Abstract
BackgroundLittle is understood of Ebola virus disease (EVD) transmission dynamics and community compliance with control measures over time. Understanding these interactions is essential if interventions are to be effective in future outbreaks. We conducted a mixed-methods study to explore these factors in a rural village that experienced sustained EVD transmission in Kailahun District, Sierra Leone.MethodsWe reconstructed transmission dynamics using a cross-sectional survey conducted in April 2015, and cross-referenced our results with surveillance, burial, and Ebola Management Centre (EMC) data. Factors associated with EVD transmission were assessed with Cox proportional hazards regression. Following the survey, qualitative semi-structured interviews explored views of community informants and households.ResultsAll households (n = 240; 1161 individuals) participated in the survey. 29 of 31 EVD probable/confirmed cases died (93·5% case fatality rate); six deaths (20·6%) had been missed by other surveillance systems. Transmission over five generations lasted 16 weeks. Although most households had ≤5 members there was a significant increase in risk of Ebola in households with > 5 members. Risk of EVD was also associated with older age. Cases were spatially clustered; all occurred in 15 households.EVD transmission was better understood when the community experience started to concord with public health messages being given. Perceptions of contact tracing changed from invading privacy and selling people to ensuring community safety. Burials in plastic bags, without female attendants or prayer, were perceived as dishonourable. Further reasons for low compliance were low EMC survival rates, family perceptions of a moral duty to provide care to relatives, poor communication with the EMC, and loss of livelihoods due to quarantine. Compliance with response measures increased only after the second generation, coinciding with the implementation of restrictive by-laws, return of the first survivor, reduced contact with dead bodies, and admission of patients to the EMC.ConclusionsTransmission occurred primarily in a few large households, with prolonged transmission and a high death toll. Return of a survivor to the village and more effective implementation of control strategies coincided with increased compliance to control measures, with few subsequent cases. We propose key recommendations for management of EVD outbreaks based on this experience.
Highlights
Introduction of Ebola virus disease (EVD) in the villageWhen discussing how EVD had been introduced to the village, all participants referred to a single member or index case in the family or community, ranging from a family visitor to a health worker.“The man [index case] brought Ebola here
Return of a survivor to the village and more effective implementation of control strategies coincided with increased compliance to control measures, with few subsequent cases
We propose key recommendations for management of EVD outbreaks based on this experience
Summary
“The man [index case] brought Ebola here He used to treat people in [city] that was a hotspot at the time. Little is understood of Ebola virus disease (EVD) transmission dynamics and community compliance with control measures over time. Understanding these interactions is essential if interventions are to be effective in future outbreaks. The first case of Ebola virus disease (EVD) in Sierra Leone is believed to have occurred in mid-May 2014, in a remote village of Kailahun District (estimated population 465,048) [1, 2]. Médecins sans Frontières (MSF) opened an Ebola Management Centre (EMC) in Kailahun on 26th June 2014 to support the district MoHS [4]. The district MoHS reported 565 confirmed EVD cases in the population of Kailahun (attack rate 0·12%), including 287 deaths (case fatality rate [CFR] 51·0%) [5]
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