Social resistance drives persistent transmission of Ebola virus disease in Eastern Democratic Republic of Congo: A mixed-methods study

A comprehensive analysis of non-pharmaceutical interventions and vaccination on Ebolavirus disease outbreak: Stochastic modeling approach

Ebolavirus disease (EVD) outbreaks have intermittently occurred since the first documented case in the 1970s. Due to its transmission characteristics, large outbreaks have not been observed outside Africa. However, within the continent, significant outbreaks have been attributed to factors such as endemic diseases with similar symptoms and inadequate medical infrastructure, which complicate timely diagnosis. In this study, we employed a stochastic modeling approach to analyze the spread of EVD during the early stages of an outbreak, with an emphasis on inherent risks. We developed a model that considers healthcare workers and unreported cases, and assessed the effect of non-pharmaceutical interventions (NPIs) using actual data. Our results indicate that the implementation of NPIs led to a decrease in the transmission rate and infectious period by 30% and 40% respectively, following the declaration of the outbreak. We also investigated the risks associated with delayed outbreak recognition. Our simulations suggest that, when accounting for NPIs and recognition delays, prompt detection could have resulted in a similar outbreak scale, with approximately 50% of the baseline NPIs effect. Finally, we discussed the potential effects of a vaccination strategy as a follow-up measure after the outbreak declaration. Our findings suggest that a vaccination strategy can reduce both the burden of NPIs and the scale of the outbreak.

The Uptake of Pneumococcal and Seasonal Influenza Vaccinations Based on Perceptions and Attitudes Toward the COVID-19 Vaccine Among Patients With Diabetes

Objective In this study, we aimed to assess the rates of pneumococcal and seasonal influenza vaccinations among elderly and nonelderly diabetes patients and examine their perceptions and attitudes toward the coronavirus disease 2019 (COVID-19) vaccine. Methods A single-center study was conducted among patients with diabetes, employing a structured survey encompassing sociodemographic data, vaccination records, and the COVID-19 vaccine perception and attitude scale. Results Among the 280 diabetes patients in our study, the vaccination rates for COVID-19, seasonal influenza, and pneumococcal vaccines were 96.1%, 16.8%, and 17.5%, respectively. A higher cumulative dosage of the COVID-19 vaccine was associated with older age (r = 0.463; p<0.001), increased safety score (r = 0.479; p<0.001), and lower conspiracy theory score (r = -0.336; p<0.001). Participants who had received COVID-19 and influenza vaccines were observed to have significantly higher safety scores related to COVID-19 vaccines (p<0.001; d = 2.381 and p = 0.008; d = 0.525, respectively). Notably, vaccination rates for influenza and pneumococcus were significantly different between nonelderly and elderly patients (8.7% vs. 29.6%; p<0.001 and 13.4% vs. 24.1%; p = 0.022). Elderly patients with diabetes were 3.3 times more likely to receive the influenza vaccine than nonelderly participants [odds ratio (OR) = 3.319; 95% confidence interval (CI) = 1.592 - 6.920; p = 0.001] and had a higher safety score related to COVID-19 vaccines (OR = 1.076; 95% CI = 1.011 - 1.146; p = 0.021). Conclusions Both influenza and pneumococcal vaccination rates were below the desired targets in this study. The vaccination rates among the nonelderly diabetes population suggest that this group may be more likely to neglect to receive vaccination compared to the elderly diabetes population. The association between vaccination rates and post-pandemic safety perceptions highlights the critical need to implement public health strategies specifically designed to address and improve safety-related information dissemination.

Perceptions toward Ebola vaccination and correlates of vaccine uptake among high-risk community members in North Kivu, Democratic Republic of the Congo

The tenth Ebola Virus Disease (EVD) outbreak (2018-2020, North Kivu, Ituri, South Kivu) in the Democratic Republic of the Congo (DRC) was the second-largest EVD outbreak in history. During this outbreak, Ebola vaccination was an integral part of the EVD response. We evaluated community perceptions toward Ebola vaccination and identified correlates of Ebola vaccine uptake among high-risk community members in North Kivu, DRC. In March 2021, a cross-sectional survey among adults was implemented in three health zones. We employed a sampling approach mimicking ring vaccination, targeting EVD survivors, their household members, and their neighbors. Outbreak experiences and perceptions toward the Ebola vaccine were assessed, and modified Poisson regression was used to identify correlates of Ebola vaccine uptake among those offered vaccination. Among the 631 individuals surveyed, most (90.2%) reported a high perceived risk of EVD and 71.6% believed that the vaccine could reduce EVD severity; however, 63.7% believed the vaccine had serious side effects. Among the 474 individuals who had been offered vaccination, 397 (83.8%) received the vaccine, 180 (45.3%) of those vaccinated received the vaccine after two or more offers. Correlates positively associated with vaccine uptake included having heard positive information about the vaccine (RR 1.30, 95% CI 1.06-1.60), the belief that the vaccine could prevent EVD (RR 1.23, 95% CI 1.09-1.39), and reporting that religion influenced all decisions (RR 1.13, 95% CI 1.02-1.25). Ebola vaccine uptake was high in this population, although mixed attitudes and vaccine delays were common. Communicating positive vaccine information, emphasizing the efficacy of the Ebola vaccine, and engaging religious leaders to promote vaccination may aid in increasing Ebola vaccine uptake during future outbreaks.

Impact of Ebola epidemics on the daily operation of existing systems in Eastern Democratic Republic of the Congo: a brief review

AIMS

to provide insights into the recent Ebola virus disease (EVD) outbreaks on different aspects of daily life in the Democratic Republic of the Congo and propose possible solutions.

METHODS

We collected information regarding the effects of EVD outbreaks on existing systems in the eastern part of the Democratic Republic of the Congo (DRC). We searched the PubMed database using the terms "impact effect Ebola outbreak system", "Management Ebola Poor Resources Settings", "Health Economic Challenges Ebola" and "Economic impact Ebola systems." Only studies focusing on epidemiology, diagnostics, sequencing, vaccination, therapeutics, ecology, work force, governance, healthcare provision and health system, and social, political, and economic aspects were considered. The search included the electronic archives of EVD outbreak reports from government and partners.

RESULTS

EVD outbreaks negatively impacts the functions of countries. The disruption in activities is proportional to the magnitude of the epidemic and slows down the transport of goods, decreases the region's tourist appeal, and increases 'brain drain'. Most low- and medium-income countries, such as the DRC, do not have a long-term holistic emergency plan for unexpected situations or sufficient resources to adequately implement countermeasures against EVD outbreaks. Although the DRC has acquired sufficient expertise in diagnostics, genomic sequencing, administration of vaccines and therapeutics, clinical trials, and research activities, deployment, operation, and maintenance of these expertise and associated tools remains a concern.

LIMITATIONS

Despite the data search extension, additional reports addressing issues related to social aspects of EVD outbreaks in DRC were not retrieved.

CONCLUSION

National leadership has not yet taken the lead in strategic, operational, or financial aspects. Therefore, national leaders should double their efforts and awareness to encourage local fundraising, sufficient budget al.location, infrastructure construction, equipment provision, and staff training, to effectively support a holistic approach in response to outbreaks, providing effective results, and all types of research activities.

Access to healthcare services and confidence in healthcare professionals' management of malaria: the views of Francophone sub-Saharan African Immigrants living in western Canada

BACKGROUND

There is a paucity of knowledge about the healthcare attitudes and practices of French-speaking immigrants originating from Sub-Saharan Africa (FISSA) living in minority settings. The purpose of this study was to characterize FISSA healthcare experiences and confidence in the malaria-related knowledge of health professionals in Edmonton.

METHODS

A structured survey was used to examine a cohort of 382 FISSA (48% female; 52% male) living in Edmonton. FISSA general healthcare attitudes, experiences and satisfaction with the Canadian healthcare system were studied. Healthcare Competency Perception (HCP) was characterized by using an index score. Statistical analyses were performed to evaluate the impact of healthcare experiences and other outcomes.

