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Nyenswah TG, Schue JL. nOPV2 development as a global effort for polio outbreak response - Authors' reply. Lancet Glob Health 2023; 11:e1696. [PMID: 37858580 DOI: 10.1016/s2214-109x(23)00374-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/01/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Tolbert G Nyenswah
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | - Jessica L Schue
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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2
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Nyenswah TG, Skrip L, Stone M, Schue JL, Peters DH, Brieger WR. Documenting the development, adoption and pre-ebola implementation of Liberia's integrated disease surveillance and response (IDSR) strategy. BMC Public Health 2023; 23:2093. [PMID: 37880607 PMCID: PMC10601278 DOI: 10.1186/s12889-023-17006-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND In the immediate aftermath of a 14-year civil conflict that disrupted the health system, Liberia adopted the internationally recommended integrated disease surveillance and response (IDSR) strategy in 2004. Despite this, Liberia was among the three West African countries ravaged by the worst Ebola epidemic in history from 2014 to 2016. This paper describes successes, failures, strengths, and weaknesses in the development, adoption, and implementation of IDSR following the civil war and up until the outbreak of Ebola, from 2004 to early 2014. METHODS We reviewed 112 official Government documents and peer-reviewed articles and conducted 29 in-depth interviews with key informants from December 2021 to March 2022 to gain perspectives on IDSR in the post-conflict and pre-Ebola era in Liberia. We assessed the core and supportive functions of IDSR, such as notification of priority diseases, confirmation, reporting, analysis, investigation, response, feedback, monitoring, staff training, supervision, communication, and financial resources. Data were triangulated and presented via emerging themes and in-depth accounts to describe the context of IDSR introduction and implementation, and the barriers surrounding it. RESULTS Despite the adoption of the IDSR framework, Liberia failed to secure the resources-human, logistical, and financial-to support effective implementation over the 10-year period. Documents and interview reports demonstrate numerous challenges prior to Ebola: the surveillance system lacked key components of IDSR including laboratory testing capacity, disease reporting, risk communication, community engagement, and staff supervision systems. Insufficient financial support and an abundance of vertical programs further impeded progress. In-depth accounts by donors and key governmental informants demonstrate that although the system had a role in detecting Ebola in Liberia, it could not respond effectively to control the disease. CONCLUSION Our findings suggest that post-war, Liberia's health system intended to prioritize epidemic preparedness and response with the adoption of IDSR. However, insufficient investment and systems development meant IDSR was not well implemented, leaving the country vulnerable to the devastating impact of the Ebola epidemic.
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Affiliation(s)
- Tolbert G Nyenswah
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Laura Skrip
- School of Public Health, University of Liberia, Monrovia, Liberia
| | - Mardia Stone
- Division of Global Psychiatry, Boston University School of Medicine, Boston Medical Center, Boston, USA
| | - Jessica L Schue
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - William R Brieger
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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3
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Nyenswah TG, Schue JL. Halting vaccine-derived poliovirus circulation: the novel type 2 oral vaccine might not be enough. Lancet Glob Health 2023; 11:e811-e812. [PMID: 37202011 DOI: 10.1016/s2214-109x(23)00161-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/15/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Tolbert G Nyenswah
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, MD, USA.
| | - Jessica L Schue
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, MD, USA
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4
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Marzi A, Chadinah S, Haddock E, Feldmann F, Arndt N, Martellaro C, Scott DP, Hanley PW, Nyenswah TG, Sow S, Massaquoi M, Feldmann H. Recently Identified Mutations in the Ebola Virus-Makona Genome Do Not Alter Pathogenicity in Animal Models. Cell Rep 2019; 23:1806-1816. [PMID: 29742435 DOI: 10.1016/j.celrep.2018.04.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 12/01/2017] [Accepted: 04/04/2018] [Indexed: 10/16/2022] Open
Abstract
Ebola virus (EBOV), isolate Makona, the causative agent of the West African EBOV epidemic, has been the subject of numerous investigations to determine the genetic diversity and its potential implication for virus biology, pathogenicity, and transmissibility. Despite various mutations that have emerged over time through multiple human-to-human transmission chains, their biological relevance remains questionable. Recently, mutations in the glycoprotein GP and polymerase L, which emerged and stabilized early during the outbreak, have been associated with improved viral fitness in cell culture. Here, we infected mice and rhesus macaques with EBOV-Makona isolates carrying or lacking those mutations. Surprisingly, all isolates behaved very similarly independent of the genotype, causing severe or lethal disease in mice and macaques, respectively. Likewise, we could not detect any evidence for differences in virus shedding. Thus, no specific biological phenotype could be associated with these EBOV-Makona mutations in two animal models.
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Affiliation(s)
- Andrea Marzi
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Rocky Mountain Laboratories, Hamilton, MT, USA.
| | - Spencer Chadinah
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Rocky Mountain Laboratories, Hamilton, MT, USA
| | - Elaine Haddock
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Rocky Mountain Laboratories, Hamilton, MT, USA
| | - Friederike Feldmann
- Rocky Mountain Veterinary Branch, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Rocky Mountain Laboratories, Hamilton, MT, USA
| | - Nicolette Arndt
- Rocky Mountain Veterinary Branch, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Rocky Mountain Laboratories, Hamilton, MT, USA
| | - Cynthia Martellaro
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Rocky Mountain Laboratories, Hamilton, MT, USA
| | - Dana P Scott
- Rocky Mountain Veterinary Branch, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Rocky Mountain Laboratories, Hamilton, MT, USA
| | - Patrick W Hanley
- Rocky Mountain Veterinary Branch, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Rocky Mountain Laboratories, Hamilton, MT, USA
| | | | - Samba Sow
- Centre des Operations d'Urgence, Centre pour le Développement des Vaccins (CVD-Mali), Centre National d'Appui à la lutte contre la Maladie, Ministère de la Sante et de l'Hygiène Publique, Bamako, Mali
| | | | - Heinz Feldmann
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Rocky Mountain Laboratories, Hamilton, MT, USA.
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5
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Mate SE, Wiley MR, Ladner JT, Dokubo EK, Fakoli L, Fallah M, Nyenswah TG, DiClaro JW, Deboer JT, Williams DE, Bolay F, Palacios G. Cross-Border Transmission of Ebola Virus as the Cause of a Resurgent Outbreak in Liberia in April 2016. Clin Infect Dis 2019; 67:1147-1149. [PMID: 29659740 DOI: 10.1093/cid/ciy281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Suzanne E Mate
- Center for Genome Sciences, US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, Maryland
| | - Michael R Wiley
- Center for Genome Sciences, US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, Maryland
| | - Jason T Ladner
- Center for Genome Sciences, US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, Maryland
| | - E Kainne Dokubo
- US Centers for Disease Control and Prevention, Monrovia, Liberia.,Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Mosoka Fallah
- Ministry of Health and Social Welfare, Monrovia, Liberia
| | | | | | - Jason T Deboer
- Center for Genome Sciences, US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, Maryland
| | - Desmond E Williams
- US Centers for Disease Control and Prevention, Monrovia, Liberia.,Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Fatorma Bolay
- Liberian Institute for Biomedical Research, Charlesville
| | - Gustavo Palacios
- Center for Genome Sciences, US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, Maryland
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6
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Den Boon S, Marston BJ, Nyenswah TG, Jambai A, Barry M, Keita S, Durski K, Senesie SS, Perkins D, Shah A, Green HH, Hamblion EL, Lamunu M, Gasasira A, Mahmoud NO, Djingarey MH, Morgan O, Crozier I, Dye C. Ebola Virus Infection Associated with Transmission from Survivors. Emerg Infect Dis 2019; 25:249-255. [PMID: 30500321 PMCID: PMC6346469 DOI: 10.3201/eid2502.181011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Ebola virus (EBOV) can persist in immunologically protected body sites in survivors of Ebola virus disease, creating the potential to initiate new chains of transmission. From the outbreak in West Africa during 2014-2016, we identified 13 possible events of viral persistence-derived transmission of EBOV (VPDTe) and applied predefined criteria to classify transmission events based on the strength of evidence for VPDTe and source and route of transmission. For 8 events, a recipient case was identified; possible source cases were identified for 5 of these 8. For 5 events, a recipient case or chain of transmission could not be confidently determined. Five events met our criteria for sexual transmission (male-to-female). One VPDTe event led to at least 4 generations of cases; transmission was limited after the other events. VPDTe has increased the importance of Ebola survivor services and sustained surveillance and response capacity in regions with previously widespread transmission.
