Ebola Virus Disease In Liberia Research Articles

Documenting the development, adoption and pre-ebola implementation of Liberia’s integrated disease surveillance and response (IDSR) strategy

BackgroundIn 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.MethodsWe 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.ResultsDespite 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.ConclusionOur 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.

Correction to: Postcolonial riskscapes: risk, trust, and the community-based response to Ebola virus disease in Liberia

Correction to: Postcolonial riskscapes: risk, trust, and the community-based response to Ebola virus disease in Liberia

Postcolonial riskscapes: risk, trust, and the community-based response to Ebola virus disease in Liberia

Postcolonial riskscapes: risk, trust, and the community-based response to Ebola virus disease in Liberia

Pregnancy, pregnancy outcomes, and infant growth and development after recovery from Ebola virus disease in Liberia: an observational cohort study

Minimal data exist on pregnancy following recovery from Ebola in people of child-bearing potential (females aged roughly 18-45 years). The aim of this study was to assess viral persistence or reactivation in pregnancy, the frequency of placental transfer of anti-Ebola IgG antibodies, and pregnancy outcomes in this population. In this observational cohort study, we studied self-reported pregnancies in two groups: seropositive people who had recovered from Ebola virus disease (seropositive group) and seronegative people who had close contact with people with Ebola (seronegative group). Participants had enrolled in the PREVAIL III longitudinal study and were exposed during the 2014-2016 Liberian Ebola outbreak. The primary outcome was pregnancy result. We assessed rates of livebirths and other pregnancy results in both study groups, and presence of Ebola RNA by PCR in samples of placenta, maternal and cord blood, breastmilk, and vaginal secretions from people who had recovered from Ebola who conceived a median of 14 months after acute Ebola virus disease. Mixed-model logistic regression evaluated associations between first-reported pregnancy outcome, age, and study group. Growth and neurodevelopment in the infants born to people in the seropositive group were assessed at 6-month intervals for 2 years. Data were accrued by PREVAIL III study staff. 1566 participants were enrolled between June 17, 2015, and Dec 14, 2017, of whom 639 became pregnant (215 seropositive, 424 seronegative) and 589 reported pregnancy outcomes (206 seropositive, 383 seronegative). 105 infants born to 98 mothers in the seropositive group were enrolled in the birth cohort. Ebola RNA was not detected in 205 samples of placenta, cord blood, or maternal blood taken at birth from 54 mothers in the seropositive group, nor in 367 vaginal swabs. Viral RNA was found in two of 354 longitudinal breastmilk samples. All but one of 57 infants born during these 54 births were seropositive for anti-Ebola antibodies. Neonates showed high concentrations of anti-Ebola IgG, which declined after 6 months. Odds of adverse pregnancy outcome among the two groups were indistinguishable (OR 1·13, 95% CI 0·71-1·79). Compared with WHO standards, infants born to those in the seropositive group had lower median weight and length, and larger median head circumference over 2 years. Compared with a cohort from the USA accrual of gross motor developmental milestones was similar, whereas attainment of pincer grasp and early vocalisation were mildly delayed. The risks of Ebola virus reactivation in the peripartum and postpartum period and of adverse birth outcomes are low in those who have recovered from Ebola virus disease and become pregnant approximately 1 year after acute Ebola virus disease. The implication for clinical practice is that care of people who are pregnant and who have recovered from Ebola can be offered without risks to health-care providers or stigmatisation of the mothers and their offspring. The implication for prospective mothers is that safe pregnancies are entirely possible after recovery from Ebola. National Institute of Allergy and Infectious Diseases and Liberia Ministry of Health.

Evaluating the economic effects of the Ebola virus disease in Liberia: A synthetic control approach

AbstractWe use the synthetic control method to isolate the impact of the 2014–2016 Ebola virus disease epidemic on the Liberian economy. We find a slight initial decline in the unemployment rate, followed by an increase of roughly 1% (p‐value ≤5%). The effect on inflation is more substantial (close to a 7% and 18% increase 4 and 5years after the outbreak) but statistically insignificant in the preceding period (2014–2016). We do not identify any other significant income and welfare effects. Synthetic control evidence for Guinea and Sierra Leone suggest even more limited long‐term impacts.

Evaluation of viral load in patients with Ebola virus disease in Liberia: a retrospective observational study

