whose deaths were not reported to the 1-1-7 system.

RESULTS

Death reporting barriers were driven by the lack of awareness to report all deaths, lack of services linked to reporting, negative experiences from the Ebola outbreak including prohibition of traditional burial rituals, perception that inevitable deaths do not need to be reported and situations where prompt burials may be needed. Facilitators of future willingness to report deaths were largely influenced by the perceived communicability and severity of the disease, unexplained circumstances of the death that need investigation and the potential to leverage existing death notification practices through local leaders.

CONCLUSIONS

Social mobilisation and risk communication efforts are needed to help the public understand the importance and benefits of sustained and ongoing death reporting after an Ebola outbreak. Localised practices for informal death notification through community leaders could be integrated into the formal reporting system to capture community-based deaths that may otherwise be missed.

Building the Sierra Leone Ebola Database: organization and characteristics of data systematically collected during 2014-2015 Ebola epidemic

PURPOSE

During the 2014-2016 Ebola outbreak in West Africa, the Sierra Leone Ministry of Health and Sanitation (MoHS), the US Centers for Disease Control and Prevention, and responding partners under the coordination of the National Ebola Response Center (NERC) and the MoHS's Emergency Operation Center (EOC) systematically recorded information from the 117 Call Center system and district alert phone lines, case investigations, laboratory sample testing, clinical management, and safe and dignified burial records. Since 2017, CDC assisted MoHS in building and managing the Sierra Leone Ebola Database (SLED) to consolidate these major data sources. The primary objectives of the project were helping families to identify the location of graves of their loved ones who died at the time of the Ebola epidemic through the SLED Family Reunification Program and creating a data source for epidemiological research. The objective of this paper is to describe the process of consolidating epidemic records into a useful and accessible data collection and to summarize data characteristics, strength, and limitations of this unique information source for public health research.

METHODS

Because of the unprecedented conditions during the epidemic, most of the records collected from responding organizations required extensive processing before they could be used as a data source for research or the humanitarian purpose of locating burial sites. This process required understanding how the data were collected and used during the outbreak. To manage the complexity of processing the data obtained from various sources, the Sierra Leone Ebola Database (SLED) Team used an organizational strategy that allowed tracking of the data provenance and lifecycle.

RESULTS

The SLED project brought raw data into one consolidated data collection. It provides researchers with secure and ethical access to the SLED data and serves as a basis for the research capacity building in Sierra Leone. The SLED Family Reunification Program allowed Sierra Leonean families to identify location of the graves of loved ones who died during the Ebola epidemic.

CONCLUSIONS

The SLED project consolidated and utilized epidemic data recorded during the Sierra Leone Ebola Virus Disease outbreak that were collected and contributed to SLED by national and international organizations. This project has provided a foundation for developing a method of ethical and secure SLED data access while preserving the host nation's data ownership. SLED serves as a data source for the SLED Family Reunification Program and for epidemiological research. It presents an opportunity for building research capacity in Sierra Leone and provides a foundation for developing a relational database. Large outbreak data systems such as SLED provide a unique opportunity for researchers to improve responses to epidemics and indicate the need to include data management preparedness in the plans for emergency response.

A Quantitative Framework for Defining the End of an Infectious Disease Outbreak: Application to Ebola Virus Disease

The end-of-outbreak declaration is an important step in controlling infectious disease outbreaks. Objective estimation of the confidence level that an outbreak is over is important to reduce the risk of postdeclaration flare-ups. We developed a simulation-based model with which to quantify that confidence and tested it on simulated Ebola virus disease data. We found that these confidence estimates were most sensitive to the instantaneous reproduction number, the reporting rate, and the time between the symptom onset and death or recovery of the last detected case. For Ebola virus disease, our results suggested that the current World Health Organization criterion of 42 days since the recovery or death of the last detected case is too short and too sensitive to underreporting. Therefore, we suggest a shift to a preliminary end-of-outbreak declaration after 63 days from the symptom onset day of the last detected case. This preliminary declaration should still be followed by 90 days of enhanced surveillance to capture potential flare-ups of cases, after which the official end of the outbreak can be declared. This sequence corresponds to more than 95% confidence that an outbreak is over in most of the scenarios examined. Our framework is generic and therefore could be adapted to estimate end-of-outbreak confidence for other infectious diseases.