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7
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Marston BJ, Dokubo EK, van Steelandt A, Martel L, Williams D, Hersey S, Jambai A, Keita S, Nyenswah TG, Redd JT. Ebola Response Impact on Public Health Programs, West Africa, 2014-2017. Emerg Infect Dis 2018; 23. [PMID: 29155674 PMCID: PMC5711323 DOI: 10.3201/eid2313.170727] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Events such as the 2014–2015 West Africa epidemic of Ebola virus disease highlight the importance of the capacity to detect and respond to public health threats. We describe capacity-building efforts during and after the Ebola epidemic in Liberia, Sierra Leone, and Guinea and public health progress that was made as a result of the Ebola response in 4 key areas: emergency response, laboratory capacity, surveillance, and workforce development. We further highlight ways in which capacity-building efforts such as those used in West Africa can be accelerated after a public health crisis to improve preparedness for future events.
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8
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Fallah MP, Skrip LA, Dahn BT, Nyenswah TG, Flumo H, Glayweon M, Lorseh TL, Kaler SG, Higgs ES, Galvani AP. Pregnancy outcomes in Liberian women who conceived after recovery from Ebola virus disease. Lancet Glob Health 2018; 4:e678-9. [PMID: 27633422 DOI: 10.1016/s2214-109x(16)30147-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Mosoka P Fallah
- Ministry of Health, Monrovia, Liberia; A M Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia; US National Institute of Allergy and Infectious Diseases, PREVAIL-III Study, Monrovia, Liberia
| | - Laura A Skrip
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT 06510, USA
| | | | | | - Hilary Flumo
- US National Institute of Allergy and Infectious Diseases, PREVAIL-III Study, Monrovia, Liberia
| | | | | | - Stephen G Kaler
- Section on Translational Neuroscience, Molecular Medicine Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth S Higgs
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Bethesda, MD, USA
| | - Alison P Galvani
- A M Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT 06510, USA.
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9
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Kirsch TD, Moseson H, Massaquoi M, Nyenswah TG, Goodermote R, Rodriguez-Barraquer I, Lessler J, Cumings DAT, Peters DH. Impact of interventions and the incidence of ebola virus disease in Liberia-implications for future epidemics. Health Policy Plan 2018; 32:205-214. [PMID: 28207062 DOI: 10.1093/heapol/czw113] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 11/14/2022] Open
Abstract
To better understand the impact of national and global efforts to contain the Ebola virus disease epidemic of 2014–15 in Liberia, we provide a detailed timeline of the major interventions and relate them to the epidemic curve.
In addition to personal experience in the response, we systematically reviewed situation reports from the Liberian government, UN, CDC, WHO, UNICEF, IFRC, USAID, and local and international news reports to create the timeline. We extracted data on the timing and nature of activities and compared them to the timeline of the epidemic curve using the reproduction number—the estimate of the average number of new cases caused by a single case.
Interventions were organized around five major strategies, with the majority of resources directed to the creation of treatment beds. We conclude that no single intervention stopped the epidemic; rather, the interventions likely had reinforcing effects, and some were less likely than others to have made a major impact. We find that the epidemic’s turning coincided with a reorganization of the response in August–September 2014, the emergence of community leadership in control efforts, and changing beliefs and practices in the population. Ebola Treatment Units were important for Ebola treatment, but the vast majority of these treatment centre beds became available after the epidemic curve began declining. Similarly, the United Nations Mission for Ebola Emergency Response was launched after the epidemic curve had already turned.
These findings have significant policy implications for future epidemics and suggest that much of the decline in the epidemic curve was driven by critical behaviour changes within local communities, rather than by international efforts that came after the epidemic had turned. Future global interventions in epidemic response should focus on building community capabilities, strengthening local ownership, and dramatically reducing delays in the response.
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Affiliation(s)
- Thomas D Kirsch
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heidi Moseson
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Moses Massaquoi
- Liberian Ministry of Health, Tubman Blvd, Monrovia, Liberia and
| | | | - Rachel Goodermote
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Justin Lessler
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Derek A T Cumings
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Biology and Emerging Pathogens Institute, University of Florida, FL, USA
| | - David H Peters
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
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10
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Fallah MP, Skrip LA, Raftery P, Kullie M, Borbor W, Laney AS, Blackley DJ, Christie A, Dokubo EK, Lo TQ, Coulter S, Baller A, Vonhm BT, Bemah P, Lomax S, Yeiah A, Wapoe-Sackie Y, Mann J, Clement P, Davies-Wayne G, Hamblion E, Wolfe C, Williams D, Gasasira A, Kateh F, Nyenswah TG, Galvani AP. Bolstering Community Cooperation in Ebola Resurgence Protocols: Combining Field Blood Draw and Point-of-Care Diagnosis. PLoS Med 2017; 14:e1002227. [PMID: 28118353 PMCID: PMC5261562 DOI: 10.1371/journal.pmed.1002227] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Alison Galvani and colleagues describe a community-based protocol to improve cooperation with Ebola testing as well as contact tracing, quarantining, and treatment.
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Affiliation(s)
- Mosoka P. Fallah
- Ministry of Health, Monrovia, Liberia
- Community-Based Initiative, United Nations Development Programme, Ministry of Health, Monrovia, Liberia
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
- National Institute of Allergy and Infectious Diseases, PREVAIL-III Study, Monrovia, Liberia
| | - Laura A. Skrip
- Center for Infectious Disease Modeling and Analysis (CIDMA), Yale School of Public Health, New Haven, Connecticut, United States of America
| | | | | | | | - A. Scott Laney
- Centers for Disease Control and Prevention, Monrovia, Liberia
| | | | | | | | - Terrence Q. Lo
- Centers for Disease Control and Prevention, Monrovia, Liberia
| | - Stewart Coulter
- Centers for Disease Control and Prevention, Monrovia, Liberia
| | | | | | | | | | | | | | - Jennifer Mann
- Centers for Disease Control and Prevention, Monrovia, Liberia
| | | | | | | | | | | | | | | | | | - Alison P. Galvani
- A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
- Center for Infectious Disease Modeling and Analysis (CIDMA), Yale School of Public Health, New Haven, Connecticut, United States of America
- * E-mail:
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11
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Nyenswah TG, Kateh F, Bawo L, Massaquoi M, Gbanyan M, Fallah M, Nagbe TK, Karsor KK, Wesseh CS, Sieh S, Gasasira A, Graaff P, Hensley L, Rosling H, Lo T, Pillai SK, Gupta N, Montgomery JM, Ransom RL, Williams D, Laney AS, Lindblade KA, Slutsker L, Telfer JL, Christie A, Mahoney F, De Cock KM. Ebola and Its Control in Liberia, 2014-2015. Emerg Infect Dis 2016; 22:169-77. [PMID: 26811980 PMCID: PMC4734504 DOI: 10.3201/eid2202.151456] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Several factors explain the successful response to the outbreak in this country. The severe epidemic of Ebola virus disease in Liberia started in March 2014. On May 9, 2015, the World Health Organization declared Liberia free of Ebola, 42 days after safe burial of the last known case-patient. However, another 6 cases occurred during June–July; on September 3, 2015, the country was again declared free of Ebola. Liberia had by then reported 10,672 cases of Ebola and 4,808 deaths, 37.0% and 42.6%, respectively, of the 28,103 cases and 11,290 deaths reported from the 3 countries that were heavily affected at that time. Essential components of the response included government leadership and sense of urgency, coordinated international assistance, sound technical work, flexibility guided by epidemiologic data, transparency and effective communication, and efforts by communities themselves. Priorities after the epidemic include surveillance in case of resurgence, restoration of health services, infection control in healthcare settings, and strengthening of basic public health systems.