SummaryBackgroundViral load in patients with Ebola virus disease affects case fatality rate and is an important parameter used for diagnostic cutoffs, stratification in randomised controlled trials, and epidemiological studies. However, viral load in Ebola virus disease is currently estimated using numerous different assays and protocols that were not developed or validated for this purpose. Here, our aim was to conduct a laboratory-based re-evaluation of the viral loads of a large cohort of Liberian patients with Ebola virus disease and analyse these data in the broader context of the west Africa epidemic.MethodsIn this retrospective observational study, whole blood samples from patients at the Eternal Love Winning Africa Ebola treatment unit (Monrovia, Liberia) were re-extracted with an optimised protocol and analysed by droplet digital PCR (ddPCR) using a novel semi-strand specific assay to measure viral load. To allow for more direct comparisons, the ddPCR viral loads were also back-calculated to cycle threshold (Ct) values. The new viral load data were then compared with the Ct values from the original diagnostic quantitative RT-PCR (qRT-PCR) testing to identify differing trends and discrepancies.FindingsBetween Aug 28 and Dec 18, 2014, 727 whole blood samples from 528 individuals were collected. 463 (64%) were first-draw samples and 409 (56%) were from patients positive for Ebola virus (EBOV), species Zaire ebolavirus. Of the 307 first-draw EBOV-positive samples, 127 (41%) were from survivors and 180 (59%) were from non-survivors; 155 (50%) were women, 145 (47%) were men, and seven (2%) were not recorded, and the mean age was 29·3 (SD 15·0) years for women and 31·8 (SD 14·8) years for men. Survivors had significantly lower mean viral loads at presentation than non-survivors in both the reanalysed dataset (5·61 [95% CI 5·34–5·87] vs 7·19 [6·99–7·38] log10 EBOV RNA copies per mL; p<0·0001) and diagnostic dataset (Ct value 28·72 [27·97–29·47] vs 26·26 [25·72–26·81]; p<0·0001). However, the prognostic capacity of viral load increased with the reanalysed dataset (odds ratio [OR] of death 8·06 [95% CI 4·81–13·53], p<0·0001 for viral loads above 6·71 log10 EBOV RNA copies per mL vs OR of death 2·02 [1·27–3·20], p=0·0028 for Ct values below 27·37). Diagnostic qRT-PCR significantly (p<0·0001) underestimated viral load in both survivors and non-survivors (difference in diagnostic Ct value minus laboratory Ct value of 1·79 [95% CI 1·16–2·43] for survivors and 5·15 [4·43–5·87] for non-survivors). Six samples that were reported negative by diagnostic testing were found to be positive upon reanalysis and had high viral loads.InterpretationInaccurate viral load estimation from diagnostic Ct values is probably multifactorial; however, unaddressed PCR inhibition from tissue damage in patients with fulminant Ebola virus disease could largely account for the discrepancies observed in our study. Testing protocols for Ebola virus disease require further standardisation and validation to produce accurate viral load estimates, minimise false negatives, and allow for reliable epidemiological investigation.

Clinical sequelae among individuals with pauci-symptomatic or asymptomatic Ebola virus infection and unrecognised Ebola virus disease in Liberia: a longitudinal cohort study

SummaryBackgroundWhether or not individuals with pauci-symptomatic or asymptomatic Ebola virus infection and unrecognised Ebola virus disease develop clinical sequelae is unknown. We assessed current symptoms and physical examination findings among individuals with pauci-symptomatic or asymptomatic infection and unrecognised Ebola virus disease compared with Ebola virus disease survivors and uninfected contacts.MethodsBetween June 17, 2015, and June 30, 2017, we studied a cohort of Ebola virus disease survivors and their contacts in Liberia. Surveys, current symptoms and physical examination findings, and serology were used to characterise disease status of reported Ebola virus disease, unrecognised Ebola virus disease, pauci-symptomatic or asymptomatic Ebola virus infection, or no infection. We pre-specified findings known to be differentially prevalent among Ebola virus disease survivors versus their contacts (urinary frequency, headache, fatigue, muscle pain, memory loss, joint pain, neurological findings, chest findings, muscle findings, joint findings, abdominal findings, and uveitis). We estimated the prevalence and incidence of selected clinical findings by disease status.FindingsOur analytical cohort included 991 reported Ebola virus disease survivors and 2688 close contacts. The median time from acute Ebola virus disease onset to baseline was 317 days (IQR 271–366). Of 222 seropositive contacts, 115 had pauci-symptomatic or asymptomatic Ebola virus infection and 107 had unrecognised Ebola virus disease. At baseline, prevalent findings of joint pain, memory loss, muscle pain, and fatigue were lowest among those with pauci-symptomatic or asymptomatic infection or no infection, higher among contacts with unrecognised Ebola virus disease, and highest in reported survivors of Ebola virus disease. Joint pain was the most prevalent finding, and was reported in 434 (18%) of 2466 individuals with no infection, 14 (12%) of 115 with pauci-symptomatic or asymptomatic infection, 31 (29%) of 107 with unrecognised Ebola virus disease, and 476 (48%) of 991 with reported Ebola virus disease. In adjusted analyses, this pattern remained for joint pain and memory loss. Survivors had an increased odds of joint pain compared with unrecognised Ebola virus disease contacts (adjusted odds ratio [OR] 2·13, 95% CI 1·34–3·39); unrecognised Ebola virus disease contacts had an increased odds of joint pain compared with those with pauci-symptomatic or asymptomatic infection and uninfected contacts (adjusted OR 1·89, 95% CI 1·21–2·97). The adjusted odds of memory loss was more than four-times higher among survivors than among unrecognised Ebola virus disease contacts (adjusted OR 4·47, 95% CI 2·41–8·30) and two-times higher among unrecognised Ebola virus disease contacts than in those with pauci-symptomatic or asymptomatic infection and uninfected contacts (adjusted OR 2·05, 95% CI 1·10–3·84). By 12 months, prevalent findings had decreased in the three infected groups.InterpretationOur findings provide evidence of post-Ebola virus disease clinical sequelae among contacts with unrecognised Ebola virus disease but not in people with pauci-symptomatic or asymptomatic Ebola virus infection.FundingNational Cancer Institute and National Institute of Allergy and Infectious Diseases of the National Institutes of Health.