RESULTS

Intriguingly, while only 42% of FISSA had a French-speaking family physician, 83% (197/238) of those who had received health care services in Alberta found that access to medical treatment was easy, and 77% (188/243) were satisfied with received care. Although 70% (171/243) of FISSA did not receive services in French, 82% (199/243) surprisingly reported having good levels of comprehension during their visits. Satisfaction with care was associated with having a family physician (p = 0.018) and having health insurance (p = 0.041). Nevertheless, confidence in the healthcare system's ability to treat malaria effectively was significantly lower, with only 39% (148/382) receiving a positive score on the HCP index.

CONCLUSION

This study provides an important insight into FISSA experience with and perception of the Alberta's healthcare system.

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.

Ebola vaccine uptake and attitudes among healthcare workers in North Kivu, Democratic Republic of the Congo, 2021

Introduction

During the 2018-2020 Ebola virus disease (EVD) outbreak in the eastern part of the Democratic Republic of the Congo (DRC), prevention and control measures, such as Ebola vaccination were challenging by community mistrust. We aimed to understand perceptions regarding Ebola vaccination and identify determinants of Ebola vaccine uptake among HCWs.

Methods

In March 2021, we conducted a cross-sectional survey among 438 HCWs from 100 randomly selected health facilities in three health zones (Butembo, Beni, Mabalako) affected by the 10th EVD outbreak in North Kivu, DRC. HCWs were eligible if they were ≥ 18 years and were working in a health facility during the outbreak. We used survey logistic regression to assess correlates of first-offer uptake (i.e., having received the vaccine the first time it was offered vs. after subsequent offers).

Results

Of the 438 HCWs enrolled in the study, 420 (95.8%) reported that they were eligible and offered an Ebola vaccine. Among those offered vaccination, self-reported uptake of the Ebola vaccine was 99.0% (95% confidence interval (CI) [98.5-99.4]), but first-offer uptake was 70.2% (95% CI [67.1, 73.5]). Nearly all HCWs (94.3%; 95% CI [92.7-95.5]) perceived themselves to be at risk of contracting EVD. The most common concern was that the vaccine would cause side effects (65.7%; 95% CI [61.4-69.7]). In the multivariable analysis, mistrust of the vaccine source or how the vaccine was produced decreased the odds of first-time uptake.

Discussion

Overall uptake of the Ebola vaccine was high among HCWs, but uptake at the first offer was substantially lower, which was associated with mistrust of the vaccine source. Future Ebola vaccination efforts should plan to make repeated vaccination offers to HCWs and address their underlying mistrust in the vaccines, which can, in turn, improve community uptake.

A community-based contact isolation strategy to reduce the spread of Ebola virus disease: an analysis of the 2018-2020 outbreak in the Democratic Republic of the Congo

INTRODUCTION

Despite tremendous progress in the development of diagnostics, vaccines and therapeutics for Ebola virus disease (EVD), challenges remain in the implementation of holistic strategies to rapidly curtail outbreaks. We investigated the effectiveness of a community-based contact isolation strategy to limit the spread of the disease in the Democratic Republic of Congo (DRC).

METHODS

We did a quasi-experimental comparison study. Eligible participants were EVD contacts registered from 12 June 2019 to 18 May 2020 in Beni and Mabalako Health Zones. Intervention group participants were isolated to specific community sites for the duration of their follow-up. Comparison group participants underwent contact tracing without isolation. The primary outcome was measured as the reproduction number (R) in the two groups. Secondary outcomes were the delay from symptom onset to isolation and case management, case fatality rate (CFR) and vaccination uptake.

RESULTS

27 324 EVD contacts were included in the study; 585 in the intervention group and 26 739 in the comparison group. The intervention group generated 32 confirmed cases (5.5%) in the first generation, while the comparison group generated 87 (0.3%). However, the 32 confirmed cases arising from the intervention contacts did not generate any additional transmission (R=0.00), whereas the 87 confirmed cases arising from the comparison group generated 99 secondary cases (R=1.14). The average delay between symptom onset and case isolation was shorter (1.3 vs 4.8 days; p<0.0001), CFR lower (12.5% vs 48.4%; p=0.0001) and postexposure vaccination uptake higher (86.0% vs 56.8%; p<0.0001) in the intervention group compared with the comparison group. A significant difference was also found between intervention and comparison groups in survival rate at the discharge of hospitalised confirmed patients (87.9% vs 47.7%, respectively; p=0.0004).

CONCLUSION

The community-based contact isolation strategy used in DRC shows promise as a potentially effective approach for the rapid cessation of EVD transmission, highlighting the importance of rapidly implemented, community-oriented and trust-building control strategies.

Burial workers' perceptions of community resistance and support systems during an Ebola outbreak in the Eastern Democratic Republic of the Congo: a qualitative study

BACKGROUND

Community Health Workers (CHWs) provide vital services during disease outbreaks. Appropriate burials of those who died from an infectious disease outbreak is a critical CHW function to prevent infection and disease spread. During the 2018 Ebola Virus Disease (EVD) outbreak in Beni Town, North Kivu, Democratic Republic of the Congo, we sought to understand the levels of understanding, trust, and cooperation of the community in response to the outbreak, the barriers burial workers faced in their health work and its impact on local burial workers and other CHWs.

METHODS

12 EVD burial CHWs in Beni Town completed an hour-long qualitative in-depth interview on their experiences. They were recruited from a local counseling center. Interviews were recorded, transcribed and translated into English. A team of 3 researchers identified structural and emergent themes using applied thematic analysis.

RESULTS

Workers reported major misconceptions in the community surrounding the initiation of the outbreak. Community misconceptions were based on widespread governmental mistrust as well as a belief system that intertwines traditional and scientific understandings of the world. EVD burial workers identified violence directed at them and community misinformation as the two largest barriers to effectively carrying out their work. They named several important support systems including family and friends, personal relaxation techniques, and a local counseling center.

CONCLUSIONS

As with other disease outbreaks globally, we found that government mistrust and religious beliefs strongly impacted community perceptions of the EVD outbreak. Previous studies have demonstrated clinic-based medical personnel are often the targets of violence. Our research shows that burial workers were also targeted and exposed to extreme levels of violence in their work. Along with their ability to effectively respond to the outbreak, violence has a negative impact on their own mental wellbeing. Burial workers found group counseling sessions to be an effective tool for managing the stress associated with their work. Further developing and testing of group-based interventions for this group is a priority for future research.

Epidemic Response amidst Insecurity: Addressing the Ebola Virus Epidemic in the Provinces of North Kivu and Ituri

This paper examines the impact of insecurity on the management of the Ebola virus disease epidemic in the Democratic Republic of the Congo provinces of North Kivu and Ituri. In these provinces, insecurity has been one of the biggest obstacles in the response to the Ebola outbreak. When the epidemic began, these provinces were already insecure-creating unfavorable circumstances for implementing epidemic response activities. While the ninth epidemic in the Equateur province was brought under control in record time, the same was not true for the tenth epidemic in North Kivu and Ituri. Since the epidemic began, teams were organized to address all aspects of the response. These response teams conducted extensive fieldwork, including epidemiological surveillance, risk communication and community involvement, infection prevention and control, vaccination, dignified and safe burials, care at transit centers and Ebola treatment centers, and medical and psychosocial care for the recovered. They faced confrontational reactions from the communities, which jeopardized their security. The insecure state of the provinces led to the destruction and damage of infrastructure, including healthcare facilities, which affected the ability of rescue teams to access people needing care as well as the resources they needed to care for the ill. Worse yet, the insecurity took other forms, including threatening and kidnapping members of the response teams, lodging protests against the response activities in towns or health zones, committing violence against teams responsible for safe and dignified burials, instigating altercations between community members and members of the response team, and encouraging general resistance by the population. This level of insecurity interrupted or even halted response activities in some areas-sometimes for more than two weeks, decreasing the efficiency of the response teams, particularly in monitoring contacts due to the inability to access certain communities. Additionally, certain acts of protest, such as community members handling bodies as a demonstration of their opposition to safe and dignified burials, likely intensified disease spread. However, the involvement of community leaders, at least, made dialogue and negotiation possible between the response teams and community members, as such efforts led to communities contributing to the security of personnel involved in the fight against the Ebola epidemic in North Kivu and Ituri provinces.