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12
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de Wit E, Falzarano D, Onyango C, Rosenke K, Marzi A, Ochieng M, Juma B, Fischer RJ, Prescott JB, Safronetz D, Omballa V, Owuor C, Hoenen T, Groseth A, van Doremalen N, Zemtsova G, Self J, Bushmaker T, McNally K, Rowe T, Emery SL, Feldmann F, Williamson B, Nyenswah TG, Grolla A, Strong JE, Kobinger G, Stroeher U, Rayfield M, Bolay FK, Zoon KC, Stassijns J, Tampellini L, de Smet M, Nichol ST, Fields B, Sprecher A, Feldmann H, Massaquoi M, Munster VJ. The Merits of Malaria Diagnostics during an Ebola Virus Disease Outbreak. Emerg Infect Dis 2016; 22:323-6. [PMID: 26814608 PMCID: PMC4734533 DOI: 10.3201/eid2202.151656] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Malaria is a major public health concern in the countries affected by the Ebola virus disease epidemic in West Africa. We determined the feasibility of using molecular malaria diagnostics during an Ebola virus disease outbreak and report the incidence of Plasmodium spp. parasitemia in persons with suspected Ebola virus infection.
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13
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Soka MJ, Choi MJ, Baller A, White S, Rogers E, Purpura LJ, Mahmoud N, Wasunna C, Massaquoi M, Abad N, Kollie J, Dweh S, Bemah PK, Christie A, Ladele V, Subah OC, Pillai S, Mugisha M, Kpaka J, Kowalewski S, German E, Stenger M, Nichol S, Ströher U, Vanderende KE, Zarecki SM, Green HHW, Bailey JA, Rollin P, Marston B, Nyenswah TG, Gasasira A, Knust B, Williams D. Prevention of sexual transmission of Ebola in Liberia through a national semen testing and counselling programme for survivors: an analysis of Ebola virus RNA results and behavioural data. Lancet Glob Health 2016; 4:e736-43. [PMID: 27596037 DOI: 10.1016/s2214-109x(16)30175-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 06/29/2016] [Accepted: 07/15/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Ebola virus has been detected in semen of Ebola virus disease survivors after recovery. Liberia's Men's Health Screening Program (MHSP) offers Ebola virus disease survivors semen testing for Ebola virus. We present preliminary results and behavioural outcomes from the first national semen testing programme for Ebola virus. METHODS The MHSP operates out of three locations in Liberia: Redemption Hospital in Montserrado County, Phebe Hospital in Bong County, and Tellewoyan Hospital in Lofa County. Men aged 15 years and older who had an Ebola treatment unit discharge certificate are eligible for inclusion. Participants' semen samples were tested for Ebola virus RNA by real-time RT-PCR and participants received counselling on safe sexual practices. Participants graduated after receiving two consecutive negative semen tests. Counsellors collected information on sociodemographics and sexual behaviours using questionnaires administered at enrolment, follow up, and graduation visits. Because the programme is ongoing, data analysis was restricted to data obtained from July 7, 2015, to May 6, 2016. FINDINGS As of May 6, 2016, 466 Ebola virus disease survivors had enrolled in the programme; real-time RT-PCR results were available from 429 participants. 38 participants (9%) produced at least one semen specimen that tested positive for Ebola virus RNA. Of these, 24 (63%) provided semen specimens that tested positive 12 months or longer after Ebola virus disease recovery. The longest interval between discharge from an Ebola treatment unit and collection of a positive semen sample was 565 days. Among participants who enrolled and provided specimens more than 90 days since their Ebola treatment unit discharge, men older than 40 years were more likely to have a semen sample test positive than were men aged 40 years or younger (p=0·0004). 84 (74%) of 113 participants who reported not using a condom at enrolment reported using condoms at their first follow-up visit (p<0·0001). 176 (46%) of 385 participants who reported being sexually active at enrolment reported abstinence at their follow-up visit (p<0·0001). INTERPRETATION Duration of detection of Ebola virus RNA by real-time RT-PCR varies by individual and might be associated with age. By combining behavioural counselling and laboratory testing, the Men's Health Screening Program helps male Ebola virus disease survivors understand their individual risk and take appropriate measures to protect their sexual partners. FUNDING World Health Organization and the US Centers for Disease Control and Prevention.
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Affiliation(s)
| | - Mary J Choi
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | | | | | | | | | | | | | - Neetu Abad
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | | | | | | | | | - Satish Pillai
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | | | - Emilio German
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mark Stenger
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stuart Nichol
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ute Ströher
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | | | - Jeffrey A Bailey
- Academic Consortium Combating Ebola in Liberia, University of Massachusetts Medical School, MA, USA
| | - Pierre Rollin
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Barbara Marston
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Barbara Knust
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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14
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Rosenke K, Adjemian J, Munster VJ, Marzi A, Falzarano D, Onyango CO, Ochieng M, Juma B, Fischer RJ, Prescott JB, Safronetz D, Omballa V, Owuor C, Hoenen T, Groseth A, Martellaro C, van Doremalen N, Zemtsova G, Self J, Bushmaker T, McNally K, Rowe T, Emery SL, Feldmann F, Williamson BN, Best SM, Nyenswah TG, Grolla A, Strong JE, Kobinger G, Bolay FK, Zoon KC, Stassijns J, Giuliani R, de Smet M, Nichol ST, Fields B, Sprecher A, Massaquoi M, Feldmann H, de Wit E. Plasmodium Parasitemia Associated With Increased Survival in Ebola Virus-Infected Patients. Clin Infect Dis 2016; 63:1026-33. [PMID: 27531847 DOI: 10.1093/cid/ciw452] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/28/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The ongoing Ebola outbreak in West Africa has resulted in 28 646 suspected, probable, and confirmed Ebola virus infections. Nevertheless, malaria remains a large public health burden in the region affected by the outbreak. A joint Centers for Disease Control and Prevention/National Institutes of Health diagnostic laboratory was established in Monrovia, Liberia, in August 2014, to provide laboratory diagnostics for Ebola virus. METHODS All blood samples from suspected Ebola virus-infected patients admitted to the Médecins Sans Frontières ELWA3 Ebola treatment unit in Monrovia were tested by quantitative real-time polymerase chain reaction for the presence of Ebola virus and Plasmodium species RNA. Clinical outcome in laboratory-confirmed Ebola virus-infected patients was analyzed as a function of age, sex, Ebola viremia, and Plasmodium species parasitemia. RESULTS The case fatality rate of 1182 patients with laboratory-confirmed Ebola virus infections was 52%. The probability of surviving decreased with increasing age and decreased with increasing Ebola viral load. Ebola virus-infected patients were 20% more likely to survive when Plasmodium species parasitemia was detected, even after controlling for Ebola viral load and age; those with the highest levels of parasitemia had a survival rate of 83%. This effect was independent of treatment with antimalarials, as this was provided to all patients. Moreover, treatment with antimalarials did not affect survival in the Ebola virus mouse model. CONCLUSIONS Plasmodium species parasitemia is associated with an increase in the probability of surviving Ebola virus infection. More research is needed to understand the molecular mechanism underlying this remarkable phenomenon and translate it into treatment options for Ebola virus infection.
