Mosoka Fallah

Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola

Harvard Global Health Institute (Prof A Jha MD, S Moon PhD, L R Woskie MSc, J A Leigh MPH), Harvard T.H. Chan School of Public Health (Prof A K Jha, S Moon, L R Woskie, J A Leigh), and Harvard Kennedy School (S Moon), Harvard University, Boston, MA, USA; University of Edinburgh Medical School, Edinburgh (Prof D Sridhar DPhil); Duke Global Health Institute, Durham, NC, USA (M A Pate MD); Bill, Hillary & Chelsea Clinton Foundation, New York, NY, USA (C Clinton DPhil); Medecins Sans Frontieres, New York , NY, USA (S Delaunay MA); Campaign for Good Governance, Freetown, Sierra Leone (V Edwin MA); Action Contre La Faim International , Monrovia, Liberia (M Fallah PhD); Indiana University Maurer School of Law, Bloomington, IN, USA (Prof D P Fidler JD); Council on Foreign Relations, New York, NY, USA (L Garrett PhD); University of California, San Francisco, CA, USA (Prof E Goosby MD); Georgetown University, Washington, DC, USA (Prof L Gostin JD); Chatham House, London, UK (Prof D L Heymann MD); Simon Fraser University, Burnaby, BC, Canada (Prof K Lee DPhil); Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China (Prof G M Leung MD); Center for Strategic and International Studies, Washington DC, USA (J S Morrison PhD); AIDS Executive summary The west African Ebola epidemic that began in 2013 exposed deep inadequacies in the national and international institutions responsible for protecting the public from the far-reaching human, social, economic, and political consequences of infectious disease outbreaks. The Ebola epidemic raised a crucial question: what reforms are needed to mend the fragile global system for outbreak prevention and response, rebuild confi dence, and prevent future disasters? To address this question, the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine jointly launched the Independent Panel on the Global Response to Ebola. Panel members from academia, think tanks, and civil society have collectively reviewed the worldwide response to the Ebola outbreak. After diffi cult and lengthy deliberation, we concluded that major reforms are both warranted and feasible. The Panel’s conclusions off er a roadmap of ten interrelated recommendations across four thematic areas:

Effect of Ebola Progression on Transmission and Control in Liberia

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.

Community-Centered Responses to Ebola in Urban Liberia: The View from Below

Background The West African Ebola epidemic has demonstrated that the existing range of medical and epidemiological responses to emerging disease outbreaks is insufficient, especially in post-conflict contexts with exceedingly poor healthcare infrastructures. In this context, community-based responses have proven vital for containing Ebola virus disease (EVD) and shifting the epidemic curve. Despite a surge in interest in local innovations that effectively contained the epidemic, the mechanisms for community-based response remain unclear. This study provides baseline information on community-based epidemic control priorities and identifies innovative local strategies for containing EVD in Liberia. Methodology/Principal Findings This study was conducted in September 2014 in 15 communities in Monrovia and Montserrado County, Liberia – one of the epicenters of the Ebola outbreak. Findings from 15 focus group discussions with 386 community leaders identified strategies being undertaken and recommendations for what a community-based response to Ebola should look like under then-existing conditions. Data were collected on the following topics: prevention, surveillance, care-giving, community-based treatment and support, networks and hotlines, response teams, Ebola treatment units (ETUs) and hospitals, the management of corpses, quarantine and isolation, orphans, memorialization, and the need for community-based training and education. Findings have been presented as community-based strategies and recommendations for (1) prevention, (2) treatment and response, and (3) community sequelae and recovery. Several models for community-based management of the current Ebola outbreak were proposed. Additional findings indicate positive attitudes towards early Ebola survivors, and the need for community-based psychosocial support. Conclusions/Significance Local communities’ strategies and recommendations give insight into how urban Liberian communities contained the EVD outbreak while navigating the systemic failures of the initial state and international response. Communities in urban Liberia adapted to the epidemic using multiple coping strategies. In the absence of health, infrastructural and material supports, local people engaged in self-reliance in order to contain the epidemic at the micro-social level. These innovations were regarded as necessary, but as less desirable than a well-supported health-systems based response; and were seen as involving considerable individual, social, and public health costs, including heightened vulnerability to infection.

Reduced evolutionary rate in reemerged Ebola virus transmission chains.

Surveillance of Ebola virus disease flare-ups uncovers a reduced rate of Ebola virus evolution during persistent infections. On 29 June 2015, Liberia’s respite from Ebola virus disease (EVD) was interrupted for the second time by a renewed outbreak (“flare-up”) of seven confirmed cases. We demonstrate that, similar to the March 2015 flare-up associated with sexual transmission, this new flare-up was a reemergence of a Liberian transmission chain originating from a persistently infected source rather than a reintroduction from a reservoir or a neighboring country with active transmission. Although distinct, Ebola virus (EBOV) genomes from both flare-ups exhibit significantly low genetic divergence, indicating a reduced rate of EBOV evolution during persistent infection. Using this rate of change as a signature, we identified two additional EVD clusters that possibly arose from persistently infected sources. These findings highlight the risk of EVD flare-ups even after an outbreak is declared over.

Ebola and Its Control in Liberia, 2014–2015

Several factors explain the successful response to the outbreak in this country.