COVID-19 Vaccine Perceptions among Ebola-Affected Communities in North Kivu, Democratic Republic of the Congo, 2021

Populations affected by humanitarian crises and emerging infectious disease outbreaks may have unique concerns and experiences that influence their perceptions toward vaccines. In March 2021, we conducted a survey to examine the perceptions toward COVID-19 vaccines and identify the factors associated with vaccine intention among 631 community members (CMs) and 438 healthcare workers (HCWs) affected by the 2018-2020 Ebola Virus Disease outbreak in North Kivu, Democratic Republic of the Congo. A multivariable logistic regression was used to identify correlates of vaccine intention. Most HCWs (81.7%) and 53.6% of CMs felt at risk of contracting COVID-19; however, vaccine intention was low (27.6% CMs; 39.7% HCWs). In both groups, the perceived risk of contracting COVID-19, general vaccine confidence, and male sex were associated with the intention to get vaccinated, with security concerns preventing vaccine access being negatively associated. Among CMs, getting the Ebola vaccine was associated with the intention to get vaccinated (RR 1.43, 95% CI 1.05-1.94). Among HCWs, concerns about new vaccines' safety and side effects (OR 0.72, 95% CI 0.57-0.91), religion's influence on health decisions (OR 0.45, 95% CI 0.34-0.61), security concerns (OR 0.52, 95% CI 0.37-0.74), and governmental distrust (OR 0.50, 95% CI 0.35-0.70) were negatively associated with vaccine perceptions. Enhanced community engagement and communication that address this population's concerns could help improve vaccine perceptions and vaccination decisions. These findings could facilitate the success of vaccine campaigns in North Kivu and similar settings.

Community knowledge, attitude and practices regarding zoonotic viral haemorrhagic fevers in five geo-ecological zones in Tanzania

BACKGROUND

Viral haemorrhagic fevers (VHF) cause significant economic and public health impact in Sub-Saharan Africa. Community knowledge, awareness and practices regarding such outbreaks play a pivotal role in their management and prevention. This study was carried out to assess community knowledge, attitude and practices regarding VHF in five geo-ecological zones in Tanzania.

METHODS

A cross-sectional study was conducted in Buhigwe, Kalambo, Kyela, Kinondoni, Kilindi, Mvomero, Kondoa and Ukerewe districts representing five geo-ecological zones in Tanzania. Study participants were selected by multistage cluster sampling design. A semi-structured questionnaire was used to collect socio-demographic and information related to knowledge, attitude and practices regarding VHFs. Descriptive statistics and logistic regression were used for the analysis.

RESULTS

A total of 2,965 individuals were involved in the study. Their mean age was 35 (SD ± 18.9) years. Females accounted for 58.2% while males 41.8%. Most of the respondents (70.6%; n = 2093) had never heard of VHF, and those who heard, over three quarters (79%) mentioned the radio as their primary source of information. Slightly over a quarter (29.4%) of the respondents were knowledgeable, 25% had a positive attitude, and 17.9% had unfavourable practice habits. The level of knowledge varied between occupation and education levels (P < 0.005). Most participants were likely to interact with a VHF survivor or take care of a person suffering from VHF (75%) or visit areas with known VHF (73%). There were increased odds of having poor practice among participants aged 36-45 years (AOR: 3.566, 95% CI: 1.593-7.821) and those living in Western, North-Eastern and Lake Victoria zones (AOR: 2.529, 95% CI: 1.071-6.657; AOR: 2.639, 95% CI: 1.130-7.580 AOR: 2.248, 95% CI: 1.073-3.844, respectively).

CONCLUSION

Overall, the knowledge on VHF among communities is low, while a large proportion of individuals in the community are involved in activities that expose them to the disease pathogens in Tanzania. These findings highlight the need for strengthening health educational and promotion efforts on VHF targeting specific populations.

Community engagement in Ebola outbreaks in sub-Saharan Africa and implications for COVID-19 control: A scoping review

OBJECTIVES

There is a paucity of scoping data on the specific roles community engagement played in preventing and managing the Ebola virus disease (EVD) outbreak in sub-Saharan Africa. We assessed the role, benefits, and mechanisms of community engagement to understand its effect on EVD case detection, survival, and mortality in sub-Saharan Africa. The implications for COVID-19 prevention and control were also highlighted.

METHODS

We searched for articles between 2010 and 2020 in the MEDLINE and Embase databases. The study types included were randomized trials, quasiexperimental studies, observational studies, case series, and reports.

RESULTS

A total of 903 records were identified for screening. A total of 216 articles met the review criteria, 103 were initially selected, and 44 were included in the final review. Our findings show that effective community involvement during the EVD outbreak depended on the survival rates, testimonials of survivors, risk perception, and the inclusion of community leaders. Community-based interventions improved knowledge and attitudes, case findings, isolation efforts, and treatment uptake.

CONCLUSION

Although the studies included in this review were of highly variable quality, findings from this review may provide lessons for the role of community engagement in the COVID-19 pandemic's prevention and control in sub-Saharan Africa.

Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic

BACKGROUND

Health challenges like coronavirus disease 2019 (COVID-19) are becoming increasingly complex, transnational, and unpredictable. Studying health system responses to the COVID-19 pandemic is an opportunity to enhance our understanding of health system resilience and establish a clearer link between theoretical concepts and practical ideas on how to build resilience.

METHODS

This narrative literature review aims to address four questions using a health system resilience framework: (i) What do we understand about the dimensions of resilience? (ii) What aspects of the resilience dimensions remain uncertain? (iii) What aspects of the resilience dimensions are missing from the COVID-19 discussions? and (iv) What has COVID-19 taught us about resilience that is missing from the framework? A scientific literature database search was conducted in December 2020 and in April 2022 to identify publications that discussed health system resilience in relation to COVID-19, excluding articles on psychological and other types of resilience. A total of 63 publications were included.

RESULTS

There is good understanding around information sharing, flexibility and good leadership, learning, maintaining essential services, and the need for legitimate, interdependent systems. Decision-making, localized trust, influences on interdependence, and transformation remain uncertain. Vertical interdependence, monitoring risks beyond the health system, and consequences of changes on the system were not discussed. Teamwork, actor legitimacy, values, inclusivity, trans-sectoral resilience, and the role of the private sector are identified as lessons from COVID-19 that should be further explored for health system resilience.

CONCLUSION

Knowledge of health system resilience has continued to cohere following the pandemic. The eventual consequences of system changes and the resilience of subsystems are underexplored. Through governance, the concept of health system resilience can be linked to wider issues raised by the pandemic, like inclusivity. Our findings show the utility of resilience theory for strengthening health systems for crises and the benefit of continuing to refine existing resilience theory.

CDC's COVID-19 International Vaccine Implementation and Evaluation Program and Lessons from Earlier Vaccine Introductions

The US Centers for Disease Control and Prevention (CDC) supports international partners in introducing vaccines, including those against SARS-CoV-2 virus. CDC contributes to the development of global technical tools, guidance, and policy for COVID-19 vaccination and has established its COVID-19 International Vaccine Implementation and Evaluation (CIVIE) program. CIVIE supports ministries of health and their partner organizations in developing or strengthening their national capacities for the planning, implementation, and evaluation of COVID-19 vaccination programs. CIVIE's 7 priority areas for country-specific technical assistance are vaccine policy development, program planning, vaccine confidence and demand, data management and use, workforce development, vaccine safety, and evaluation. We discuss CDC's work on global COVID-19 vaccine implementation, including priorities, challenges, opportunities, and applicable lessons learned from prior experiences with Ebola, influenza, and meningococcal serogroup A conjugate vaccine introductions.

