Gateways not gatekeepers – reaching seldom-heard groups to gather public health community insights

Background

Each local authority in England must develop a Health and Wellbeing Strategy (HWS) in collaboration with NHS partners to plan and support delivery of local improvements in health and wellbeing. HWSs often draw on diverse sources but few are informed by consultative exercises involving citizens. South Tyneside Council in Northern England sought to ensure their new HWS was community-informed, specifically including seldom-heard groups and individuals. Specific objectives of this community insights research were to:

1.Target sampling and recruitment activities at typically marginalized, vulnerable or otherwise underrepresented groups

2.Explore the health and wellbeing-related views and priorities of these groups to address health inequalities

Methods

A mapping exercise was undertaken to identify organisations who might act as gatekeepers to accessing participants from underrepresented groups. Focus groups were held in settings-based venues where members would be comfortable and known to one another. Representatives of voluntary and community sector (VCS) organisations often helped to co-facilitate the discussions.

Results

119 participants took part in 16 group discussions. Three were held online, two were outdoors, while 11 involved community venues where the groups regularly met. We reached older and younger people, minority ethnic groups, and vulnerable men and women, including residents who had experienced homelessness, mental health issues, substance misuse, offending, domestic violence and learning disabilities. Participants were largely concerned with the wider determinants of health (such as poverty, employment, and leisure spaces), shifting the narrative away from individual lifestyle factors that tend to be the focus of much public health discourse.

Conclusions

Gatekeepers from the VCS were essentially gateways, enabling us to include underrepresented voices in local consultation processes and generate new insights to inform the South Tyneside HWS.

Key messages

Assessment of Community Event-Based Surveillance for Ebola Virus Disease, Sierra Leone, 2015

Case detection improved, but many false alerts were generated, suggesting a need for additional staff training.

In 2015, community event–based surveillance (CEBS) was implemented in Sierra Leone to assist with the detection of Ebola virus disease (EVD) cases. We assessed the sensitivity of CEBS for finding EVD cases during a 7-month period, and in a 6-week subanalysis, we assessed the timeliness of reporting cases with no known epidemiologic links at time of detection. Of the 12,126 CEBS reports, 287 (2%) met the suspected case definition, and 16 were confirmed positive. CEBS detected 30% (16/53) of the EVD cases identified during the study period. During the subanalysis, CEBS staff identified 4 of 6 cases with no epidemiologic links. These CEBS-detected cases were identified more rapidly than those detected by the national surveillance system; however, too few cases were detected to determine system timeliness. Although CEBS detected EVD cases, it largely generated false alerts. Future versions of community-based surveillance could improve case detection through increased staff training and community engagement.

Community Event-Based Surveillance for Ebola Virus Disease in Sierra Leone: Implementation of a National-Level System During a Crisis

INTRODUCTION: There are few documented examples of community networks that have used unstructured information to support surveillance during a health emergency. In January 2015, the Ebola Response Consortium rapidly implemented community event-based surveillance for Ebola virus disease at a national scale in Sierra Leone.

METHODS: Community event based surveillance uses community health monitors in each community to provide an early warning system of events that are suggestive of Ebola virus disease transmission. The Ebola Response Consortium, a consortium of 15 nongovernmental organizations, applied a standardized procedure to implement community event-based surveillance across nine of the 14 districts. To evaluate system performance during the first six months of operation (March to August 2015), we conducted a process evaluation. We analyzed the production of alerts, conducted interviews with surveillance stakeholders and performed rapid evaluations of community health monitors to assess their knowledge and reported challenges.

RESULTS: The training and procurement of supplies was expected to begin in January 2015 and attain full scale by March 2015. We found several logistical challenges that delayed full implementation until June 2015 when the epidemic was past its peak. Community health monitors reported 9,131 alerts during this period. On average, 82% of community health monitors reported to their supervisor at least once per week. Most alerts (87%) reported by community health monitors were deaths unrelated to Ebola. During the rapid evaluations, the mean recall by community health monitors was three of the six trigger events. Implementation of the national system achieved scale, but three months later than anticipated.

DISCUSSION: Community event based surveillance generated consistent surveillance information during periods of no- to low-levels of transmission across districts. We interpret this to mean that community health monitors are an effective tool for generating useful, unstructured information at the village level. However, to maximize validity, the triggers require more training, may be too many in number, and need increased relevance to the context of the tail end of the epidemic.

