Analysis of patient data from laboratories during the Ebola virus disease outbreak in Liberia, April 2014 to March 2015

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Indirect Effects of Ebola Virus Disease Epidemics on Health Systems in the Democratic Republic of the Congo, Guinea, Sierra Leone and Liberia: A Scoping Review Supplemented with Expert Interviews

Ebola Virus Disease (EVD) epidemics have been extensively documented and have received large scientific and public attention since 1976. Until July 2022, 16 countries worldwide had reported at least one case of EVD, resulting in 43 epidemics. Most of the epidemics occurred in the Democratic Republic of Congo (DRC) but the largest epidemic occurred from 2014-2016 in Guinea, Sierra Leone and Liberia in West Africa. The indirect effects of EVD epidemics on these countries' health systems, i.e., the consequences beyond infected patients and deaths immediately related to EVD, can be significant. The objective of this review was to map and measure the indirect effects of the EVD epidemics on the health systems of DRC, Guinea, Sierra Leone and Liberia and, from thereon, draw lessons for strengthening their resilience vis-à-vis future EVD outbreaks and other similar health emergencies. A scoping review of published articles from the PubMed database and gray literature was conducted. It was supplemented by interviews with experts. Eighty-six articles were included in this review. The results were structured based on WHO's six building blocks of a health system. During the EVD outbreaks, several healthcare services and activities were disrupted. A significant decline in indicators of curative care utilization, immunization levels and disease control activities was noticeable. Shortages of health personnel, poor health data management, insufficient funding and shortages of essential drugs characterized the epidemics that occurred in the above-mentioned countries. The public health authorities had virtually lost their leadership in the management of an EVD response. Governance was characterized by the development of a range of new initiatives to ensure adequate response. The results of this review highlight the need for countries to invest in and strengthen their health systems, through the continuous reinforcement of the building blocks, even if there is no imminent risk of an epidemic.

[Comprehensive understanding of viral diseases by field, molecular, and theoretical studies]

Viral diseases are responsible for substantial morbidity and mortality and continue to be of great concern. To ensure better control of viral infections, I have been tackling the issue as a medical doctor, an academic researcher, and a public health officer. Especially, I have studied respiratory viruses, such as the influenza virus, from the perspectives of molecular virology, theoretical modeling, and field epidemiology. RNA biology and its involvement with viral life-cycle and pathogenicity are central topics of molecular study, while mathematical models of transmission dynamics and phylogenetics are major components of theoretical research. As a field epidemiologist, I work with public health authorities during viral disease outbreaks. I was deployed to West Africa for viral hemorrhagic fever outbreak responses as a WHO consultant, and I have served the Japanese Government as an advisor for COVID-19 countermeasures. I would like to integrate various approaches from clinical medicine to epidemiology, theoretical modeling, evolutionary biology, genetics, and molecular biology in my research. In that way, we could gain a more comprehensive understanding of viral diseases. I hope these findings will help ease the disease burden of viral infections around the world.

[Epidemiology of Viral Hemorrhagic Fever in Africa]

A variety of viral hemorrhagic fevers such as Ebola virus disease exist in Africa and impose a great threat in public health due to their high fatality. It is considered to be difficult to eradicate the etiological agents of viral hemorrhagic fever because they have non-human natural hosts. Therefore, the importance of public health measures remains high in addition to the urgent need for the development of medicines for treatment and prevention. Furthermore, public health measures directly lead to the accumulation of epidemiological knowledge about the diseases. As an infectious disease consultant for the World Health Organization, I have been involved with public health activities including the development of clinical guidelines, the establishment of laboratory diagnostic systems, the training for infection, prevention and control, the planning of budget for outbreak response, and the analysis of epidemiological data. On the last point, I reported the situation of Ebola virus disease outbreak in Liberia, 2014-2015 and Lassa fever outbreak in Nigeria, 2018-2019 describing the risk factors, morbidity, and mortality of the diseases.

A meta-analysis of clinical studies conducted during the West Africa Ebola virus disease outbreak confirms the need for randomized control groups

Recent Ebola virus disease outbreaks affirm the dire need for treatments with proven efficacy. Randomized controlled clinical trials remain the gold standard but, during disease outbreaks, may be difficult to conduct due to ethical concerns and challenging field conditions. In the absence of a randomized control group, statistical modeling to create a control group could be a possibility. Such a model-based reference control would only be credible if it had the same mortality risk as that of the experimental group in the absence of treatment. One way to test this counterfactual assumption is to evaluate whether reasonable similarity exists across nonrandomized control groups from different clinical studies, which might suggest that a future control group would be similarly homogeneous. We evaluated similarity across six clinical studies conducted during the 2013-2016 West Africa outbreak of Ebola virus disease. These studies evaluated favipiravir, the biologic ZMapp, the antimalarial drug amodiaquine, or administration of convalescent plasma or convalescent whole blood. We compared the nonrandomized control groups of these six studies comprising 1147 individuals infected with Ebola virus. We found considerable heterogeneity, which did not disappear after statistical modeling to adjust for prognostic variables. Mortality risk varied widely (31 to 66%) across the nonrandomized control arms of these six studies. Models adjusting for baseline covariates (age, sex, and cycle threshold, a proxy for viral load) failed to sufficiently recalibrate these studies and showed that heterogeneity remained. Our findings highlight concerns about making invalid conclusions when comparing nonrandomized control groups to cohorts receiving experimental treatments.