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.

Corona was scary, lockdown was worse: A mixed-methods study of community perceptions on COVID-19 from urban informal settlements of Mumbai

The COVID-19 pandemic has magnified the multiple vulnerabilities of people living in urban informal settlements globally. To bring community voices from such settlements to the center of COVID-19 response strategies, we undertook a study in the urban informal settlements of Dharavi, Mumbai, from September 2020-April 2021. In this study, we have examined the awareness, attitudes, reported practices, and some broader experiences of the community in Dharavi with respect to COVID-19. We have used a mixed-methods approach, that included a cross-sectional survey of 468 people, and in-depth interviews and focus group discussions with 49 people living in this area. Data was collected via a mix of phone and face-to-face interviews. We have presented here the descriptive statistics from the survey and the key themes that emerged from our qualitative data. People reported high levels of knowledge about COVID-19, with television (90%), family and friends (56%), and social media (47%) being the main sources of information. The knowledge people had, however, was not free of misconceptions and fear; people were scared of being forcefully quarantined and dying alone during the early days of COVID-19. These fears had negative repercussions in the form of patient-related stigma and hesitancy in seeking healthcare. A year into the pandemic, however, people reported a shift in attitudes from ‘extreme fear to low fear’ (67% reported perceiving low/no COVID risk in October 2020), contributing to a general laxity in following COVID-appropriate behaviors. Currently, the community is immensely concerned about the revival of livelihoods, that have been adversely impacted due to the lockdown in 2020 as well as the continued ‘othering’ of Dharavi for being a COVID hotspot. These findings suggest that urban informal settlements like Dharavi need community-level messaging that counters misinformation and denial of the outbreak; local reinforcement of COVID-appropriate behaviours; and long-term social protection measures.

Adverse pregnancy outcome disclosure and women's social networks: a qualitative multi-country study with implications for improved reporting in surveys

Background

Globally, approximately 6,700 newborn deaths and 5,400 stillbirths occur daily. The true figure is likely higher, with under reporting of adverse pregnancy outcomes (APOs) noted. Decision-making in health is influenced by various factors, including one’s social networks. We sought to understand APOs disclosure within social networks in Uganda, Ghana, Guinea-Bissau and Bangladesh and how this could improve formal reporting of APOs in surveys. 

Methods

A qualitative, exploratory multi-country study was conducted within four health and demographic surveillance system sites. 16 focus group discussions were held with 147 women aged 15–49 years, who had participated in a recent household survey. Thematic analysis, with both deductive and inductive elements, using three pre-defined themes of Sender, Message and Receiver was done using NVivo software.

Results

Disclosure of APOs was a community concern, with news often shared with people around the bereaved for different reasons, including making sense of what happened and decision-making roles of receivers. Social networks responded with comfort, providing emotional, in-kind and financial support. Key decision makers included men, spiritual and traditional leaders. Non-disclosure was usually to avoid rumors in cases of induced abortions, or after a previous bad experience with health workers, who were frequently excluded from disclosure, except for instances where a woman sought advice on APOs.

Conclusions

Communities must understand why they should report APOs and to whom. Efforts to improve APOs reporting could be guided by diffusion of innovation theory, for instance for community entry and sensitization before the survey, since it highlights how information can be disseminated through community role models. In this case, these gatekeepers we identified could promote reporting of APOs. The stage at which a person is in decision-making, what kind of adopter they are and their take on the benefits and other attributes of reporting are important. In moving beyond survey reporting to getting better routine data, the theory would be applicable too. Health workers should demonstrate a more comforting and supportive response to APOs as the social networks do, which could encourage more bereaved women to inform them and seek care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04622-1.

Obstacles and Policy Measures Toward COVID-19 Vaccination: Creating a Road Map for Malawi

The Coronavirus Disease 2019 (COVID-19) pandemic is a public health threat for Malawi which is facing several challenges concurrently including disease burden; inadequate finances; illiteracy; and public mistrust in government. In this pandemic, vaccines are the most reliable and cost-effective public health intervention, and the Malawian government has instituted an action plan which includes prioritizing the vaccination of traditional and religious leaders, increased vaccination sites to include workplaces and shopping malls, and health promotion. However, there is still considerable hesitancy around the use of the available vaccines in Malawi. In this paper, we explore the multiple interrelated factors driving COVID-19 vaccine hesitancy in Malawi. It is therefore recommended that the Malawian government embrace multicomponent and wide-ranging strategies to address COVID-19 vaccine hesitancy in the country. This includes reviving trust in national health authorities by offering population-specific, target-driven, and effective, transparent, and timely communication to its citizens and relevant stakeholders about the safety and efficacy of the COVID-19 vaccine.

Feasibility, acceptability, and effectiveness of non-pharmaceutical interventions against infectious diseases among crisis-affected populations: a scoping review

Background

Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. Despite being particularly important for crisis-affected populations and those living in informal settlements, who typically reside in overcrowded and resource limited settings with inadequate access to healthcare, guidance on NPI implementation rarely takes the specific needs of such populations into account. We therefore conducted a systematic scoping review of the published evidence to describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settlements.

Methods

We systematically reviewed peer-reviewed articles published between 1970 and 2020 to collate available evidence on the feasibility, acceptability, and effectiveness of NPIs in crisis-affected populations and informal settlements. We performed quality assessments of each study using a standardised questionnaire. We analysed the data to produce descriptive summaries according to a number of categories: date of publication; geographical region of intervention; typology of crisis, shelter, modes of transmission, NPI, research design; study design; and study quality.

Results

Our review included 158 studies published in 85 peer-reviewed articles. Most research used low quality study designs. The acceptability, feasibility, and effectiveness of NPIs was highly context dependent. In general, simple and cost-effective interventions such as community-level environmental cleaning and provision of water, sanitation and hygiene services, and distribution of items for personal protection such as insecticide-treated nets, were both highly feasible and acceptable. Logistical, financial, and human resource constraints affected both the implementation and sustainability of measures. Community engagement emerged as a strong factor contributing to the effectiveness of NPIs. Conversely, measures that involve potential restriction on personal liberty such as case isolation and patient care and burial restrictions were found to be less acceptable, despite apparent effectiveness.

Conclusions

Overall, the evidence base was variable, with substantial knowledge gaps which varied between settings and pathogens. Based on the current landscape, robust evidence-based guidance is not possible, and a research agenda is urgently required that focusses on these specific vulnerable populations. Although implementation of NPIs presents unique practical challenges in these settings, it is critical that such an agenda is put in place, and that the lessons learned from historical and present experiences are documented to build a firm evidence base.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00935-7.

Public and health professional epidemic risk perceptions in countries that are highly vulnerable to epidemics: a systematic review

Background

Risk communication interventions during epidemics aim to modify risk perceptions to achieve rapid shifts in population health behaviours. Exposure to frequent and often concurrent epidemics may influence how the public and health professionals perceive and respond to epidemic risks. This review aimed to systematically examine the evidence on risk perceptions of epidemic-prone diseases in countries highly vulnerable to epidemics.

Methods

We conducted a systematic review using PRISMA standards. We included peer-reviewed studies describing or measuring risk perceptions of epidemic-prone diseases among the general adult population or health professionals in 62 countries considered highly vulnerable to epidemics. We searched seven bibliographic databases and applied a four-stage screening and selection process, followed by quality appraisal. We conducted a narrative meta-synthesis and descriptive summary of the evidence, guided by the Social Amplification of Risk Framework.