Nosocomial transmission of Ebola virus disease on pediatric and maternity wards: Bombali and Tonkolili, Sierra Leone, 2014

BACKGROUND

In the largest Ebola virus disease (EVD) outbreak in history, nosocomial transmission of EVD increased spread of the disease. We report on 2 instances in Sierra Leone where patients unknowingly infected with EVD were admitted to a general hospital ward (1 pediatric ward and 1 maternity ward), exposing health care workers, caregivers, and other patients to EVD. Both patients died on the general wards, and were later confirmed as being infected with EVD. We initiated contact tracing and assessed risk factors for secondary infections to guide containment recommendations.

METHODS

We reviewed medical records to establish the index patients' symptom onset. Health care workers, patients, and caregivers were interviewed to determine exposures and personal protective equipment (PPE) use. Contacts were monitored daily for EVD symptoms. Those who experienced EVD symptoms were isolated and tested.

RESULTS

Eighty-two contacts were identified: 64 health care workers, 7 caregivers, 4 patients, 4 newborns, and 3 children of patients. Seven contacts became symptomatic and tested positive for EVD: 2 health care workers (1 nurse and 1 hospital cleaner), 2 caregivers, 2 newborns, and 1 patient. The infected nurse placed an intravenous catheter in the pediatric index patient with only short gloves PPE and the hospital cleaner cleaned the operating room of the maternity ward index patient wearing short gloves PPE. The maternity ward index patient's caregiver and newborn were exposed to her body fluids. The infected patient and her newborn shared the ward and latrine with the maternity ward index patient. Hospital staff members did not use adequate PPE. Caregivers were not offered PPE.

CONCLUSIONS

Delayed recognition of EVD and inadequate PPE likely led to exposures and secondary infections. Earlier recognition of EVD and adequate PPE might have reduced direct contact with body fluids. Limiting nonhealth-care worker contact, improving access to PPE, and enhancing screening methods for pregnant women, children, and inpatients may help decrease EVD transmission in general health care settings.

Barriers to and acceptability of provider-initiated HIV testing and counselling and adopting HIV-prevention behaviours in rural Uganda: a qualitative study

In Uganda, a nationwide scale-up of provider-initiated HIV testing and counselling presents an opportunity to deliver HIV-prevention services to large numbers of people. In a rural Ugandan hospital, focus group discussions and key informant interviews were conducted with outpatients receiving provider-initiated HIV testing and counselling and staff to explore the HIV-prevention information, motivation and behavioural skills strengths and weaknesses, and community-level and structural barriers to provider-initiated HIV testing and counselling acceptability and HIV prevention among this population. Strengths and weakness occurred at all levels, and results suggest brief client-centred interventions during provider-initiated HIV testing and counselling may be an effective approach to increase prevention behaviours in outpatient settings.

Influence of organic carbon loading, sediment associated metal oxide content and sediment grain size distributions upon Cryptosporidium parvum removal during riverbank filtration operations, Sonoma County, CA

This study assessed the efficacy for removing Cryptosporidium parvum oocysts of poorly sorted, Fe- and Al-rich, subsurface sediments collected from 0.9 to 4.9 and 1.7-13.9 m below land surface at an operating riverbank filtration (RBF) site (Russian River, Sonoma County, CA). Both formaldehyde-killed oocysts and oocyst-sized (3 microm) microspheres were employed in sediment-packed flow-through and static columns. The degree of surface coverage of metal oxides on sediment grain surfaces correlated strongly with the degrees of oocyst and microsphere removals. In contrast, average grain size (D(50)) was not a good indicator of either microsphere or oocyst removal, suggesting that the primary mechanism of immobilization within these sediments is sorptive filtration rather than physical straining. A low specific UV absorbance (SUVA) for organic matter isolated from the Russian River, suggested that the modest concentration of the SUVA component (0.8 mg L(-1)) of the 2.2 mg L(-1) dissolved organic carbon (DOC) is relatively unreactive. Nevertheless, an amendment of 2.2 mg L(-1) of isolated river DOC to column sediments resulted in up to a 35.7% decrease in sorption of oocysts and (or) oocyst-sized microspheres. Amendments (3.2 microM) of the anionic surfactant, sodium dodecyl benzene sulfonate (SDBS) also caused substantive decreases (up to 31.9 times) in colloid filtration. Although the grain-surface metal oxides were found to have a high colloid-removal capacity, our study suggested that any major changes within the watershed that would result in long-term alterations in either the quantity and (or) the character of the river's DOC could alter the effectiveness of pathogen removal during RBF operations.