Engaging religious leaders to promote safe burial practices during the 2014-2016 Ebola virus disease outbreak, Sierra Leone

OBJECTIVE

To quantify the potential impact of engaging religious leaders in promoting safe burial practices during the 2014-2016 Ebola virus disease outbreak in Sierra Leone.

METHODS

We analysed population-based household survey data from 3540 respondents collected around the peak of the outbreak in Sierra Leone, December 2014. Respondents were asked if in the past month they had heard an imam or pastor say that people should not touch or wash a dead body. We used multilevel logistic regression modelling to examine if exposure to religious leaders' messages was associated with protective burial intentions if a family member died at home and other Ebola protective behaviours.

FINDINGS

Of the respondents, 3148 (89%) had been exposed to faith-based messages from religious leaders on safe Ebola burials and 369 (10%) were unexposed. Exposure to religious leaders' messages was associated with a nearly twofold increase in the intention to accept safe alternatives to traditional burials and the intention to wait ≥ 2 days for burial teams (adjusted odds ratio, aOR: 1.69; 95% confidence interval, CI: 1.23-2.31 and aOR: 1.84; 95% CI: 1.38-2.44, respectively). Exposure to messages from religious leaders was also associated with avoidance of traditional burials and of contact with suspected Ebola patients (aOR: 1.46; 95% CI: 1.14-1.89 and aOR: 1.65; 95% CI: 1.27-2.13, respectively).

CONCLUSION

Public health messages promoted by religious leaders may have influenced safe burial behaviours during the Ebola outbreak in Sierra Leone. Engagement of religious leaders in risk communication should be prioritized during health emergencies in similar settings.

Preparedness of health care systems for Ebola outbreak response in Kasese and Rubirizi districts, Western Uganda

BACKGROUND

The level of preparedness of the health care workers, the health facility and the entire health system determines the magnitude of the impact of an Ebola Virus Disease (EVD) outbreak as demonstrated by the West African Ebola outbreak. The objective of the study was to assess preparedness of the health care facilities and identify appropriate preparedness measures for Ebola outbreak response in Kasese and Rubirizi districts in western Uganda.

METHODS

A cross sectional descriptive study was conducted by interviewing 189 health care workers using a structured questionnaire and visits to 22 health facilities to determine the level of health care system preparedness to EVD outbreak. District level infrastructure capabilities, existence of health facility logistics and supplies, and health care workers' knowledge of EVD was assessed. EVD Preparedness was assessed on infrastructure and logistical capabilities and the level of knowledge of an individual health work about the etiology, control and prevention of EVD.

RESULTS

Twelve out of the 22 of the health facilities, especially health center III's and IV's, did not have a line budget to respond to EVD when there was a threat of EVD in a nearby country. The majority (n = 13) of the facilities did not have the following: case definition books, rapid response teams and/or committees, burial teams, and simulation drills. There were no personal protective equipment that could be used within 8 h in case of an EVD outbreak in fourteen of the 22 health facilities. All facilities did not have Viral Hemorrhagic Fever (VHF) incident management centers, isolation units, guidelines for burial, and one-meter distance between a health care worker and a patient during triage. Overall, 54% (n = 102) of health care workers (HCWs) did not know the incubation period of EVD. HCWs who had tertiary education (aOR = 5.79; CI = 1.79-18.70; p = 0.003), and were Christian (aOR = 10.47; CI = 1.94-56.4; p = 0.006) were more likely to know about the biology, incubation period, causes and prevention of EVD.

CONCLUSIONS

Feedback on the level of preparedness for the rural districts helps inform strategies for building capacity of these health centers in terms of infrastructure, logistics and improving knowledge of health care workers.