Ebola interventions: listen to communities

In late November, 2014, Liberia’s Ministry of Health and World Health Organization (WHO) Liberia did a rapid qualitative assessment (supported by the World Bank) of the perceptions of selected communities in Monrovia on an incentive scheme that intends to increase the reporting of EVD cases. Participants from various groups living in Monrovia were invited to participate in focus-group discussions: contact tracers, active case finders, community leaders, young people, and women. Participants argued that the following pressing problems have to be solved in order to curb the disease: 1) Provide food for families in quarantine. Although there are steps in place to provide all contacts with food while under follow-up, a substantial number of families who are quarantined do not receive food or they receive it late. It forces families to break the quarantine to buy food. (2) Enable reliable communication between Ebola treatment units and the families of the sick. Families are often not informed to which unit their loved ones are taken or what the condition of their relative is. People see the treatment units as “black holes” where loved ones disappear. (3) Restore and improve basic health services. Very few clinics and hospitals are operational; pregnant women especially are often rejected when they attend for delivery. (4) Provide psychosocial support to families of EVD patients. Supporting families who have lost loved ones should be an essential part of care in any Ebola response. (5) Include Ebola survivors in the teams of active case finders and contact tracers. The investigation revealed some important information from the demand side on how to make sure active case finding and community based EVD interventions work.

Post-Ebola reforms: ample analysis, inadequate action

Reports on the response to Ebola broadly agree on what needs to be done to deal with disease outbreaks. But Suerie Moon and colleagues find that the world is not yet prepared for future outbreaks

Quantifying Poverty as a Driver of Ebola Transmission

Background Poverty has been implicated as a challenge in the control of the current Ebola outbreak in West Africa. Although disparities between affected countries have been appreciated, disparities within West African countries have not been investigated as drivers of Ebola transmission. To quantify the role that poverty plays in the transmission of Ebola, we analyzed heterogeneity of Ebola incidence and transmission factors among over 300 communities, categorized by socioeconomic status (SES), within Montserrado County, Liberia. Methodology/Principal Findings We evaluated 4,437 Ebola cases reported between February 28, 2014 and December 1, 2014 for Montserrado County to determine SES-stratified temporal trends and drivers of Ebola transmission. A dataset including dates of symptom onset, hospitalization, and death, and specified community of residence was used to stratify cases into high, middle and low SES. Additionally, information about 9,129 contacts was provided for a subset of 1,585 traced individuals. To evaluate transmission within and across socioeconomic subpopulations, as well as over the trajectory of the outbreak, we analyzed these data with a time-dependent stochastic model. Cases in the most impoverished communities reported three more contacts on average than cases in high SES communities (p<0.001). Our transmission model shows that infected individuals from middle and low SES communities were associated with 1.5 (95% CI: 1.4–1.6) and 3.5 (95% CI: 3.1–3.9) times as many secondary cases as those from high SES communities, respectively. Furthermore, most of the spread of Ebola across Montserrado County originated from areas of lower SES. Conclusions/Significance Individuals from areas of poverty were associated with high rates of transmission and spread of Ebola to other regions. Thus, Ebola could most effectively be prevented or contained if disease interventions were targeted to areas of extreme poverty and funding was dedicated to development projects that meet basic needs.

Harnessing Case Isolation and Ring Vaccination to Control Ebola

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.

Psychological Distress among Ebola Survivors Discharged from an Ebola Treatment Unit in Monrovia, Liberia - A Qualitative Study

Introduction A consequence of the West Africa Ebola outbreak 2014–2015 was the unprecedented number of Ebola survivors discharged from the Ebola Treatment Units (ETUs). Liberia alone counted over 5,000 survivors. We undertook a qualitative study in Monrovia to better understand the mental distress experienced by survivors during hospitalization and reintegration into their community. Methods Purposively selected Ebola survivors from ELWA3, the largest ETU in Liberia, were invited to join focus group discussions. Verbal-informed consent was sought. Three focus groups with a total of 17 participants were conducted between February and April 2015. Thematic analysis approach was applied to analyze the data. Results The main stressors inside the ETU were the daily exposure to corpses, which often remained several hours among the living; the patients’ isolation from their families and worries about their well-being; and sometimes, the perception of disrespect by ETU staff. However, most survivors reported how staff motivated patients to drink, eat, bathe, and walk. Additionally, employing survivors as staff fostered hope, calling patients by their name increased confidence and familiarity, and organizing prayer and singing activities brought comfort. When Ebola virus disease survivors returned home, the experience of being alive was both a gift and a burden. Flashbacks were common among survivors. Perceived as contagious, many were excluded from their family, professional, and social life. Some survivors faced divorce, were driven out of their houses, or lost their jobs. The subsequent isolation prevented survivors from picking up daily life, and the multiple losses affected their coping mechanisms. However, when available, the support of family, friends, and prayer enabled survivors to cope with their mental distress. For those excluded from society, psychosocial counseling and the survivor’s network were ways to give a meaning to life post-Ebola. Conclusion Exposure to death in the ETU and stigma in the communities induced posttraumatic stress reactions and symptoms of depression among Ebola survivors. Distress in the ETU can be reduced through timely management of corpses. Coping mechanisms can be strengthened through trust relationships, religion, peer/community support, and community-based psychosocial care. Mental health disorders need to be addressed with appropriate specialized care and follow-up.