Results

Fifty-six studies were eligible for the final review. They were conducted in eighteen countries and addressed thirteen epidemic-prone diseases. Forty-five studies were quantitative, six qualitative and five used mixed methods. Forty-one studies described epidemic risk perceptions in the general public and nineteen among health professionals. Perceived severity of epidemic-prone diseases appeared high across public and health professional populations. However, perceived likelihood of acquiring disease varied from low to moderate to high among the general public, and appeared consistently high amongst health professionals. Other occupational groups with high exposure to specific diseases, such as bushmeat handlers, reported even lower perceived likelihood than the general population. Among health professionals, the safety and effectiveness of the work environment and of the broader health system response influenced perceptions. Among the general population, disease severity, familiarity and controllability of diseases were influential factors. However, the evidence on how epidemic risk perceptions are formed or modified in these populations is limited.

Conclusions

The evidence affords some insights into patterns of epidemic risk perception and influencing factors, but inadequately explores what underlies perceptions and their variability, particularly among diseases, populations and over time. Approaches to defining and measuring epidemic risk perceptions are relatively underdeveloped.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00927-z.

The Kivu Ebola Epidemic

The Kivu Ebola epidemic began on 1 August 2018, when four cases of Ebola virus disease (EVD) were confirmed in the eastern region of Kivu in the Democratic Republic of the Congo (DRC). The disease affected the DRC, Uganda, and is suspected to have also affected Tanzania, though the Ministry of Health there never shared information with the WHO. The outbreak was declared ended on 25 June 2020, with a total of 3,470 cases and 2,280 deaths. Other locations in the DRC affected included the Ituri Province, where the first case was confirmed on 13 August 2018. In November 2018, it became the biggest Ebola outbreak in the DRC's history, and by November, it had become the second-largest Ebola outbreak in recorded history, behind only the 2013–2016 Western Africa epidemic. On 3 May 2019, 9 months into the outbreak, the DRC death toll surpassed 1,000. In June 2019, the virus reached Uganda, having infected a 5-year-old Congolese boy who entered with his family, but this was contained. Since January 2015, the affected province and general area have been experiencing a military conflict, which hindered treatment and prevention efforts. The World Health Organization (WHO) has described the combination of military conflict and civilian distress as a potential "perfect storm" that could lead to a rapid worsening of the situation. In May 2019, the WHO reported that, since January of that year, there had been 42 attacks on health facilities and 85 health workers had been wounded or killed. In some areas, aid organizations have had to stop their work due to violence. Health workers also had to deal with misinformation spread by opposing politicians. Due to the deteriorating security situation in North Kivu and surrounding areas, the WHO raised the risk assessment at the national and regional level from "high" to "very high" in September 2018. In October, the United Nations Security Council stressed that all armed hostility in the DRC should come to a stop to address the ongoing outbreak better. A confirmed case in Goma triggered the decision by the WHO to convene an emergency committee for the fourth time, and on 17 July 2019, the WHO announced a Public Health Emergency of International Concern (PHEIC), the highest level of alarm the WHO can sound. On 15 September 2019, some slowdown of cases was noted in the DRC. However, contact tracing continued to be less than 100%; at the time, it was at 89%. In mid-October the transmission of the virus had significantly reduced; by then it was confined to the Mandima region near where the outbreak began, and was only affecting 27 health zones in the DRC (down from a peak of 207). New cases decreased to zero by 17 February 2020, but after 52 days without a case, surveillance and response teams confirmed three new cases in mid-April. As a new and separate outbreak, was reported on 1 June 2020 in Équateur Province in north-western DRC, described as the eleventh Ebola outbreak since records began; after almost two years the tenth outbreak was declared ended on 25 June 2020, with a total of 3,470 cases and 2,280 deaths.

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.

Novel Use of Capture-Recapture Methods to Estimate Completeness of Contact Tracing during an Ebola Outbreak, Democratic Republic of the Congo, 2018-2020

Despite its critical role in containing outbreaks, the efficacy of contact tracing, measured as the sensitivity of case detection, remains an elusive metric. We estimated the sensitivity of contact tracing by applying unilist capture-recapture methods on data from the 2018–2020 outbreak of Ebola virus disease in the Democratic Republic of the Congo. To compute sensitivity, we applied different distributional assumptions to the zero-truncated count data to estimate the number of unobserved case-patients with any contacts and infected contacts. Geometric distributions were the best-fitting models. Our results indicate that contact tracing efforts identified almost all (n = 792, 99%) of case-patients with any contacts but only half (n = 207, 48%) of case-patients with infected contacts, suggesting that contact tracing efforts performed well at identifying contacts during the listing stage but performed poorly during the contact follow-up stage. We discuss extensions to our work and potential applications for the ongoing coronavirus pandemic.

Parallel Pandemics Illustrate the Need for One Health Solutions

African Swine Fever (ASF) was reported in domestic pigs in China in 2018. This highly contagious viral infection with no effective vaccine reached pandemic proportions by 2019, substantially impacting protein availability in the same region where the COVID-19 pandemic subsequently emerged. We discuss the genesis, spread, and wide-reaching impacts of this epidemic in a vital livestock species, noting parallels and potential contributions to ignition of COVID-19. We speculate about impacts of these pandemics on global public health infrastructure and suggest intervention strategies using a cost: benefit approach for low-risk, massive-impact events. We note that substantive changes in how the world reacts to potential threats will be required to overcome catastrophes driven by climate change, food insecurity, lack of surveillance infrastructure, and other gaps. A One Health approach creating collaborative processes connecting expertise in human, animal, and environmental health is essential for combating future global health crises.

Perceptions of ebola virus disease among the bambuti hunter group: a mixed-methods study

The second largest Ebola virus disease (EVD) epidemic occurred in the Democratic Republic of the Congo (DRC) from 2018-20. The Bambuti, a hunter population in the Ituri Forest of the DRC, may be vulnerable to the zoonotic spread of EVD due to their frequent handling of forest animals. We conducted five focus group discussions and surveyed 113 Bambuti and 91 Bantu (control group), to discern how the Bambuti perceived and responded to EVD. Thematic analysis of focus group discussions revealed three major themes: (1) deprivation and discrimination; (2) mistrust; and (3) epistemic dissonance with public health messages emphasizing risks posed by forest animals. In surveys, 98% of Bambuti were deprived using the multidimensional poverty index (versus 78% of Bantu controls, p < 0.0001) and 77% had no formal education (versus 29% of controls, p < 0.0001). Bambuti were more dependent on wild meat for survival (51% versus 32% of controls, p = 0.008) and more frequently opposed the implementation of a bushmeat ban (48% versus 19% of controls, p < 0.0001). Trust in government was similar among Bambuti and Bantu. Comprehensive EVD knowledge was poor overall, and lower among the Bambuti (2% versus 8% of controls, p = 0.041). Compliance with public health measures was associated with higher levels of education and trust in government but did not differ between Bambuti and Bantu survey respondents. Together, our findings point to a particular vulnerability of the Bambuti to the effects of EVD, attributable at least in part to multidimensional poverty.

Conspiracy Theories: A Public Health Concern and How to Address It

The SARS-CoV-2 pandemic was characterized by a significant increase in the endorsement of conspiracy theories. Conspiracy theories are narratives that can enable and accentuate distrust toward health professionals and authorities. As such, they can lead to violent radicalization and should be considered a public health issue. This perspective article aims to further the understanding of professionals on conspiracy theories via the 3N model of radicalization and self-determination theory. Based on empirical research, theory, and existing interventions, potential initiatives intended to tackle the issue of conspiracy theories during pandemics are also presented.

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.