Behaviour adoption approaches during public health emergencies: implications for the COVID-19 pandemic and beyond

Human behaviour will continue to play an important role as the world grapples with public health threats. In this paper, we draw from the emerging evidence on behaviour adoption during diverse public health emergencies to develop a framework that contextualises behaviour adoption vis-à-vis a combination of top-down, intermediary and bottom-up approaches. Using the COVID-19 pandemic as a case study, we operationalise the contextual framework to demonstrate how these three approaches differ in terms of their implementation, underlying drivers of action, enforcement, reach and uptake. We illustrate how blended strategies that include all three approaches can help accelerate and sustain protective behaviours that will remain important even when safe and effective vaccines become more widely available. As the world grapples with the COVID-19 pandemic and prepares to respond to (re)emerging public health threats, our contextual framework can inform the design, implementation, tracking and evaluation of comprehensive public health and social measures during health emergencies.

Emerging viral threats and the simultaneity of the non-simultaneous: zooming out in times of Corona

This paper addresses global bioethical challenges entailed in emerging viral diseases, focussing on their socio-cultural dimension and seeing them as symptomatic of the current era of globalisation. Emerging viral threats exemplify the extent to which humans evolved into a global species, with a pervasive and irreversible impact on the planetary ecosystem. To effectively address these disruptive threats, an attitude of preparedness seems called for, not only on the viroscientific, but also on bioethical, regulatory and governance levels. This paper analyses the global bioethical challenges of emerging viral threats from a dialectical materialist (Marxist) perspective, focussing on three collisions: (1) the collision of expanding networks of globalisation with local husbandry practices; (2) the collision of global networks of mobility with disrupted ecosystems; and (3) the collision of viroscience as a globalised research field with existing regulatory frameworks. These collisions emerge in a force field defined by the simultaneity of the non-simultaneous. Evidence-based health policies invoke discontent as they reflect the normative logic of a globalised knowledge regime. The development of a global bioethics or macro-ethics requires us to envision these collisions not primarily as issues of benefits and risks, but first and foremost as normative tensions closely entangled with broader socio-economic and socio-cultural developments.

National reporting of deaths after enhanced Ebola surveillance in Sierra Leone

Background

Sierra Leone experienced the largest documented epidemic of Ebola Virus Disease in 2014–2015. The government implemented a national tollfree telephone line (1-1-7) for public reporting of illness and deaths to improve the detection of Ebola cases. Reporting of deaths declined substantially after the epidemic ended. To inform routine mortality surveillance, we aimed to describe the trends in deaths reported to the 1-1-7 system and to quantify people’s motivations to continue reporting deaths after the epidemic.

Methods

First, we described the monthly trends in the number of deaths reported to the 1-1-7 system between September 2014 and September 2019. Second, we conducted a telephone survey in April 2017 with a national sample of individuals who reported a death to the 1-1-7 system between December 2016 and April 2017. We described the reported deaths and used ordered logistic regression modeling to examine the potential drivers of reporting motivations.

Findings

Analysis of the number of deaths reported to the 1-1-7 system showed that 12% of the expected deaths were captured in 2017 compared to approximately 34% in 2016 and over 100% in 2015. We interviewed 1,291 death reporters in the survey. Family members reported 56% of the deaths. Nearly every respondent (94%) expressed that they wanted the 1-1-7 system to continue. The most common motivation to report was to obey the government’s mandate (82%). Respondents felt more motivated to report if the decedent exhibited Ebola-like symptoms (adjusted odds ratio 2.3; 95% confidence interval 1.8–2.9).

Conclusions

Motivation to report deaths that resembled Ebola in the post-outbreak setting may have been influenced by knowledge and experiences from the prolonged epidemic. Transitioning the system to a routine mortality surveillance tool may require a robust social mobilization component to match the high reporting levels during the epidemic, which exceeded more than 100% of expected deaths in 2015.

