Abstract
Between March 2014 and July 2015 at least 10,500 Ebola cases including more than 4,800 deaths occurred in Liberia, the majority in Monrovia. However, official numbers may have underestimated the size of the outbreak. Closure of health facilities and mistrust in existing structures may have additionally impacted on all-cause morbidity and mortality. To quantify mortality and morbidity and describe health-seeking behaviour in Monrovia, Médecins sans Frontières (MSF) conducted a mobile phone survey from December 2014 to March 2015. We drew a random sample of households in Monrovia and conducted structured mobile phone interviews, covering morbidity, mortality and health-seeking behaviour from 14 May 2014 until the day of the survey. We defined an Ebola-related death as any death meeting the Liberian Ebola case definition. We calculated all-cause and Ebola-specific mortality rates. The sample consisted of 6,813 household members in 905 households. We estimated a crude mortality rate (CMR) of 0.33/10,000 persons/day (95%CI:0.25–0.43) and an Ebola-specific mortality rate of 0.06/10,000 persons/day (95%-CI:0.03–0.11). During the recall period, 17 Ebola cases were reported including those who died. In the 30 days prior to the survey 277 household members were reported sick; malaria accounted for 54% (150/277). Of the sick household members, 43% (122/276) did not visit any health care facility. The mobile phone-based survey was found to be a feasible and acceptable alternative method when data collection in the community is impossible. CMR was estimated well below the emergency threshold of 1/10,000 persons/day. Non-Ebola-related mortality in Monrovia was not higher than previous national estimates of mortality for Liberia. However, excess mortality directly resulting from Ebola did occur in the population. Importantly, the small proportion of sick household members presenting to official health facilities when sick might pose a challenge for future outbreak detection and mitigation. Substantial reported health-seeking behaviour outside of health facilities may also suggest the need for adapted health messaging and improved access to health care.
Highlights
Health care providers in the field have assumed that closure of health facilities and mistrust in existing structures resulted in Ebola virus disease (EVD)-related excess morbidity and mortality and had an impact on non-EVD morbidity and mortality: In Monrovia—similar to what has been described in other affected countries and cities [6]–the capacity of health care facilities was greatly reduced in August 2014 as compared to prior to the epidemic [7,8,9,10]
The non-EVD-related mortality was similar to national estimates of the mortality rate prior to the outbreak for Liberia [13,14,15], suggesting that there was no increase of non-EVD-related mortality during the EVD outbreak to the extent initially expected by actors in the field
It is possible that the mortality rate in Monrovia prior to the Ebola epidemic was lower than the countrywide estimates, as access to health care was better in Monrovia compared with other parts of the country [10,19]
Summary
Between March 2014 and July 2015, more than 10,500 Ebola virus disease (EVD) cases, including over 4,800 deaths, occurred in Liberia; the majority of these cases was identified in Montserrado County, where the capital city of Liberia, Monrovia, is located [1].official reported numbers of EVD cases might underestimate the size of the outbreak for several reasons: i) during the intense phase of the outbreak in August 2014, Ebola treatment units (ETUs) were overwhelmed with patients, some of whom were turned away uncounted [2]; ii) the continued identification of cases that had not been registered as contacts of known EVD cases beforehand indicates that contact tracing remained incomplete throughout the outbreak and cases are likely to have been missed [3] and iii) communities hesitated to send sick members to ETUs [2,4]. Health care providers in the field have assumed that closure of health facilities and mistrust in existing structures resulted in EVD-related excess morbidity and mortality and had an impact on non-EVD morbidity and mortality: In Monrovia—similar to what has been described in other affected countries and cities [6]–the capacity of health care facilities was greatly reduced in August 2014 as compared to prior to the epidemic [7,8,9,10]. Even in health facilities that continued to provide health care in Monrovia, the number of consultations was reduced by at least 40% compared to previous years [7]. Fear of EVD and mistrust in existing health care structures led to underutilization of services [7,8,12]
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