New Mixed Methods Approach for Monitoring Community Perceptions of Ebola and Response Efforts in the Democratic Republic of the Congo

The Red Cross community feedback system enabled rapid collection and analysis of extensive verbal feedback during an Ebola outbreak in eastern DRC. Using this information, Ebola response leaders adapted strategies to address community concerns. In an epidemic, community feedback is critical to ensure that response strategies are accepted and appropriate.

Background:

Efforts to contain the spread of Ebola in the eastern Democratic Republic of the Congo (DRC) during the 2018–2020 epidemic faced challenges in gaining community trust and participation. This affected implementation of community alerts, early isolation, contact tracing, vaccination, and safe and dignified burials. To quickly understand community perspectives and improve community engagement, collaborators from the DRC Red Cross, the International Federation of the Red Cross, and the U.S. Centers for Disease Control and Prevention explored a new method of collecting, coding, and quickly analyzing community feedback.

Methods:

Over 800 DRC Red Cross local volunteers recorded unstructured, free-text questions and comments from community members during community Ebola awareness activities. Comments were coded and analyzed using a text-coding system developed by the collaborators. Coded comments were then aggregated and qualitatively grouped into major themes, and time trends were examined.

Results:

Communities reported a lack of information about the outbreak and the response, as well as concerns about the Ebola vaccination program and health care quality. Some doubted that Ebola was real. The response used the feedback to revise some community engagement approaches. For example, 2 procedural changes that were followed by drops in negative community responses were: using transparent body bags, which allayed fears that bodies or organs were being stolen, and widening the eligibility criteria for Ebola vaccination, which addressed concerns that selectively vaccinating individuals within Ebola-affected communities was unfair.

Discussion:

This system is unique in that unstructured feedback collected by local volunteers in the course of their work was rapidly coded, analyzed, and given to health authorities for use in making course corrections throughout the response. It provides a platform for local voices to be heard throughout an emergency response and provides a mechanism for assessing the effects of program adjustments on community sentiments.

Individually optimal choices can be collectively disastrous in COVID-19 disease control

BACKGROUND

The word 'pandemic' conjures dystopian images of bodies stacked in the streets and societies on the brink of collapse. Despite this frightening picture, denialism and noncompliance with public health measures are common in the historical record, for example during the 1918 Influenza pandemic or the 2015 Ebola epidemic. The unique characteristics of SARS-CoV-2-its high basic reproduction number (R0), time-limited natural immunity and considerable potential for asymptomatic spread-exacerbate the public health repercussions of noncompliance with interventions (such as vaccines and masks) to limit disease transmission. Our work explores the rationality and impact of noncompliance with measures aimed at limiting the spread of SARS-CoV-2.

METHODS

In this work, we used game theory to explore when noncompliance confers a perceived benefit to individuals. We then used epidemiological modeling to predict the impact of noncompliance on control of SARS-CoV-2, demonstrating that the presence of a noncompliant subpopulation prevents suppression of disease spread.

RESULTS

Our modeling demonstrates that noncompliance is a Nash equilibrium under a broad set of conditions and that the existence of a noncompliant population can result in extensive endemic disease in the long-term after a return to pre-pandemic social and economic activity. Endemic disease poses a threat for both compliant and noncompliant individuals; all community members are protected if complete suppression is achieved, which is only possible with a high degree of compliance. For interventions that are highly effective at preventing disease spread, however, the consequences of noncompliance are borne disproportionately by noncompliant individuals.

CONCLUSIONS

In sum, our work demonstrates the limits of free-market approaches to compliance with disease control measures during a pandemic. The act of noncompliance with disease intervention measures creates a negative externality, rendering suppression of SARS-CoV-2 spread ineffective. Our work underscores the importance of developing effective strategies for prophylaxis through public health measures aimed at complete suppression and the need to focus on compliance at a population level.

Responding to the 2018-2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches

The Democratic Republic of Congo (DRC) presents a challenging context in which to respond to public health crises. Its 2018-2020 Ebola outbreak was the second largest in history. Lessons were known from the previous West African outbreak. Chief among these was the recognition that local action and involvement are key to establishing effective epidemic-response. It remains unclear whether and how this was achieved in DRC's Ebola response. Additionally, there is a lack of scholarship on how to build resilience (the ability to adapt or transform under pressure) in crisis-response. In this article, we critically review literature to examine evidence on whether and how communities were involved, trust built, and resilience strengthened through adaptation or transformation of DRC's 2018-2020 Ebola response measures. Overall, we found limited evidence that the response adapted to engage and involve local actors and institutions or respond to locally expressed concerns. When adaptations occurred, they were shaped by national and international actors rather than enabling local actors to develop locally trusted initiatives. Communities were "engaged" to understand their perceptions but were not involved in decision-making or shaping responses. Few studies documented how trust was built or analyzed power dynamics between different groups in DRC. Yet, both these elements appear to be critical in building effective, resilient responses. These failures occurred because there was no willingness by the national government or international agencies to concede decision-making power to local people. Emergency humanitarian response is entrenched in highly medicalized, military style command and control approaches which have no space for decentralizing decision-making to "non-experts". To transform humanitarian responses, international responders can no longer be regarded as "experts" who own the knowledge and control the response. To successfully tackle future humanitarian crises requires a transformation of international humanitarian and emergency response systems such that they are led, or shaped, through inclusive, equitable collaboration with local actors.

Inaccuracies in Google's Health-Based Knowledge Panels Perpetuate Widespread Misconceptions Involving Infectious Disease Transmission

Google health-based Knowledge Panels were designed to provide users with high-quality basic medical information on a specific condition. However, any errors contained within Knowledge Panels could result in the widespread distribution of inaccurate health information. We explored the potential for inaccuracies to exist within Google's health-based Knowledge Panels by focusing on a single well-studied pathogen, Ebola virus (EBOV). We then evaluated the accuracy of those transmission modes listed within the Google Ebola Knowledge Panel and investigated the pervasiveness of any misconceptions associated with inaccurate transmission modes among persons living in Africa. We found that the Google Ebola Knowledge Panel inaccurately listed insect bites or stings as modes of EBOV transmission. Our scoping review found 27 articles and reports that revealed that 9 of 11 countries where misconceptions regarding insect transmission of EBOV have been reported are locations of current (i.e., Democratic Republic of Congo and Guinea) or previous EBOV outbreaks. We found reports that up to 26.6% (155/582) of study respondents in Democratic Republic of Congo believed mosquito bite avoidance would prevent EBOV; in other locations of previous large-scale EBOV outbreaks (e.g., Guinea), up to 61.0% (304/498) of respondents believed insects were involved in EBOV transmission. Our findings highlight the potential for errors to exist within the health information contained in Google's health-based Knowledge Panels. Such errors could perpetuate misconceptions or misinformation, leading to mistrust of health workers and aid agencies and in turn undermining public health education or outbreak response efforts.

Exploring stress coping strategies of frontline emergency health workers dealing Covid-19 in Pakistan: A qualitative inquiry

Background

The COVID-19 outbreak has gravely impacted the physical and psychological health of people. As the outbreak is ongoing, it is crucial to equip the emergency healthcare workers (HCWs) to be medically and psychologically prepared.

Objective

To examine the psychological impact of COVID-19 on emergency HCWs and to understand how they are dealing with COVID-19 pandemic, their stress coping strategies or protective factors, and challenges while dealing with COVID-19 patients.

Methods

Using a framework thematic analysis approach, 15 frontline emergency HCWs directly dealing with COVID-19 patients from April 2, 2020 to April 25, 2020. The semi-structured interviews were conducted face-to-face or by telephone. Data were analyzed using thematic analysis.

Results

Findings highlighted first major theme of stress coping, including, limiting media exposure, limited sharing of Covid-19 duty details, religious coping, just another emergency approach, altruism, and second major theme of Challenges includes, psychological response and noncompliance of public/denial by religious scholar.

Conclusions

Participants practiced and recommended various coping strategies to deal with stress and anxiety emerging from COVID-19 pandemic. Media was reported to be a principal source of raising stress and anxiety among the public. Religious coping as well as their passion to serve humanity and country were the commonly employed coping strategies.