By November 2015 when the World Health Organization declared the Ebola epidemic in Sierra Leone to be over, approximately 95% of the population had become aware of the risk of Ebola transmission linked to physical contact with infected corpses, especially during traditional burials. Enhanced Ebola surveillance was implemented between November 2015 and June 2016, i.e. after the epidemic had officially ended to improve detection of possible new cases. Reporting to the 1-1-7 system declined nationally after enhanced Ebola surveillance ended even though the Government of Sierra Leone continued to mandate that all deaths must be reported. Based on a request from the Sierra Leone Ministry of Health and Sanitation, we conducted a telephone survey with a national sample of people who had reported a death in 2017 after the end of enhanced surveillance to understand their motivations for reporting and describe the deaths that they reported. In addition, we analyzed the five-year trends (2014–2019) in the number of deaths reported through the system. Analysis of monthly summary data of deaths reported showed that on the last month of enhanced surveillance, 3,851 deaths were reported compared to 2,456 deaths in the month immediately after (July 2016). The monthly numbers of reported deaths continued to plummet and reached as low as 1,550 in January 2017, 673 in January 2018, and 586 in January 2019. In the survey, we uncovered that people who reported deaths were mainly motivated to do so in order to comply with the Government’s mandate. After adjusting for potential confounders, motivations to report were strongly associated with the presence of Ebola-like symptoms in the decedent. Additional investigations are needed to unveil reporting barriers among people who failed to report household deaths to the 1-1-7 system to optimize reporting levels. It has been shown that during the Ebola epidemic that it is possible to reach high levels of death reporting in Sierra Leone as exemplified by the fact that in 2015 more than 100% of the expected deaths nationally were reported; albeit not counting potential duplicates. The post-Ebola-outbreak setting provides a unique opportunity to improve future overall mortality surveillance in Sierra Leone and contribute to the establishment of civil registration of vital statistics.

“More than an intensive care phenomenon”: Religious communities and the WHO Guidelines for Ebola and Covid-19

This article draws on anthropological fieldwork conducted during the West African Ebola outbreak (2014-2016) and reports of the ongoing Covid-19 crisis to discuss the role played by religion in infectious disease control. While much separates Ebola and Covid-19, the religious practices prevalent in both contexts produce similar challenges to hospital staff and caregivers. In West Africa, at least 20 % of all infections were suspected to be related to the burial of deceased Ebola victims; yet at the same time, local communities at times reacted very negatively to infectious disease control measures. This article discusses how, based on this recognition, a systematic exchange began between anthropologists, faith-based organisations (FBOs) and humanitarian organisations active in the provision of healthcare, culminating in a WHO protocol for the “safe and dignified” burial of Ebola victims. The model of ‘contactless’ adaptations of religious practices it put forth may have significantly contributed to the control of the epidemic. In the second part, this article turns to the Covid-19 pandemic to show how religious communities have responded to the risks associated with many religious practices, and how the WHO, drawing on its experience with Ebola, developed comparable guidelines aimed at religious leaders and faith communities. As the experience in West Africa has shown, it is argued, the active involvement of religious actors in the formulation of public health measures may not only help to provide safe comfort in the midst of a profoundly alienating experience, but significantly reduce the spread of the virus.

Adequacy of SEIR models when epidemics have spatial structure: Ebola in Sierra Leone

Dynamic SEIR (Susceptible, Exposed, Infectious, Removed) compartmental models provide a tool for predicting the size and duration of both unfettered and managed outbreaks-the latter in the context of interventions such as case detection, patient isolation, vaccination and treatment. The reliability of this tool depends on the validity of key assumptions that include homogeneity of individuals and spatio-temporal homogeneity. Although the SEIR compartmental framework can easily be extended to include demographic (e.g. age) and additional disease (e.g. healthcare workers) classes, dependence of transmission rates on time, and metapopulation structure, fitting such extended models is hampered by both a proliferation of free parameters and insufficient or inappropriate data. This raises the question of how effective a tool the basic SEIR framework may actually be. We go some way here to answering this question in the context of the 2014-2015 outbreak of Ebola in West Africa by comparing fits of an SEIR time-dependent transmission model to both country- and district-level weekly incidence data. Our novel approach in estimating the effective-size-of-the-populations-at-risk ( N_eff) and initial number of exposed individuals ( E₀) at both district and country levels, as well as the transmission function parameters, including a time-to-halving-the-force-of-infection ( t_f/2) parameter, provides new insights into this Ebola outbreak. It reveals that the estimate R₀ ≈ 1.7 from country-level data appears to seriously underestimate R₀ ≈ 3.3 - 4.3 obtained from more spatially homogeneous district-level data. Country-level data also overestimate t_f/2 ≈ 22 weeks, compared with 8-10 weeks from district-level data. Additionally, estimates for the duration of individual infectiousness is around two weeks from spatially inhomogeneous country-level data compared with 2.4-4.5 weeks from spatially more homogeneous district-level data, which estimates are rather high compared with most values reported in the literature. This article is part of the theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: approaches and important themes'. This issue is linked with the subsequent theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: epidemic forecasting and control'.

