Successful Control of Ebola Virus Disease: Analysis of Service Based Data from Rural Sierra Leone

Introduction

The scale and geographical distribution of the current outbreak in West Africa raised doubts as to the effectiveness of established methods of control. Ebola Virus Disease (EVD) was first detected in Sierra Leone in May 2014 in Kailahun district. Despite high case numbers elsewhere in the country, transmission was eliminated in the district by December 2014. We describe interventions underpinning successful EVD control in Kailahun and implications for EVD control in other areas.

Methods

Internal service data and published reports from response agencies were analysed to describe the structure and type of response activities, EVD case numbers and epidemic characteristics. This included daily national situation reports and District-level data and reports of the Sierra Leone Ministry of Health and Sanitation, and Médecins Sans Frontières (MSF) patient data and internal epidemiological reports. We used EVD case definitions provided by the World Health Organisation over the course of the outbreak. Characteristics assessed included level of response activities and epidemiological features such as reported exposure (funeral-related or not), time interval between onset of illness and admission to the EVD Management Centre (EMC), work-related exposures (health worker or not) and mortality. We compared these characteristics between two time periods—June to July (the early period of response), and August to December (when coverage and quality of response had improved). A stochastic model was used to predict case numbers per generation with different numbers of beds and a varying percentage of community cases detected.

Results

There were 652 probable/confirmed EVD cases from June-December 2014 in Kailahun. An EMC providing patient care opened in June. By August 2014 an integrated detection, treatment, and prevention strategy was in place across the district catchment zone. From June-July to August-December 2014 surveillance and contact tracing staff increased from 1.0 to 8.8 per confirmed EVD case, EMC capacity increased from 32 to 100 beds, the number of burial teams doubled, and health promotion activities increased in coverage. These improvements in response were associated with the following changes between the same periods: the proportion of confirmed/probable cases admitted to the EMC increased from 35% to 83% (χ² p-value<0·001), the proportion of confirmed patients admitted to the EMC <3 days of symptom onset increased from 19% to 37% (χ² p-value <0·001), and reported funeral contact in those admitted decreased from 33% to 16% (χ² p-value <0·001). Mathematical modelling confirmed the importance of both patient management capacity and surveillance and contact tracing for EVD control.

Discussion

Our findings demonstrate that control of EVD can be achieved using established interventions based on identification and appropriate management of those who are at risk of and develop EVD, including in the context of ongoing transmission in surrounding regions. Key attributes in achieving control were sufficient patient care capacity (including admission to specialist facilities of suspect and probable cases for assessment), integrated with adequate staffing and resourcing of community-based case detection and prevention activities. The response structure and coverage targets we present are of value in informing effective control in current and future EVD outbreaks.

Ebola Virus Disease (EVD) is a severe illness that is usually spread from person to person through caring for someone who is sick, or if they die, contact with their body during their funeral. The recent EVD outbreak in West Africa caused illness and death in many thousands in Guinea, Sierra Leone and Liberia. It has been the largest and most difficult to control of any EVD outbreak in history, and this led to doubts as to the effectiveness of established control measures. Our study describes the successful control of EVD in a rural district of Sierra Leone. As in previous outbreaks, we found that control was achieved by working with communities to identify people who may have been exposed to EVD; if they then became sick, their early admission for testing and care to specialised centres that have equipment and procedures to prevent EVD passing on to staff or other patients, and safe burial of those who die of EVD by trained workers with appropriate protective equipment. We describe the resources and response structure needed to implement such measures effectively, information that will assist in controlling future outbreaks.