Ethics of emerging infectious disease outbreak responses: Using Ebola virus disease as a case study of limited resource allocation

Emerging infectious diseases such as Ebola Virus Disease (EVD), Nipah Virus Encephalitis and Lassa fever pose significant epidemic threats. Responses to emerging infectious disease outbreaks frequently occur in resource-constrained regions and under high pressure to quickly contain the outbreak prior to potential spread. As seen in the 2020 EVD outbreaks in the Democratic Republic of Congo and the current COVID-19 pandemic, there is a continued need to evaluate and address the ethical challenges that arise in the high stakes environment of an emerging infectious disease outbreak response. The research presented here provides analysis of the ethical challenges with regard to allocation of limited resources, particularly experimental therapeutics, using the 2013–2016 EVD outbreak in West Africa as a case study. In-depth semi-structured interviews were conducted with senior healthcare personnel (n = 16) from international humanitarian aid organizations intimately engaged in the 2013–2016 EVD outbreak response in West Africa. Interviews were recorded in private setting, transcribed, and iteratively coded using grounded theory methodology. A majority of respondents indicated a clear propensity to adopt an ethical framework of guiding principles for international responses to emerging infectious disease outbreaks. Respondents agreed that prioritization of frontline workers’ access to experimental therapeutics was warranted based on a principle of reciprocity. There was widespread acceptance of adaptive trial designs and greater trial transparency in providing access to experimental therapeutics. Many respondents also emphasized the importance of community engagement in limited resource allocation scheme design and culturally appropriate informed consent procedures. The study results inform a potential ethical framework of guiding principles based on the interview participants’ insights to be adopted by international response organizations and their healthcare workers in the face of allocating limited resources such as experimental therapeutics in future emerging infectious disease outbreaks to ease the moral burden of individual healthcare providers.

Review of Ebola virus disease in children - how far have we come?

Ebola virus (EBOV) causes an extremely contagious viral haemorrhagic fever associated with high mortality. While, historically, children have represented a small number of total cases of Ebolavirus disease (EVD), in recent outbreaks up to a quarter of cases have been in children. They pose unique challenges in clinical management and infection prevention and control. In this review of paediatric EVD, the epidemiology of past EVD outbreaks with specific focus on children is discussed, the clinical manifestations and laboratory findings are described and key developments in clinical management including specific topics such as viral persistence and breastfeeding while considering unique psychosocial and anthropological considerations for paediatric care including of survivors and orphans and the stigma they face are discussed. In addition to summarising the literature, perspectives based on the authors' experience of EVD outbreaks in the Democratic Republic of the Congo (DRC) are described.Abbreviations: ARDS: acute respiratory distress syndrome; aOR: adjusted odds ratio; ALT: alanine transferase; ALIMA: Alliance for International Medical Action; AST: aspartate transaminase; BUN: blood urea nitrogen; CNS: central nervous system; CUBE: chambre d'urgence biosécurisée pour épidémie; COVID-19: coronavirus disease 2019; C_t: cycle threshold; DRC: Democratic Republic of Congo; ETC: ebola treatment centre; ETU: ebola treatment unit; EBOV: ebola virus; EVD: ebolavirus disease; FEAST: fluid expansion as supportive therapy; GP: glycoprotein; IV: intravenous; MEURI: monitored emergency use of unregistered interventions; NETEC: National Ebola Training and Education Centre; NP: nucleoprotein; ORS: oral rehydration solution; PALM: Pamoja Tulinde Maisha; PREVAIL: Partnership for Research on Ebola Virus in Liberia; PPE: personal protective equipment; PCR: polymerase chain reaction; PEP: post-exposure prophylaxis; RDTs: rapid diagnostic tests; RT: reverse transcriptase; RNA: ribonucleic acid; UNICEF: United Nations International Children's Emergency Fund; USA: United States of America; WHO: World Health Organization.

Governmental actions to address COVID-19 misinformation

Since COVID-19 emerged, a plethora of misinformation has undermined the public’s ability to identify reliable sources of accurate information. To identify the range of methods governments used to address COVID-19 misinformation, we conducted a content analysis of international media and evaluated government actions in light of international law, which protects freedom of expression and calls on governments to guarantee this fundamental right even during a pandemic or other emergency. We identified five categories of government activities: (1) disseminating and increasing access to accurate information; (2) restricting access to accurate information; (3) disseminating disinformation, false information, and misinformation; (4) addressing commercial fraud; and (5) criminalizing expression. The goal of addressing COVID-19 misinformation is best served by protecting expression, disseminating factual information, ensuring strong protections for whistleblowers, and supporting an independent media environment. Conversely, governments undermine public health when they create a state of uncertainty and violate human rights.

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.

Preparing for Emerging Zoonotic Viruses

The risk of emergence and spread of novel human pathogens originating from an animal reservoir has increased in the past decades. However, the unpredictable nature of disease emergence makes surveillance and preparedness challenging. Knowledge of general risk factors for emergence and spread, combined with local level data is needed to develop a risk-based methodology for early detection. This involves the implementation of the One Health approach, integrating human, animal and environmental health sectors, as well as social sciences, bioinformatics and more. Recent technical advances, such as metagenomic sequencing, will aid the rapid detection of novel pathogens on the human-animal interface.

Prevention of COVID-19 in Internally Displaced Persons Camps in War-Torn North Kivu, Democratic Republic of the Congo: A Mixed-Methods Study

Internally displaced persons fleeing violent conflict represent a neglected population with heightened vulnerability to pandemic COVID-19. We provide a rare snapshot of the overwhelming challenges faced by internally displaced persons in Eastern Democratic Republic of the Congo as they brace for COVID-19.

Background:

The coronavirus disease (COVID-19) pandemic poses a grave threat to refugees and internally displaced persons (IDPs). We examined knowledge, attitudes, and practices with respect to COVID-19 prevention among IDPs in war-torn Eastern Democratic Republic of the Congo (DRC).

Methods:

Mixed-methods study with qualitative (focus group discussions, [FGDs]) and quantitative (52-item survey questionnaire) data collection and synthesis.

Results:

FGDs (N=23) and survey questionnaires (N=164 IDPs; N=143 comparison group) were conducted in May 2020. FGD participants provided narratives of violence that they had fled. IDPs were statistically more likely to have larger household size, experience more extreme poverty, have lower educational attainment, and have less access to information through media and internet versus the comparison group (P<.05 for the comparison group). IDPs had a high level of awareness (99%) and fear (98%) of COVID-19, but lower specific knowledge (15% sufficient knowledge versus 30% among the comparison group, P<.0001), a difference which remained significant in a multivariable model adjusting for confounding. IDPs faced major barriers to implementing COVID-19 prevention measures. Physical distancing was impossible for IDPs in crowded shelters, and 70% reported coming in close contact with someone other than a family member within the past 24 hours (versus 56% of the comparison group, P=.014). Frequent movements in and out of the camp for subsistence left IDPs vulnerable to the introduction of COVID-19: 61% left the camp on a daily basis and 65% had received a visitor in the past month. Despite acceptance of hand hygiene for prevention, 92% lacked soap (versus 65% of the comparison group, P<.0001). IDPs’ desire for peace and to return to their native homes, where COVID-19 precautions could be feasibly implemented, overshadowed their perceived benefits of measures such as a COVID-19 vaccine.

Conclusions:

These findings provide empiric evidence supporting the vulnerability of IDPs to COVID-19 and call for action to protect neglected displaced populations.

The Impact of Different Types of Violence on Ebola Virus Transmission During the 2018-2020 Outbreak in the Democratic Republic of the Congo

BACKGROUND

Our understanding of the different effects of targeted versus nontargeted violence on Ebola virus (EBOV) transmission in Democratic Republic of the Congo (DRC) is limited.