Evidence of behaviour change during an Ebola virus disease outbreak, Sierra Leone

Objective

To evaluate changes in Ebola-related knowledge, attitudes and prevention practices during the Sierra Leone outbreak between 2014 and 2015.

Methods

Four cluster surveys were conducted: two before the outbreak peak (3499 participants) and two after (7104 participants). We assessed the effect of temporal and geographical factors on 16 knowledge, attitude and practice outcomes.

Findings

Fourteen of 16 knowledge, attitude and prevention practice outcomes improved across all regions from before to after the outbreak peak. The proportion of respondents willing to: (i) welcome Ebola survivors back into the community increased from 60.0% to 89.4% (adjusted odds ratio, aOR: 6.0; 95% confidence interval, CI: 3.9–9.1); and (ii) wait for a burial team following a relative’s death increased from 86.0% to 95.9% (aOR: 4.4; 95% CI: 3.2–6.0). The proportion avoiding unsafe traditional burials increased from 27.3% to 48.2% (aOR: 3.1; 95% CI: 2.4–4.2) and the proportion believing spiritual healers can treat Ebola decreased from 15.9% to 5.0% (aOR: 0.2; 95% CI: 0.1–0.3). The likelihood respondents would wait for burial teams increased more in high-transmission (aOR: 6.2; 95% CI: 4.2–9.1) than low-transmission (aOR: 2.3; 95% CI: 1.4–3.8) regions. Self-reported avoidance of physical contact with corpses increased in high but not low-transmission regions, aOR: 1.9 (95% CI: 1.4–2.5) and aOR: 0.8 (95% CI: 0.6–1.2), respectively.

Conclusion

Ebola knowledge, attitudes and prevention practices improved during the Sierra Leone outbreak, especially in high-transmission regions. Behaviourally-targeted community engagement should be prioritized early during outbreaks.

The International Red Cross and Red Crescent Movement Response to the West African Ebola Outbreak 2014

The International Health Regulations 2005 (IHR) are the most up to date international legal rules on the control of infectious diseases and provide a unified code for infectious disease control. The IHR name the International Federation of the Red Cross (IFRC) as one of the international organisations with whom the WHO must cooperate and co-ordinate in implementing the IHR. It was organisations like the IFRC and MSF, that worked to stop the spread of Ebola following the outbreak in 2014. The focus of this chapter is the work of the IFRC during the Ebola outbreak. The IFRC carries out relief operations to assist victims of disasters, and combines this with development work to strengthen the capacities of its member National Societies. The IFRC’s work focuses on four core areas: promoting humanitarian values, disaster response, disaster preparedness, and health and community care. Combining a study of the IFRC as an organisation with a legal mandate of its own, elucidated in the Statutes of the International Red Cross and Red Crescent Movement, and the more general international legal framework, this chapter uses international law as a framework to reflect on the limits and effectiveness of legal measures in responding to Ebola. To this end, international law provides a logical and global method to respond to infectious diseases. This chapter finds that the mandate and practice of the IFRC in the response to Ebola provides material to critically analyse each of these parts in light of infectious disease proliferation in 2014–2016. Since outbreak was announced in early 2014 more than 10,000 Red Cross volunteers were trained in Ebola response. IFRC supported emergency operations in Guinea, Liberia, and Sierra Leone have targeted 23 million people.