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Affiliation(s)
- Kyle Rosenke
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Jennifer Adjemian
- Epidemiology Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda Commissioned Corps, US Public Health Service, Rockville, Maryland
| | - Vincent J Munster
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Andrea Marzi
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Darryl Falzarano
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Clayton O Onyango
- Center for Global Health, Division of Global Health Protection, Centers for Disease Control and Prevention
| | - Melvin Ochieng
- Kenya Medical Research Institute, Center for Global Health Research, Nairobi
| | - Bonventure Juma
- Center for Global Health, Division of Global Health Protection, Centers for Disease Control and Prevention
| | - Robert J Fischer
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Joseph B Prescott
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - David Safronetz
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Victor Omballa
- Kenya Medical Research Institute, Center for Global Health Research, Nairobi
| | - Collins Owuor
- Kenya Medical Research Institute, Center for Global Health Research, Nairobi
| | - Thomas Hoenen
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Allison Groseth
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Cynthia Martellaro
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Neeltje van Doremalen
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Galina Zemtsova
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joshua Self
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Trenton Bushmaker
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Kristin McNally
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Thomas Rowe
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shannon L Emery
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Friederike Feldmann
- Rocky Mountain Veterinary Branch, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rocky Mountain Laboratories, National Institutes of Health, Hamilton, Montana
| | - Brandi N Williamson
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Sonja M Best
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Tolbert G Nyenswah
- Ministry of Health and Social Welfare/Incident Management System, Monrovia, Liberia
| | - Allen Grolla
- Special Pathogens Program, Public Health Agency of Canada, Winnipeg, Manitoba
| | - James E Strong
- Special Pathogens Program, Public Health Agency of Canada, Winnipeg, Manitoba
| | - Gary Kobinger
- Special Pathogens Program, Public Health Agency of Canada, Winnipeg, Manitoba
| | | | - Kathryn C Zoon
- Cytokine Biology Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | | | | | - Martin de Smet
- Médecins Sans Frontières, Operational Center, Brussels, Belgium
| | - Stuart T Nichol
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Barry Fields
- Center for Global Health, Division of Global Health Protection, Centers for Disease Control and Prevention
| | - Armand Sprecher
- Médecins Sans Frontières, Operational Center, Brussels, Belgium
| | - Moses Massaquoi
- Ministry of Health and Social Welfare/Incident Management System, Monrovia, Liberia
| | - Heinz Feldmann
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | - Emmie de Wit
- Laboratory of Virology, Division of Intramural Research, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
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15
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de Wit E, Kramer S, Prescott J, Rosenke K, Falzarano D, Marzi A, Fischer RJ, Safronetz D, Hoenen T, Groseth A, van Doremalen N, Bushmaker T, McNally KL, Feldmann F, Williamson BN, Best SM, Ebihara H, Damiani IAC, Adamson B, Zoon KC, Nyenswah TG, Bolay FK, Massaquoi M, Sprecher A, Feldmann H, Munster VJ. Clinical Chemistry of Patients With Ebola in Monrovia, Liberia. J Infect Dis 2016; 214:S303-S307. [PMID: 27471319 DOI: 10.1093/infdis/jiw187] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The development of point-of-care clinical chemistry analyzers has enabled the implementation of these ancillary tests in field laboratories in resource-limited outbreak areas. The Eternal Love Winning Africa (ELWA) outbreak diagnostic laboratory, established in Monrovia, Liberia, to provide Ebola virus and Plasmodium spp. diagnostics during the Ebola epidemic, implemented clinical chemistry analyzers in December 2014. Clinical chemistry testing was performed for 68 patients in triage, including 12 patients infected with Ebola virus and 18 infected with Plasmodium spp. The main distinguishing feature in clinical chemistry of Ebola virus-infected patients was the elevation in alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and γ-glutamyltransferase levels and the decrease in calcium. The implementation of clinical chemistry is probably most helpful when the medical supportive care implemented at the Ebola treatment unit allows for correction of biochemistry derangements and on-site clinical chemistry analyzers can be used to monitor electrolyte balance.
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Affiliation(s)
- Emmie de Wit
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Shelby Kramer
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Joseph Prescott
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Kyle Rosenke
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Darryl Falzarano
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Andrea Marzi
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Robert J Fischer
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - David Safronetz
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Thomas Hoenen
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Allison Groseth
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Neeltje van Doremalen
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Trenton Bushmaker
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Kristin L McNally
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Friederike Feldmann
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Brandi N Williamson
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Sonja M Best
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Hideki Ebihara
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Igor A C Damiani
- Médecins Sans Frontières, Operational Center of Brussels, Ixelles, Belgium
| | - Brett Adamson
- Médecins Sans Frontières, Operational Center of Brussels, Ixelles, Belgium
| | - Kathryn C Zoon
- Cytokine Biology Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | | | | | | | - Armand Sprecher
- Médecins Sans Frontières, Operational Center of Brussels, Ixelles, Belgium
| | - Heinz Feldmann
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
| | - Vincent J Munster
- Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rocky Mountain Laboratories, Hamilton, Montana
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16
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de Wit E, Rosenke K, Fischer RJ, Marzi A, Prescott J, Bushmaker T, van Doremalen N, Emery SL, Falzarano D, Feldmann F, Groseth A, Hoenen T, Juma B, McNally KL, Ochieng M, Omballa V, Onyango CO, Owuor C, Rowe T, Safronetz D, Self J, Williamson BN, Zemtsova G, Grolla A, Kobinger G, Rayfield M, Ströher U, Strong JE, Best SM, Ebihara H, Zoon KC, Nichol ST, Nyenswah TG, Bolay FK, Massaquoi M, Feldmann H, Fields B. Ebola Laboratory Response at the Eternal Love Winning Africa Campus, Monrovia, Liberia, 2014-2015. J Infect Dis 2016; 214:S169-S176. [PMID: 27333914 DOI: 10.1093/infdis/jiw216] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
West Africa experienced the first epidemic of Ebola virus infection, with by far the greatest number of cases in Guinea, Sierra Leone, and Liberia. The unprecedented epidemic triggered an unparalleled response, including the deployment of multiple Ebola treatment units and mobile/field diagnostic laboratories. The National Institute of Allergy and Infectious Diseases and the Centers for Disease Control and Prevention deployed a joint laboratory to Monrovia, Liberia, in August 2014 to support the newly founded Ebola treatment unit at the Eternal Love Winning Africa (ELWA) campus. The laboratory operated initially out of a tent structure but quickly moved into a fixed-wall building owing to severe weather conditions, the need for increased security, and the high sample volume. Until May 2015, when the laboratory closed, the site handled close to 6000 clinical specimens for Ebola virus diagnosis and supported the medical staff in case patient management. Laboratory operation and safety, as well as Ebola virus diagnostic assays, are described and discussed; in addition, lessons learned for future deployments are reviewed.
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Affiliation(s)
| | | | | | | | | | | | | | - Shannon L Emery
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Friederike Feldmann
- Rocky Mountain Veterinary Branch, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana
| | | | | | - Bonventure Juma
- Center for Global Health, Division of Global Health Protection, Centers for Disease Control and Prevention
| | | | - Melvin Ochieng
- Kenya Medical Research Institute, Center for Global Health Research, Nairobi
| | - Victor Omballa
- Kenya Medical Research Institute, Center for Global Health Research, Nairobi
| | - Clayton O Onyango
- Center for Global Health, Division of Global Health Protection, Centers for Disease Control and Prevention
| | - Collins Owuor
- Kenya Medical Research Institute, Center for Global Health Research, Nairobi
| | - Thomas Rowe
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Joshua Self
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Galina Zemtsova
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Allen Grolla
- Special Pathogens Program, Public Health Agency of Canada, Winnipeg
| | - Gary Kobinger
- Special Pathogens Program, Public Health Agency of Canada, Winnipeg
| | - Mark Rayfield
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ute Ströher
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James E Strong
- Special Pathogens Program, Public Health Agency of Canada, Winnipeg
| | | | | | - Kathryn C Zoon
- Cytokine Biology Section, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Stuart T Nichol
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Fatorma K Bolay
- Liberian Institute for Biomedical Research, Charlesville, Liberia
| | | | | | - Barry Fields
- Center for Global Health, Division of Global Health Protection, Centers for Disease Control and Prevention
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17
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Nyenswah TG, Fallah M, Calvert GM, Duwor S, Hamilton ED, Mokashi V, Arzoaquoi S, Dweh E, Burbach R, Dlouhy D, Oeltmann JE, Moonan PK. Cluster of Ebola Virus Disease, Bong and Montserrado Counties, Liberia. Emerg Infect Dis 2016; 21:1253-6. [PMID: 26079309 PMCID: PMC4480411 DOI: 10.3201/eid2107.150511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Lack of trust in government-supported services after the death of a health care worker with symptoms of Ebola resulted in ongoing Ebola transmission in 2 Liberia counties. Ebola transmission was facilitated by attempts to avoid cremation of the deceased patient and delays in identifying and monitoring contacts.