Reporting quality of the 2014 Ebola outbreak in Africa: A systematic analysis

The objective of this study was to conduct a systematic analysis of the reporting quality of the Ebola Virus Disease (EVD) outbreak in West Africa from 2014-2018 using the Modified STROBE statement. We included studies on the 2014 EVD outbreak alone, limited to those on human patients in Africa. We searched the following databases (MEDLINE, EMBASE, and Web of Science) for outbreak reports published between 2014-2018. We assessed factors potentially associated with the quality of reporting. A total of 69 of 131 (53%) articles within the full-text review fulfilled our eligibility criteria and underwent the Modified STROBE assessment for analyzing the quality of reporting. The Modified STROBE scores of the included studies ranged from 11-26 points and the mean was found to be 19.54 out of 30 with a standard deviation (SD) of ± 4.30. The top three reported Modified STROBE components were descriptive characteristics of study participants, scientific background and evidence rational, and clinical significance of observations. More than 75% of the studies met a majority of the criteria in the Modified STROBE assessment tool. Information that was commonly missing included addressing potential source of bias, sensitivity analysis, further results/analysis such as risk estimates and odds ratios, presence of a flowchart, and addressing missing data. In multivariable analysis, peer-reviewed publication was the only predictor that remained significantly associated with a higher Modified STROBE score. In conclusion, the large range of Modified STROBE scores observed indicates variability in the quality of outbreak reports for EVD. The review identified strong reporting in some areas, whereas other areas are in need of improvement, in particular providing an important description of the outbreak setting and identifying any external elements (potential biases and confounding factors) that could hinder the credibility of the findings.

Epidemiological characteristics, clinical manifestations, and treatment outcome of 139 paediatric Ebola patients treated at a Sierra Leone Ebola treatment center

Background

The West Africa Ebola Virus Disease (EVD) outbreak in 2014–2016 was declared by the World Health Organization (WHO) a public health emergency of international concern. Most of the previous studies done in Sierra Leone relating to the clinical and epidemiological features of EVD during the 2014–2016 West African outbreak focused on adult EVD patients. There have been conflicting reports about the effects of EVD on children during previous outbreaks.

Methods

This is an observational retrospective analysis of medical data of all laboratory confirmed paediatric EVD patients below 15 years of age who were admitted at the 34 Military Hospital Ebola Treatment Center (ETC) in Wilberforce, Sierra Leone between June 2014 to April 2015. We analyzed the sociodemographic and clinical characteristics of paediatric EVD cases contained in case report forms that were collected by Ebola surveillance officers and clinicians at the 34 Military Hospital ETC. Both univariate and multivariate logistic regression models were used to determine the sociodemographic and clinical characteristics of paediatric EVD patients that were associated with EVD facility-based mortality.

Results

The majority of the paediatric EVD cases in this study were female (56.1%), pupils (51.1%), and 43.2% belonged to the age group between 10 years and below 15 years. The median age of the paediatric EVD cases was 9 years (interquartile range = 4 to 11 years). Adjusting for other covariates in the model, male paediatric EVD patient (AOR = 13.4, 95% CI = [2.07–156-18], p <  0.05), EVD patient with abdominal pain (AOR = 11.0, 95% CI = [1.30–161.81], p <  0.05), vomiting (AOR = 35.7, 95% CI = [3.43–833.73], p <  0.05), signs of conjunctivitis (AOR = 17.4, 95% CI = [1.53–342.21], p <  0.05) and difficulty in breathing (AOR = 23.3, 95% CI = [1.92–713.01], p <  0.05) at the time of admission had increased odds of dying during EVD treatment.

Conclusions

We recommend the adoption of case definitions currently in vigour to cater for specific characteristics of paediatric patients. Subgroups that can be identified by applying the model developed in this study may require special attention and intensified care.

Correlates of social behavior change communication on care-seeking behaviors for children with fever: an analysis of malaria household survey data from Liberia

Background

In 2010, malaria was responsible for an estimated 41% of deaths among children under the age of five years in Liberia. The same year, the Rebuilding Basic Health Services Project launched “Healthy Baby, Happy Mother,” a social and behavior change communication campaign. The campaign encouraged caregivers to take children under the age of five years to a health facility as soon as children developed fever. This study investigated correlates of two case management outcomes: care-seeking for children under five with fever during the past two weeks and administration of an artemisinin-based combination therapy (ACT) the same or next day as fever onset.

Methods

Data from a 2014 cross-sectional household survey from four counties was used to investigate correlates of two case management outcomes. Using multilevel analysis, the association between these outcomes and a caregiver’s recall of the campaign, her sociodemographic characteristics, and unmeasured characteristics of the community she lived in was investigated.

Results

Caregivers living in Grand Kru County were less likely (OR = 0.21, 95% CI 0.073, 0.632) to take a child to a health facility than those in Bong County. Caregiver recall of the campaign was positively associated with the odds that a child received an ACT promptly (OR 3.62, 95% CI 1.398–9.372), but not with the odds of a caregiver taking a child in their care to a health facility. While unmeasured community-level factors accounted for 19.0% of the variation in the odds that a caregiver’s child was brought to a health facility, they did not play a role in the odds of prompt ACT treatment.

Conclusions

Recalling the “Healthy Mother, Happy Baby” campaign was positively associated with the odds that children received ACT promptly, even in the absence of other malaria prevention and treatment messaging. While caregiver exposure was not associated with care-seeking during the two weeks before interview, prompt care-seeking likely preceded prompt receipt of ACT since most ACT came from health facilities. Unmeasured community-level factors, such as distance from the health facility, may play a role in determining the odds that a caregiver takes a child to a health facility.