Lessons learned from engaging communities for Ebola vaccine trials in Sierra Leone: reciprocity, relatability, relationships and respect (the four R's)

BACKGROUND

Building trust and engaging the community are important for biomedical trials. This was core to the set up and delivery of the EBOVAC-Salone and PREVAC Ebola vaccine trials in Sierra Leone during and following the 2014-2016 West African Ebola epidemic. Local community liaison teams (CLT) engaged with the community through public meetings, radio chat shows, and other activities, while a social science team (SST) assessed community members' and participants' perceptions and regularly updated the clinical team to adapt procedures to improve the acceptability and compliance of the trial. The objective of this study was to examine the community engagement (CE) program in these trials and to identify potential barriers and facilitators.

METHODS

Fifteen CLT and SST members participated in in-depth interviews and 23 community members attended three focus groups to discuss the Ebola vaccine trials and their experiences and perspectives of the CE activities.

RESULTS

A key aim of the CE program was to build trust between the community and the trial. Four main principles (the "four R's") evolved from the discussions with team members and the community that influenced this trust: reciprocity, relatability, relationships and respect. The CLT and SST ensured reciprocal communication between the trial team and the community. The CLT delivered key messages from the trial, whilst the SST completed ethnographic research in the field to uncover rumors and perceptions of the trial in the community. These ethnographic findings were shared with the CLT and addressed in targeted messaging to the community. Both the CLT and SST approached the communities in an egalitarian manner, by dressing modestly, speaking local dialects, and using relatable examples. Appreciation and understanding of the importance of interpersonal relationships and respect for the people, their customs, and traditions also played a large role in the CE program.

CONCLUSION

These findings provide an in-depth understanding of how interdisciplinary community liaison and social science teams can work with a clinical team to strengthen trust. The four R's suggest the ways in which trust relations are central to CE and confidence in vaccine trials, and could offer an approach to CE in vaccine trials.

Ebola virus disease outbreak in Korea: use of a mathematical model and stochastic simulation to estimate risk

OBJECTIVES

According to the World Health Organization, there have been frequent reports of Ebola virus disease (EVD) since the 2014 EVD pandemic in West Africa. We aim to estimate the outbreak scale when an EVD infected person arrives in Korea.

METHODS

Western Africa EVD epidemic mathematical model SEIJR or SEIJQR was modified to create a Korean EVD outbreak model. The expected number of EVD patients and outbreak duration were calculated by stochastic simulation under the scenarios of Best case, Diagnosis delay, and Case missing.

RESULTS

The 2,000 trials of stochastic simulation for each scenario demonstrated the following results: The possible median number of patients is 2 and the estimated maximum number is 11 when the government intervention is proceeded immediately right after the first EVD case is confirmed. With a 6-day delay in diagnosis of the first case, the median number of patients becomes 7, and the maximum, 20. If the first case is missed and the government intervention is not activated until 2 cases of secondary infection occur, the median number of patients is estimated at 15, and the maximum, at 35.

CONCLUSIONS

Timely and rigorous diagnosis is important to reduce the spreading scale of infection when a new communicable disease is inflowed into Korea. Moreover, it is imperative to strengthen the local surveillance system and diagnostic protocols to avoid missing cases of secondary infection.

Ebola virus disease: An emerging and re-emerging viral threat

The genus Ebolavirus from the family Filoviridae is composed of five species including Sudan ebolavirus, Reston ebolavirus, Bundibugyo ebolavirus, Taï Forest ebolavirus, and Ebola virus (previously known as Zaire ebolavirus). These viruses have a large non-segmented, negative-strand RNA of approximately 19 kb that encodes for glycoproteins (i.e., GP, sGP, ssGP), nucleoproteins, virion proteins (i.e., VP 24, 30,40) and an RNA dependent RNA polymerase. These viruses have become a global health concern because of mortality, their rapid dissemination, new outbreaks in West-Africa, and the emergence of a new condition known as "Post-Ebola virus disease syndrome" that resembles inflammatory and autoimmune conditions such as rheumatoid arthritis, systemic lupus erythematosus and spondyloarthritis with uveitis. However, there are many gaps in the understanding of the mechanisms that may induce the development of such autoimmune-like syndromes. Some of these mechanisms may include a high formation of neutrophil extracellular traps, an uncontrolled "cytokine storm", and the possible formation of auto-antibodies. The likely appearance of autoimmune phenomena in Ebola survivors suppose a new challenge in the management and control of this disease and opens a new field of research in a special subgroup of patients. Herein, the molecular biology, pathogenesis, clinical manifestations, and treatment of Ebola virus disease are reviewed and some strategies for control of disease are discussed.