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18
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Fallah M, Dahn B, Nyenswah TG, Massaquoi M, Skrip LA, Yamin D, Mbah MN, Joe N, Freeman S, Harris T, Benson Z, Galvani AP. Interrupting Ebola Transmission in Liberia Through Community-Based Initiatives. Ann Intern Med 2016; 164:367-9. [PMID: 26746879 DOI: 10.7326/m15-1464] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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19
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Atkins KE, Pandey A, Wenzel NS, Skrip L, Yamin D, Nyenswah TG, Fallah M, Bawo L, Medlock J, Altice FL, Townsend J, Ndeffo-Mbah ML, Galvani AP. Retrospective Analysis of the 2014-2015 Ebola Epidemic in Liberia. Am J Trop Med Hyg 2016; 94:833-9. [PMID: 26928839 DOI: 10.4269/ajtmh.15-0328] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 12/09/2015] [Indexed: 12/22/2022] Open
Abstract
The 2014-2015 Ebola epidemic has been the most protracted and devastating in the history of the disease. To prevent future outbreaks on this scale, it is imperative to understand the reasons that led to eventual disease control. Here, we evaluated the shifts of Ebola dynamics at national and local scales during the epidemic in Liberia. We used a transmission model calibrated to epidemiological data between June 9 and December 31, 2014, to estimate the extent of community and hospital transmission. We found that despite varied local epidemic patterns, community transmission was reduced by 40-80% in all the counties analyzed. Our model suggests that the tapering of the epidemic was achieved through reductions in community transmission, rather than accumulation of immune individuals through asymptomatic infection and unreported cases. Although the times at which this transmission reduction occurred in the majority of the Liberian counties started before any large expansion in hospital capacity and the distribution of home protection kits, it remains difficult to associate the presence of interventions with reductions in Ebola incidence.
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Affiliation(s)
- Katherine E Atkins
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Abhishek Pandey
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Natasha S Wenzel
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Laura Skrip
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Dan Yamin
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Tolbert G Nyenswah
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Mosoka Fallah
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Luke Bawo
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Jan Medlock
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Frederick L Altice
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Jeffrey Townsend
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Martial L Ndeffo-Mbah
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Alison P Galvani
- Department of Infectious Disease Epidemiology, London School of Hygiene and Public Health, London, United Kingdom; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut; Ministry of Health and Social Welfare, Greater Monrovia, Liberia; Department of Biomedical Sciences, Oregon State University, Corvallis, Oregon; Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut; Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
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20
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Kennedy SB, Neaton JD, Lane HC, Kieh MWS, Massaquoi MBF, Touchette NA, Nason MC, Follmann DA, Boley FK, Johnson MP, Larson G, Kateh FN, Nyenswah TG. Implementation of an Ebola virus disease vaccine clinical trial during the Ebola epidemic in Liberia: Design, procedures, and challenges. Clin Trials 2016; 13:49-56. [PMID: 26768572 DOI: 10.1177/1740774515621037] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The index case of the Ebola virus disease epidemic in West Africa is believed to have originated in Guinea. By June 2014, Guinea, Liberia, and Sierra Leone were in the midst of a full-blown and complex global health emergency. The devastating effects of this Ebola epidemic in West Africa put the global health response in acute focus for urgent international interventions. Accordingly, in October 2014, a World Health Organization high-level meeting endorsed the concept of a phase 2/3 clinical trial in Liberia to study Ebola vaccines. As a follow-up to the global response, in November 2014, the Government of Liberia and the US Government signed an agreement to form a research partnership to investigate Ebola and to assess intervention strategies for treating, controlling, and preventing the disease in Liberia. This agreement led to the establishment of the Joint Liberia-US Partnership for Research on Ebola Virus in Liberia as the beginning of a long-term collaborative partnership in clinical research between the two countries. In this article, we discuss the methodology and related challenges associated with the implementation of the Ebola vaccines clinical trial, based on a double-blinded randomized controlled trial, in Liberia.
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Affiliation(s)
- Stephen B Kennedy
- Liberia-US Clinical Trials Partnership Program, Partnership for Research on Ebola Vaccines in Liberia (PREVAIL), Monrovia, Liberia Incident Management System (IMS), Emergency Operations Center (EoC), Ministry of Health (MoH), Monrovia, Liberia
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - H Clifford Lane
- Division of Clinical Research, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Mark W S Kieh
- Liberia-US Clinical Trials Partnership Program, Partnership for Research on Ebola Vaccines in Liberia (PREVAIL), Monrovia, Liberia
| | - Moses B F Massaquoi
- Liberia-US Clinical Trials Partnership Program, Partnership for Research on Ebola Vaccines in Liberia (PREVAIL), Monrovia, Liberia Incident Management System (IMS), Emergency Operations Center (EoC), Ministry of Health (MoH), Monrovia, Liberia
| | - Nancy A Touchette
- Division of Clinical Research, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Martha C Nason
- Division of Clinical Research, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Dean A Follmann
- Division of Clinical Research, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Fatorma K Boley
- Liberia-US Clinical Trials Partnership Program, Partnership for Research on Ebola Vaccines in Liberia (PREVAIL), Monrovia, Liberia Liberian Institute for Biomedical Research (LIBR), Margibi, Liberia
| | - Melvin P Johnson
- Liberia-US Clinical Trials Partnership Program, Partnership for Research on Ebola Vaccines in Liberia (PREVAIL), Monrovia, Liberia
| | - Gregg Larson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Francis N Kateh
- Incident Management System (IMS), Emergency Operations Center (EoC), Ministry of Health (MoH), Monrovia, Liberia Ministry of Health (MoH), Monrovia, Liberia
| | - Tolbert G Nyenswah
- Incident Management System (IMS), Emergency Operations Center (EoC), Ministry of Health (MoH), Monrovia, Liberia Ministry of Health (MoH), Monrovia, Liberia
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21
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Mate SE, Kugelman JR, Nyenswah TG, Ladner JT, Wiley MR, Cordier-Lassalle T, Christie A, Schroth GP, Gross SM, Davies-Wayne GJ, Shinde SA, Murugan R, Sieh SB, Badio M, Fakoli L, Taweh F, de Wit E, van Doremalen N, Munster VJ, Pettitt J, Prieto K, Humrighouse BW, Ströher U, DiClaro JW, Hensley LE, Schoepp RJ, Safronetz D, Fair J, Kuhn JH, Blackley DJ, Laney AS, Williams DE, Lo T, Gasasira A, Nichol ST, Formenty P, Kateh FN, De Cock KM, Bolay F, Sanchez-Lockhart M, Palacios G. Molecular Evidence of Sexual Transmission of Ebola Virus. N Engl J Med 2015; 373:2448-54. [PMID: 26465384 PMCID: PMC4711355 DOI: 10.1056/nejmoa1509773] [Citation(s) in RCA: 307] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A suspected case of sexual transmission from a male survivor of Ebola virus disease (EVD) to his female partner (the patient in this report) occurred in Liberia in March 2015. Ebola virus (EBOV) genomes assembled from blood samples from the patient and a semen sample from the survivor were consistent with direct transmission. The genomes shared three substitutions that were absent from all other Western African EBOV sequences and that were distinct from the last documented transmission chain in Liberia before this case. Combined with epidemiologic data, the genomic analysis provides evidence of sexual transmission of EBOV and evidence of the persistence of infective EBOV in semen for 179 days or more after the onset of EVD. (Funded by the Defense Threat Reduction Agency and others.).
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Affiliation(s)
- Suzanne E Mate
- From the Center for Genome Sciences (S.E.M., J.R.K., J.T.L., M.R.W., K.P., M.S.-L., G.P.) and Diagnostic Systems Division (R.J.S.), U.S. Army Medical Research Institute of Infectious Diseases, and the Division of Clinical Research, Integrated Research Facility at Fort Detrick, National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH) (J.P., L.E.H., J.H.K.) - all in Frederick, MD; the Ministry of Health and Social Welfare (T.G.N., S.B.S., M.B., F.N.K.) and the World Health Organization (WHO) (G.J.D.-W., R.M.), Monrovia, and the Liberian Institute for Biomedical Research, Charlesville (L.F., F.T., F.B.) - all in Liberia; WHO, Geneva (T.C.-L., A.G., P.F.); the Centers for Disease Control and Prevention, Atlanta (A.C., B.W.H., U.S., D.J.B., A.S.L., D.E.W., T.L., S.T.N., K.M.D.C.); Illumina, San Diego, CA (G.P.S., S.M.G.); WHO, New Delhi, India (S.A.S); Rocky Mountain Laboratories, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Hamilton, MT (E.W., N.D., V.J.M., D.S.); Naval Medical Research Unit 3, Cairo (J.W.D.); and the Foundation Mérieux, Washington, DC (J.F.)