METHODS

We used time-series data of case counts to compare individuals in Ebola-affected health zones in DRC, April 2018-August 2019. Exposure was number of violent events per health zone, categorized into Ebola-targeted or Ebola-untargeted, and into civilian-induced, (para)military/political, or protests. Outcome was estimated daily reproduction number (Rt) by health zone. We fit linear time-series regression to model the relationship.

RESULTS

Average Rt was 1.06 (95% confidence interval [CI], 1.02-1.11). A mean of 2.92 violent events resulted in cumulative absolute increase in Rt of 0.10 (95% CI, .05-.15). More violent events increased EBOV transmission (P = .03). Considering violent events in the 95th percentile over a 21-day interval and its relative impact on Rt, Ebola-targeted events corresponded to Rt of 1.52 (95% CI, 1.30-1.74), while civilian-induced events corresponded to Rt of 1.43 (95% CI, 1.21-1.35). Untargeted events corresponded to Rt of 1.18 (95% CI, 1.02-1.35); among these, militia/political or ville morte events increased transmission.

CONCLUSIONS

Ebola-targeted violence, primarily driven by civilian-induced events, had the largest impact on EBOV transmission.

Local perspectives on Ebola during its tenth outbreak in DR Congo: A nationwide qualitative study

BACKGROUND

The Democratic Republic of Congo (DR Congo) struggled to end the tenth outbreak of Ebola virus disease (Ebola), which appeared in North Kivu in 2018. It was reported that rumors were hampering the response effort. We sought to identify any rumors that could have influenced outbreak containment and affected prevention in unaffected areas of DR Congo.

METHODS

We conducted a qualitative study in DR Congo over a period of 2 months (from August 1 to September 30, 2019) using in-depth interviews (IDIs) and focus group discussions (FGDs). The participants were recruited from five regional blocks using purposeful sampling. Both areas currently undergoing outbreaks and presently unaffected areas were included. We collected participants' opinions, views, and beliefs about the Ebola virus. The IDIs (n = 60) were performed with key influencers (schoolteachers, religious and political leaders/analysts, and Ebola-frontline workers), following a semi-structured interview guide. FGDs (n = 10) were conducted with community members. Interviews were recorded with a digital voice recorder and simultaneous note-taking. Participant responses were categorized in terms of their themes and subthemes.

RESULTS

We identified 3 high-level themes and 15 subthemes (given here in parentheses): (1) inadequate knowledge of the origin or cause of Ebola (belief in a metaphysical origin, insufficient awareness of Ebola transmission via an infected corpse, interpretation of disease as God's punishment, belief in nosocomial Ebola, poor hygiene, and bathing in the Congo River). Ebola was interpreted as (2) a plot by multinational corporations (fears of genocide, Ebola understood as a biological weapon, concerns over organ trafficking, and Ebola was taken to be the result of business actions). Finally Ebola was rumored to be subject to (3) politicization (political authorities seen as ambivalent, exclusion of some community leaders from response efforts, distrust of political authorities, and distrust in the healthcare system).

CONCLUSIONS

Due to the skepticism against Ebola countermeasures, it is critical to understand widespread beliefs about the disease to implement actions that will be effective, including integrating response with the unmet needs of the population.

Disinformation and Epidemics: Anticipating the Next Phase of Biowarfare

While biological warfare has classically been considered a threat requiring the presence of a distinct biological agent, we argue that in light of the rise of state-sponsored online disinformation campaigns we are approaching a fifth phase of biowarfare with a "cyber-bio" framing. By examining the rise of measles cases following disinformation campaigns connected to the US 2016 presidential elections, the rise of disinformation in the current novel coronavirus disease 2019 pandemic, and the impact of misinformation on public health interventions during the 2014-2016 West Africa and 2019-2020 Democratic Republic of the Congo Ebola outbreaks, we ask whether the potential impact of these campaigns-which includes the undermining of sociopolitical systems, the delegitimization of public health and scientific bodies, and the diversion of the public health response-can be characterized as analogous to the impacts of more traditional conceptions of biowarfare. In this paper, we look at these different impacts and the norms related to the use of biological weapons and cyber campaigns. By doing so, we anticipate the advent of a combined cyber and biological warfare. The latter is not dependent on the existence of a manufactured biological weapon; it manages to undermine sociopolitical systems and public health through the weaponization of naturally occurring outbreaks.

Ebola crisis in Eastern Democratic Republic of Congo: student-led community engagement

The second largest outbreak of Ebolavirus is currently ongoing in Eastern Democratic Republic of the Congo (DRC) and is characterized by lack of compliance with recommended control measures. Trusted local health agents, including medical students, may be valuable social mobilizers in this challenging context. We report a student-led educational campaign to increase community awareness and engagement in EVD control efforts, with evaluation of student and community satisfaction. The outreach was conducted in November 2018, involving 600 students and reaching 5-10,000 community members. Key messages included: 'Ebola exists in Butembo' and 'Bring infected family members to the Ebola Treatment Unit.' Medical students (n = 355) and community participants (n = 319) evaluated the campaign. Satisfaction was high: 320 (90%) students agreed that medical students could contribute to the EVD response effort, and 233 (73%) community members agreed that the students had helped them understand Ebola in the area. Lower satisfaction scores were associated with intention to hide infected family member from authorities (ρ = -0.25, p < 0.0001), denial of the existence of Ebola (ρ = -0.17, p = 0.0018), and mistrust of the response team (ρ = -0.11, p = 0.042). Both students (77%) and community members (71%) agreed that they were more motivated to combat Ebola as a result of the outreach. In conclusion, medical students can lead to satisfactory community engagement and educational activities during an EVD epidemic. As trusted local health agents, medical students may be valuable allies in building public trust and cooperation in this epidemic.

Is Sub-Saharan Africa prepared for COVID-19?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), is the latest virus to cause global health panic. Due to the rapidly escalating numbers of new infections outside China, COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11, 2020, in a message delivered by Dr. Tedros Adhanom Ghebreyesus, the WHO Director-General [1]. As of March 21, about 166 countries globally had recoded cases of the COVID-19 in only 4 months since its outbreak in Wuhan, Hubei Province, China [2, 3]. With the Antarctic continent unaffected, Africa, in particular Sub-Saharan Africa (SSA), has recorded the least number of cases, despite the cited moderate-to-high risk of infection [4]. The biggest challenge is whether Sub-Saharan Africa is ready for this pandemic.

The 2018/19 Ebola epidemic the Democratic Republic of the Congo (DRC): epidemiology, outbreak control, and conflict

The Democratic Republic of Congo (DRC) (formerly Zaire) was the location of the first Ebola outbreak, in 1976, and since then there have been a total of ten outbreaks in different parts of the country. The current outbreak, the first in eastern DRC (North Kivu and Ituri provinces), began in July 2018, and by December 2019, there had been 3262 cases and 2232 deaths. Within weeks of the first reported cases, the World Health Organisation (WHO) and the DRC Ministry of Health (MOH) initiated a major response programme, with laboratory support, international agencies providing personnel, and material resources. Unlike previous Ebola outbreaks, including the west Africa epidemic, a proven vaccine, and trial therapeutic agents have been available as part of the outbreak response. Two therapeutic agents, mAb114 and REGN-EB3, both monoclonal antibody derived, have shown case fatality rates (CFR) of around 30%, compared to the overall of 66%. Despite these positive interventions, the outbreak has continued for eighteen months. Underlying the outbreak response has been a high number of violent incidents by local militias, and community mistrust and lack of involvement that has hampered many aspects of the response programme. As a result, many cases are not reported early and not transferred to treatment centres, deaths and increased transmission occur in the community, and the response programme is reaching only a proportion of the cases. New strategies to improve community participation, and integrate the Ebola response into the existing health structure are planned to improve the programme effectiveness.