What motivates individuals to volunteer in Ebola epidemic response? A structural approach in Guinea

BACKGROUND

The 2014-2016 Ebola epidemic in West Africa placed greater demands on the affected countries' already scarce health workforce. Consequently, governments in the most affected West African countries made appeals for volunteers to join Ebola response programs. Those volunteers played an important yet high-risk role in aiding the victims of the Ebola epidemic and in limiting its spread. However, little is known as to what motivated those volunteers to commit themselves to the Ebola response programs. This information is important for planning for volunteer recruitment strategies during future epidemics. The aim of the present study, therefore, was to identify and assess the motivations that led individuals to volunteer for Ebola response programs in West Africa.

METHODS

The study participants were 600 persons who volunteered through the Guinean Ebola response program during the 2014-2016 epidemic. From February to May 2016, they were presented with a questionnaire that contained 50 assertions referring to possible motives for volunteering in the Ebola response program and indicated their degree of agreement with each of them on a scale of 0-10. The responses were analyzed using factor analysis.

RESULTS

Seven separable volunteer motivations were identified. "Feeling of patriotic duty" (M = 9.02) and "Feeling of moral responsibility" (M = 8.12) clearly emerged as the most important. Second-tier motivations were "Compliance with authority" (M = 6.66), "Desire to use one's skills for a collective good" (M = 6.49), "Seeking personal growth" (M = 5.93), "Desire to gain community recognition" (M = 5.13), and "Hoping for a career reorientation" (M = 4.52).

CONCLUSIONS

These findings strongly suggest that volunteer recruitment, if needed in future Ebola epidemics, must adopt a multifaceted motivational approach rather than focus on one single motivator. Putting relatively more emphasis on motivational messages referring to patriotic values, as well as to moral responsibility, would likely increase volunteering.

Determinants of Transmission Risk During the Late Stage of the West African Ebola Epidemic

Understanding risk factors for Ebola transmission is key for effective prediction and design of interventions. We used data on 860 cases in 129 chains of transmission from the latter half of the 2013-2016 Ebola epidemic in Guinea. Using negative binomial regression, we determined characteristics associated with the number of secondary cases resulting from each infected individual. We found that attending an Ebola treatment unit was associated with a 38% decrease in secondary cases (incidence rate ratio (IRR) = 0.62, 95% confidence interval (CI): 0.38, 0.99) among individuals that did not survive. Unsafe burial was associated with a higher number of secondary cases (IRR = 1.82, 95% CI: 1.10, 3.02). The average number of secondary cases was higher for the first generation of a transmission chain (mean = 1.77) compared with subsequent generations (mean = 0.70). Children were least likely to transmit (IRR = 0.35, 95% CI: 0.21, 0.57) compared with adults, whereas older adults were associated with higher numbers of secondary cases. Men were less likely to transmit than women (IRR = 0.71, 95% CI: 0.55, 0.93). This detailed surveillance data set provided an invaluable insight into transmission routes and risks. Our analysis highlights the key role that age, receiving treatment, and safe burial played in the spread of EVD.