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22
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Kobayashi M, Beer KD, Bjork A, Chatham-Stephens K, Cherry CC, Arzoaquoi S, Frank W, Kumeh O, Sieka J, Yeiah A, Painter JE, Yoder JS, Flannery B, Mahoney F, Nyenswah TG. Community Knowledge, Attitudes, and Practices Regarding Ebola Virus Disease - Five Counties, Liberia, September-October, 2014. MMWR Morb Mortal Wkly Rep 2015; 64:714-8. [PMID: 26158352 PMCID: PMC4584843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
As of July 1, 2015, Guinea, Liberia, and Sierra Leone have reported a total of 27,443 confirmed, probable, and suspected Ebola virus disease (Ebola) cases and 11,220 deaths. Guinea and Sierra Leone have yet to interrupt transmission of Ebola virus. In January, 2016, Liberia successfully achieved Ebola transmission-free status, with no new Ebola cases occurring during a 42-day period; however, new Ebola cases were reported beginning June 29, 2015. Local cultural practices and beliefs have posed challenges to disease control, and therefore, targeted, timely health messages are needed to address practices and misperceptions that might hinder efforts to stop the spread of Ebola. As early as September 2014, Ebola spread to most counties in Liberia. To assess Ebola-related knowledge, attitudes, and practices (KAP) in the community, CDC epidemiologists who were deployed to the counties (field team), carried out a survey conducted by local trained interviewers. The survey was conducted in September and October 2014 in five counties in Liberia with varying cumulative incidence of Ebola cases. Survey results indicated several findings. First, basic awareness of Ebola was high across all surveyed populations (median correct responses = 16 of 17 questions on knowledge of Ebola transmission; range = 2-17). Second, knowledge and understanding of Ebola symptoms were incomplete (e.g., 61% of respondents said they would know if they had Ebola symptoms). Finally, certain fears about the disease were present: >90% of respondents indicated a fear of Ebola patients, >40% a fear of cured patients, and >50% a fear of treatment units (expressions of this last fear were greater in counties with lower Ebola incidence). This survey, which was conducted at a time when case counts were rapidly increasing in Liberia, indicated limited knowledge of Ebola symptoms and widespread fear of Ebola treatment units despite awareness of communication messages. Continued efforts are needed to address cultural practices and beliefs to interrupt Ebola transmission.
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Affiliation(s)
- Miwako Kobayashi
- Epidemic Intelligence Service, CDC,National Center for Immunization and Respiratory Diseases, CDC,Corresponding author: Miwako Kobayashi, , 404-639-2912
| | - Karlyn D. Beer
- Epidemic Intelligence Service, CDC,National Center for Emerging and Zoonotic Infectious Diseases, CDC
| | - Adam Bjork
- Division of Global HIV/AIDS, Center for Global Health
| | | | - Cara C. Cherry
- Epidemic Intelligence Service, CDC,National Park Service, Biological Resources Division, Wildlife Health Branch/Office of Public Health, Fort Collins, Colorado
| | | | | | | | | | | | - Julia E. Painter
- Epidemic Intelligence Service, CDC,National Center for Emerging and Zoonotic Infectious Diseases, CDC
| | | | | | - Frank Mahoney
- Global Immunization Division, Center for Global Health, CDC
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23
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Christie A, Davies-Wayne GJ, Cordier-Lasalle T, Blackley DJ, Laney AS, Williams DE, Shinde SA, Badio M, Lo T, Mate SE, Ladner JT, Wiley MR, Kugelman JR, Palacios G, Holbrook MR, Janosko KB, de Wit E, van Doremalen N, Munster VJ, Pettitt J, Schoepp RJ, Verhenne L, Evlampidou I, Kollie KK, Sieh SB, Gasasira A, Bolay F, Kateh FN, Nyenswah TG, De Cock KM. Possible sexual transmission of Ebola virus - Liberia, 2015. MMWR Morb Mortal Wkly Rep 2015; 64:479-81. [PMID: 25950255 PMCID: PMC4584553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
On March 20, 2015, 30 days after the most recent confirmed Ebola Virus Disease (Ebola) patient in Liberia was isolated, Ebola was laboratory confirmed in a woman in Monrovia. The investigation identified only one epidemiologic link to Ebola: unprotected vaginal intercourse with a survivor. Published reports from previous outbreaks have demonstrated Ebola survivors can continue to harbor virus in immunologically privileged sites for a period of time after convalescence. Ebola virus has been isolated from semen as long as 82 days after symptom onset and viral RNA has been detected in semen up to 101 days after symptom onset. One instance of possible sexual transmission of Ebola has been reported, although the accompanying evidence was inconclusive. In addition, possible sexual transmission of Marburg virus, a filovirus related to Ebola, was documented in 1968. This report describes the investigation by the Government of Liberia and international response partners of the source of Liberia's latest Ebola case and discusses the public health implications of possible sexual transmission of Ebola virus. Based on information gathered in this investigation, CDC now recommends that contact with semen from male Ebola survivors be avoided until more information regarding the duration and infectiousness of viral shedding in body fluids is known. If male survivors have sex (oral, vaginal, or anal), a condom should be used correctly and consistently every time.
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Affiliation(s)
| | | | | | | | | | | | | | - Moses Badio
- Ministry of Health and Social Welfare, Liberia
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24
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Wells C, Yamin D, Ndeffo-Mbah ML, Wenzel N, Gaffney SG, Townsend JP, Meyers LA, Fallah M, Nyenswah TG, Altice FL, Atkins KE, Galvani AP. Harnessing case isolation and ring vaccination to control Ebola. PLoS Negl Trop Dis 2015; 9:e0003794. [PMID: 26024528 PMCID: PMC4449200 DOI: 10.1371/journal.pntd.0003794] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 04/28/2015] [Indexed: 01/08/2023] Open
Abstract
As a devastating Ebola outbreak in West Africa continues, non-pharmaceutical control measures including contact tracing, quarantine, and case isolation are being implemented. In addition, public health agencies are scaling up efforts to test and deploy candidate vaccines. Given the experimental nature and limited initial supplies of vaccines, a mass vaccination campaign might not be feasible. However, ring vaccination of likely case contacts could provide an effective alternative in distributing the vaccine. To evaluate ring vaccination as a strategy for eliminating Ebola, we developed a pair approximation model of Ebola transmission, parameterized by confirmed incidence data from June 2014 to January 2015 in Liberia and Sierra Leone. Our results suggest that if a combined intervention of case isolation and ring vaccination had been initiated in the early fall of 2014, up to an additional 126 cases in Liberia and 560 cases in Sierra Leone could have been averted beyond case isolation alone. The marginal benefit of ring vaccination is predicted to be greatest in settings where there are more contacts per individual, greater clustering among individuals, when contact tracing has low efficacy or vaccination confers post-exposure protection. In such settings, ring vaccination can avert up to an additional 8% of Ebola cases. Accordingly, ring vaccination is predicted to offer a moderately beneficial supplement to ongoing non-pharmaceutical Ebola control efforts.
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Affiliation(s)
- Chad Wells
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America,
| | - Dan Yamin
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America,
| | - Martial L. Ndeffo-Mbah
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America,
| | - Natasha Wenzel
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America,
| | - Stephen G. Gaffney
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, United States of America,
| | - Jeffrey P. Townsend
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, United States of America,
- Program in Computational Biology and Bioinformatics, Yale University, New Haven, Connecticut, United States of America,
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, Connecticut, United States of America,
| | - Lauren Ancel Meyers
- Department of Integrative Biology, University of Texas at Austin, Austin, Texas, United States of America,
- Santa Fe Institute, Santa Fe, New Mexico, United States of America,
| | - Mosoka Fallah
- Ministry of Health and Social Welfare, Monrovia, Liberia,
| | | | - Frederick L. Altice
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, United States of America,
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America,
| | - Katherine E. Atkins
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America,
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alison P. Galvani
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut, United States of America,
- Program in Computational Biology and Bioinformatics, Yale University, New Haven, Connecticut, United States of America,
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, Connecticut, United States of America,
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America,
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25
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Yamin D, Gertler S, Ndeffo-Mbah ML, Skrip LA, Fallah M, Nyenswah TG, Altice FL, Galvani AP. Effect of Ebola progression on transmission and control in Liberia. Ann Intern Med 2015; 162:11-7. [PMID: 25347321 PMCID: PMC4402942 DOI: 10.7326/m14-2255] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The Ebola outbreak that is sweeping across West Africa is the largest, most volatile, and deadliest Ebola epidemic ever recorded. Liberia is the most profoundly affected country, with more than 3500 infections and 2000 deaths recorded in the past 3 months. OBJECTIVE To evaluate the contribution of disease progression and case fatality on transmission and to examine the potential for targeted interventions to eliminate the disease. DESIGN Stochastic transmission model that integrates epidemiologic and clinical data on incidence and case fatality, daily viral load among survivors and nonsurvivors evaluated on the basis of the 2000-2001 outbreak in Uganda, and primary data on contacts of patients with Ebola in Liberia. SETTING Montserrado County, Liberia, July to September 2014. MEASUREMENTS Ebola incidence and case-fatality records from 2014 Liberian Ministry of Health and Social Welfare. RESULTS The average number of secondary infections generated throughout the entire infectious period of a single infected case, R, was estimated as 1.73 (95% CI, 1.66 to 1.83). There was substantial stratification between survivors (RSurvivors), for whom the estimate was 0.66 (CI, 0.10 to 1.69), and nonsurvivors (RNonsurvivors), for whom the estimate was 2.36 (CI, 1.72 to 2.80). The nonsurvivors had the highest risk for transmitting the virus later in the course of disease progression. Consequently, the isolation of 75% of infected individuals in critical condition within 4 days from symptom onset has a high chance of eliminating the disease. LIMITATION Projections are based on the initial dynamics of the epidemic, which may change as the outbreak and interventions evolve. CONCLUSION These results underscore the importance of isolating the most severely ill patients with Ebola within the first few days of their symptomatic phase. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Dan Yamin
- From Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, and Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Shai Gertler
- From Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, and Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Martial L. Ndeffo-Mbah
- From Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, and Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Laura A. Skrip
- From Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, and Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Mosoka Fallah
- From Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, and Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Tolbert G. Nyenswah
- From Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, and Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Frederick L. Altice
- From Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, and Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Alison P. Galvani
- From Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, and Ministry of Health and Social Welfare, Monrovia, Liberia
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26
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Summers A, Nyenswah TG, Montgomery JM, Neatherlin J, Tappero JW. Challenges in responding to the ebola epidemic - four rural counties, Liberia, August-November 2014. MMWR Morb Mortal Wkly Rep 2014; 63:1202-4. [PMID: 25522089 PMCID: PMC5779531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The first cases of Ebola virus disease (Ebola) in West Africa were identified in Guinea on March 22, 2014. On March 30, the first Liberian case was identified in Foya Town, Lofa County, near the Guinean border. Because the majority of early cases occurred in Lofa and Montserrado counties, resources were concentrated in these counties during the first several months of the response, and these counties have seen signs of successful disease control. By October 2014, the epidemic had reached all 15 counties of Liberia. During August 27-September 10, 2014, CDC in collaboration with the Liberian Ministry of Health and Social Welfare assessed county Ebola response plans in four rural counties (Grand Cape Mount, Grand Bassa, Rivercess, and Sinoe, to identify county-specific challenges in executing their Ebola response plans, and to provide recommendations and training to enhance control efforts. Assessments were conducted through interviews with county health teams and health care providers and visits to health care facilities. At the time of assessment, county health teams reported lacking adequate training in core Ebola response strategies and reported facing many challenges because of poor transportation and communication networks. Development of communication and transportation network strategies for communities with limited access to roads and limited means of communication in addition to adequate training in Ebola response strategies is critical for successful management of Ebola in remote areas.
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Affiliation(s)
- Aimee Summers
- Epidemic Intelligence Service,Division of Global Health Protection, Center for Global Health, CDC,Corresponding authors: Aimee Summers, , 770-488-3619; Tolbert G. Nyenswah, , +231 88 655 8612
| | - Tolbert G. Nyenswah
- Liberian Ministry of Health and Social Welfare,Corresponding authors: Aimee Summers, , 770-488-3619; Tolbert G. Nyenswah, , +231 88 655 8612
| | - Joel M. Montgomery
- Division of Global Health Protection, Center for Global Health, CDC,CDC Kenya, Center for Global Health, CDC
| | - John Neatherlin
- Division of Global Health Protection, Center for Global Health, CDC,CDC Kenya, Center for Global Health, CDC
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27
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Nyenswah TG, Westercamp M, Kamali AA, Qin J, Zielinski-Gutierrez E, Amegashie F, Fallah M, Gergonne B, Nugba-Ballah R, Singh G, Aberle-Grasse JM, Havers F, Montgomery JM, Bawo L, Wang SA, Rosenberg R. Evidence for declining numbers of Ebola cases--Montserrado County, Liberia, June-October 2014. MMWR Morb Mortal Wkly Rep 2014; 63:1072-6. [PMID: 25412066 PMCID: PMC5779509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The epidemic of Ebola virus disease (Ebola) in West Africa that began in March 2014 has caused approximately 13,200 suspected, probable, and confirmed cases, including approximately 6,500 in Liberia. About 50% of Liberia's reported cases have been in Montserrado County (population 1.5 million), the most populous county, which contains the capital city, Monrovia. To examine the course of the Ebola epidemic in Montserrado County, data on Ebola treatment unit (ETU) admissions, laboratory testing of patient blood samples, and collection of dead bodies were analyzed. Each of the three data sources indicated consistent declines of 53%-73% following a peak incidence in mid-September. The declines in ETU admissions, percentage of patients with reverse transcription-polymerase chain reaction (RT-PCR) test results positive for Ebola, and dead bodies are the first evidence of reduction in disease after implementation of multiple prevention and response measures. The possible contributions of these interventions to the decline is not yet fully understood or corroborated. A reduction in cases suggests some progress; however, eliminating Ebola transmission is the critical goal and will require greatly intensified efforts for complete, high-quality surveillance to direct and drive the rapid intervention, tracking, and response efforts that remain essential.
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Affiliation(s)
| | - Matthew Westercamp
- National Center for Immunization and Respiratory Diseases, CDC,Epidemic Intelligence Service, CDC,Corresponding author: Matthew Westercamp, , 404-639-4849
| | | | - Jin Qin
- Epidemic Intelligence Service, CDC,National Center for Chronic Disease Prevention and Health Promotion, CDC
| | | | - Fred Amegashie
- Liberia Ministry of Health and Social Welfare,Montserrado County Community Health Department
| | | | | | | | - Gurudev Singh
- International Federation of Red Cross and Red Crescent Societies
| | | | - Fiona Havers
- National Center for Immunization and Respiratory Diseases, CDC
| | | | - Luke Bawo
- Liberia Ministry of Health and Social Welfare
| | | | - Ronald Rosenberg
- National Center for Emerging and Zoonotic Infectious Diseases, CDC
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28
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Abstract
The ongoing Ebola outbreak poses an alarming risk to the countries of West Africa and beyond. To assess the effectiveness of containment strategies, we developed a stochastic model of Ebola transmission between and within the general community, hospitals, and funerals, calibrated to incidence data from Liberia. We find that a combined approach of case isolation, contact-tracing with quarantine, and sanitary funeral practices must be implemented with utmost urgency in order to reverse the growth of the outbreak. As of 19 September, under status quo, our model predicts that the epidemic will continue to spread, generating a predicted 224 (134 to 358) daily cases by 1 December, 280 (184 to 441) by 15 December, and 348 (249 to 545) by 30 December.