Ebola virus disease

Ebolaviruses are pathogenic agents associated with a severe, potentially fatal, systemic disease in man and great apes. Four species of ebolaviruses have been identified in west or equatorial Africa. Once the more virulent forms enter the human population, transmission occurs primarily through contact with infected body fluids and can result in major epidemics in under-resourced settings. These viruses cause a disease characterised by systemic viral replication, immune suppression, abnormal inflammatory responses, major fluid and electrolyte losses, and high mortality. Despite recent progress on vaccines, and with no licensed prophylaxis or treatment available, case management is essentially supportive with management of severe multiple organ failure resulting from immune-mediated cell damage. The 2013-16 outbreak was classified by WHO as a Public Health Emergency of International Concern, which drew attention to the challenges of diseases caused by infections with ebolaviruses and questioned scientific, clinical, and societal preparation to handle future epidemics.

Modeling Dynamic Human Behavioral Changes in Animal Disease Models: Challenges and Opportunities for Addressing Bias

Over the past several decades, infectious disease modeling has become an essential tool for creating counterfactual scenarios that allow the effectiveness of different disease control policies to be evaluated prior to implementation in the real world. For livestock diseases, these models have become increasingly sophisticated as researchers have gained access to rich national livestock traceability databases, which enables inclusion of explicit spatial and temporal patterns in animal movements through network-based approaches. However, there are still many limitations in how we currently model animal disease dynamics. Critical among these is that many models make the assumption that human behaviors remain constant over time. As many studies have shown, livestock owners change their behaviors around trading, on-farm biosecurity, and disease management in response to complex factors such as increased awareness of disease risks, pressure to conform with social expectations, and the direct imposition of new national animal health regulations; all of which may significantly influence how a disease spreads within and between farms. Failing to account for these dynamics may produce a substantial layer of bias in infectious disease models, yet surprisingly little is currently known about the effects on model inferences. Here, we review the growing evidence on why these assumptions matter. We summarize the current knowledge about farmers' behavioral change in on-farm biosecurity and livestock trading practices and highlight the knowledge gaps that prohibit these behavioral changes from being incorporated into disease modeling frameworks. We suggest this knowledge gap can be filled only by more empirical longitudinal studies on farmers' behavioral change as well as theoretical modeling studies that can help to identify human behavioral changes that are important in disease transmission dynamics. Moreover, we contend it is time to shift our research approach: from modeling a single disease to modeling interactions between multiple diseases and from modeling a single farmer behavior to modeling interdependencies between multiple behaviors. In order to solve these challenges, there is a strong need for interdisciplinary collaboration across a wide range of fields including animal health, epidemiology, sociology, and animal welfare.

Unreported cases in the 2014-2016 Ebola epidemic: Spatiotemporal variation, and implications for estimating transmission

In the recent 2014–2016 Ebola epidemic in West Africa, non-hospitalized cases were an important component of the chain of transmission. However, non-hospitalized cases are at increased risk of going unreported because of barriers to access to healthcare. Furthermore, underreporting rates may fluctuate over space and time, biasing estimates of disease transmission rates, which are important for understanding spread and planning control measures. We performed a retrospective analysis on community deaths during the recent Ebola epidemic in Sierra Leone to estimate the number of unreported non-hospitalized cases, and to quantify how Ebola reporting rates varied across locations and over time. We then tested if variation in reporting rates affected the estimates of disease transmission rates that were used in surveillance and response. We found significant variation in reporting rates among districts, and district-specific rates of increase in reporting over time. Correcting time series of numbers of cases for variable reporting rates led, in some instances, to different estimates of the time-varying reproduction number of the epidemic, particularly outside the capital. Future analyses that compare Ebola transmission rates over time and across locations may be improved by considering the impacts of differential reporting rates.

Epidemics are defined by a surge of cases of a disease, yet often a significant number of cases in an epidemic are never reported, for example because not all infected individuals have access to medical care. This underreporting can introduce bias into analyses of disease spread, by distorting patterns in where and when the most cases are observed. Conversely, quantifying underreporting can improve epidemic forecasts and containment strategies. In this study, we analyze data from the recent Ebola epidemic in West Africa, including the time, location and Ebola status of 6491 individual community burials, conducted over 25 weeks in four districts in Sierra Leone. We quantify how reporting rates varied over space and time, and show that estimates of transmission rates that are corrected for dynamic underreporting diverge significantly from uncorrected estimates, particularly earlier in the epidemic and outside the capital.