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Affiliation(s)
- Abhishek Pandey
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA
| | - Katherine E Atkins
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA. Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Jan Medlock
- Department of Biomedical Sciences, Oregon State University, Corvallis, OR, USA
| | - Natasha Wenzel
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA
| | - Jeffrey P Townsend
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - James E Childs
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | | | - Martial L Ndeffo-Mbah
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA
| | - Alison P Galvani
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA. Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
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29
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Lewnard JA, Ndeffo Mbah ML, Alfaro-Murillo JA, Altice FL, Bawo L, Nyenswah TG, Galvani AP. Dynamics and control of Ebola virus transmission in Montserrado, Liberia: a mathematical modelling analysis. Lancet Infect Dis 2014; 14:1189-95. [PMID: 25455986 DOI: 10.1016/s1473-3099(14)70995-8] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A substantial scale-up in public health response is needed to control the unprecedented Ebola virus disease (EVD) epidemic in west Africa. Current international commitments seek to expand intervention capacity in three areas: new EVD treatment centres, case ascertainment through contact tracing, and household protective kit allocation. We aimed to assess how these interventions could be applied individually and in combination to avert future EVD cases and deaths. METHODS We developed a transmission model of Ebola virus that we fitted to reported EVD cases and deaths in Montserrado County, Liberia. We used this model to assess the effectiveness of expanding EVD treatment centres, increasing case ascertainment, and allocating protective kits for controlling the outbreak in Montserrado. We varied the efficacy of protective kits from 10% to 50%. We compared intervention initiation on Oct 15, 2014, Oct 31, 2014, and Nov 15, 2014. The status quo intervention was defined in terms of case ascertainment and capacity of EVD treatment centres on Sept 23, 2014, and all behaviour and contact patterns relevant to transmission as they were occurring at that time. The primary outcome measure was the expected number of cases averted by Dec 15, 2014. FINDINGS We estimated the basic reproductive number for EVD in Montserrado to be 2·49 (95% CI 2·38-2·60). We expect that allocating 4800 additional beds at EVD treatment centres and increasing case ascertainment five-fold in November, 2014, can avert 77 312 (95% CI 68 400-85 870) cases of EVD relative to the status quo by Dec 15, 2014. Complementing these measures with protective kit allocation raises the expectation as high as 97 940 (90 096-105 606) EVD cases. If deployed by Oct 15, 2014, equivalent interventions would have been expected to avert 137 432 (129 736-145 874) cases of EVD. If delayed to Nov 15, 2014, we expect the interventions will at best avert 53 957 (46 963-60 490) EVD cases. INTERPRETATION The number of beds at EVD treatment centres needed to effectively control EVD in Montserrado substantially exceeds the 1700 pledged by the USA to west Africa. Accelerated case ascertainment is needed to maximise effectiveness of expanding the capacity of EVD treatment centres. Distributing protective kits can further augment prevention of EVD, but it is not an adequate stand-alone measure for controlling the outbreak. Our findings highlight the rapidly closing window of opportunity for controlling the outbreak and averting a catastrophic toll of EVD cases and deaths. FUNDING US National Institutes of Health.
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Affiliation(s)
- Joseph A Lewnard
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA
| | - Martial L Ndeffo Mbah
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA
| | - Jorge A Alfaro-Murillo
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA
| | - Frederick L Altice
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Infectious Diseases Section, Yale University School of Medicine, New Haven, CT, USA
| | - Luke Bawo
- Ministry of Health and Social Welfare, Monrovia, Liberia
| | | | - Alison P Galvani
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA.
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30
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Forrester JD, Hunter JC, Pillai SK, Arwady MA, Ayscue P, Matanock A, Monroe B, Schafer IJ, Nyenswah TG, De Cock KM. Cluster of Ebola cases among Liberian and U.S. health care workers in an Ebola treatment unit and adjacent hospital -- Liberia, 2014. MMWR Morb Mortal Wkly Rep 2014; 63:925-9. [PMID: 25321070 PMCID: PMC4584750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The ongoing Ebola virus disease (Ebola) epidemic in West Africa, like previous Ebola outbreaks, has been characterized by amplification in health care settings and increased risk for health care workers (HCWs), who often do not have access to appropriate personal protective equipment. In many locations, Ebola treatment units (ETUs) have been established to optimize care of patients with Ebola while maintaining infection control procedures to prevent transmission of Ebola virus. These ETUs are considered essential to containment of the epidemic. In July 2014, CDC assisted the Ministry of Health and Social Welfare of Liberia in investigating a cluster of five Ebola cases among HCWs who became ill while working in an ETU, an adjacent general hospital, or both. No common source of exposure or chain of transmission was identified. However, multiple opportunities existed for transmission of Ebola virus to HCWs, including exposure to patients with undetected Ebola in the hospital, inadequate use of personal protective equipment during cleaning and disinfection of environmental surfaces in the hospital, and potential transmission from an ill HCW to another HCW. No evidence was found of a previously unrecognized mode of transmission. Prevention recommendations included reinforcement of existing infection control guidance for both ETUs and general medical care settings, including measures to prevent cross-transmission in co-located facilities.
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Affiliation(s)
- Joseph D. Forrester
- Epidemic Intelligence Service, National Center for Emerging and Zoonotic Infectious Disease,Corresponding author: Joseph D. Forrester, , 970-266-3587
| | - Jennifer C. Hunter
- Epidemic Intelligence Service, National Center for Emerging and Zoonotic Infectious Disease
| | - Satish K. Pillai
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Disease
| | - M. Allison Arwady
- Epidemic Intelligence Service, National Center for Emerging and Zoonotic Infectious Disease
| | - Patrick Ayscue
- Epidemic Intelligence Service, National Center for Emerging and Zoonotic Infectious Disease
| | - Almea Matanock
- Epidemic Intelligence Service, National Center for Emerging and Zoonotic Infectious Disease
| | - Ben Monroe
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Disease
| | - Ilana J. Schafer
- Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Library Services, CDC
| | | | - Kevin M. De Cock
- CDC Kenya,Division of Global HIV/AIDS, Center for Global Health, CDC
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Forrester JD, Pillai SK, Beer KD, Bjork A, Neatherlin J, Massaquoi M, Nyenswah TG, Montgomery JM, De Cock K. Assessment of ebola virus disease, health care infrastructure, and preparedness - four counties,Southeastern Liberia, august 2014. MMWR Morb Mortal Wkly Rep 2014; 63:891-3. [PMID: 25299605 PMCID: PMC4584611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ebola virus disease (Ebola) is a multisystem disease caused by a virus of the genus Ebolavirus. In late March 2014, Ebola cases were described in Liberia, with epicenters in Lofa County and later in Montserrado County. While information about case burden and health care infrastructure was available for the two epicenters, little information was available about remote counties in southeastern Liberia. Over 9 days, August 6-14, 2014, Ebola case burden, health care infrastructure, and emergency preparedness were assessed in collaboration with the Liberian Ministry of Health and Social Welfare in four counties in southeastern Liberia: Grand Gedeh, Grand Kru, River Gee, and Maryland. Data were collected by health care facility visits to three of the four county referral hospitals and by unstructured interviews with county and district health officials, hospital administrators, physicians, nurses, physician assistants, and health educators in all four counties. Local burial practices were discussed with county officials, but no direct observation of burial practices was conducted. Basic information about Ebola surveillance and epidemiology, case investigation, contact tracing, case management, and infection control was provided to local officials.
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Affiliation(s)
- Joseph D. Forrester
- Epidemic Intelligence Service,Corresponding author: Joseph D. Forrester, , 970-266-3587
| | - Satish K. Pillai
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Disease
| | | | - Adam Bjork
- Division of Global HIV/AIDS, Center for Global Health
| | - John Neatherlin
- Division of Global Health Protection, Center for Global Health,CDC Kenya, Center for Global Health, CDC
| | | | | | - Joel M. Montgomery
- Division of Global Health Protection, Center for Global Health,CDC Kenya, Center for Global Health, CDC
| | - Kevin De Cock
- Division of Global HIV/AIDS, Center for Global Health,CDC Kenya, Center for Global Health, CDC
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