Understanding One Health through biological and behavioral risk surveillance in Liberia: a cross-sectional study

BackgroundThe 2014 Ebola crisis in West Africa mainly affected Guinea, Liberia, and Sierra Leone, claiming the lives of over 11 000 people, including health-care workers. Following this crisis, the Ebola Host Project worked to identify the wildlife reservoir for the virus that started the epidemic, to detect other related filoviruses, and to better understand ecological and human behavioral dynamics that could inform future risk reduction and prevention strategies. Here, we report key ecological and behavioral results for Liberia. MethodsIn Liberia, this cross-sectional study was conducted in 13 sites throughout eight counties. The project used a One Health biological-behavioral surveillance approach that included catch-and-release wildlife sampling and behavioral risk surveys. These sites were chosen from counties with forested areas inhabited by bats and rodents and included counties that were both severely and minimally impacted by the Ebola crisis. The analysis included 5000 bat and rodent biological samples, and the behavioural risk survey included 585 enrolled human participants from eight counties. Participants were selected from villages within a 5 km range of the 18 sampling sites, and they provided writteninformed consent. In addition to US based approvals, the Liberian National Ethical and Review Board, the Liberian Forest Development Authority and local government authorities approved the study and community work. FindingsThis sampling effort led to the first-time discovery of an Ebolavirus in a west African bat (Miniopterus inflatus) in January 2019. Across five of the eight counties, including Nimba County where the infected Miniopterus inflatus was sampled, mosquitos and tsetse flies were also identified as present vectors. Respondents reported the ways in which they interfaced with taxa of interest such as rodents. These interactions included wildlife consumption and proximity to human dwellings—interactions that present the risk of zoonotic infections that may go misdiagnosed as fevers of unknown origin. Respondents additionally described gaps in knowledge around topics such as the aetiology of Ebola in Liberia, as well as changes in the level of concern towards Ebola risk, which rose during the crisis but later returned to pre-crisis levels. InterpretationOur results highlight how, against the backdrop of human-wildlife interactions in these Liberian communities that present spillover risk, there exist opportunities to bridge knowledge gaps and create cues to encourage continued vigilance against transmission. FundingThis project was funded by USAID, and analysis with regard to the risk of acute febrile illnesses continues with funding from the US Defense Threat Reduction Agency.

Risk Factors for Persistent Ebola Virus Infection in Semen Among Survivors From Liberia

Background: Long-term persistence of Ebola virus (EBOV) in immunologically privileged sites has been implicated in recent outbreaks of Ebola Virus Disease (EVD) in Guinea and the Democratic Republic of Congo. This study was designed to better understand how the acute course of EVD, convalescence, and host immune and genetic factors may play a role in prolonged viral persistence in semen. Methods: In 2017, a cohort of 131 male survivors of the 2014-2016 outbreak of EVD in Liberia were recruited from a national semen testing program into this case-case study. “Early clearers” were defined as those with two consecutive negative EBOV semen tests by real-time reverse transcriptase polymerase chain reaction (rRT-PCR) at least two weeks apart within 1 year after discharge from the Ebola Treatment Unit (ETU). “Late clearers” had detectable EBOV RNA by rRT-PCR more than one year after ETU discharge. Retrospective histories of their EVD clinical course were collected by questionnaire, followed by complete physical exams and blood work including chemistries, blood counts, hemoglobinopathies, human leukocyte antigen typing, and immunologic/inflammatory markers. Findings: Among 131 participants, 30 demonstrated long-term detection of EBOV RNA in semen by rRT-PCR, up to 852 days after ETU discharge. Compared to early clearers, late clearers were more likely to be older (median 42.5 years, p=0.0001) and reported having experienced fewer severe clinical symptoms (median 2, p=0.006). Late clearers were found to more frequently have lens opacifications (OR 3.9, 95%CI 1.1-13.3, p=0.03), after accounting for age. Finally, late clearers also exhibited elevated total serum IgG3 titers (p=0.007) and increased expression of the HLA-C*03:04 allele (OR 0.14, 95% CI 0.02-0.70, p=0.007). Interpretation: Older age and decreased illness severity may play a significant role in determining the clearance of EBOV from the semen of survivors. Immune and host genetic factors including total serum IgG3 and HLA-C*03:04 may mediate that interaction. In addition, our finding that late clearers were more likely to have lens opacifications after accounting for age suggests that individuals with EBOV persistence in semen may also have EBOV persistence in other immunologically protected sites, such as the eye. Identifying risk factors for viral persistence in semen among male survivors is critical to inform screening efforts and prevent recurrent outbreaks of EBOV. Funding Information: This was work was supported by funds from the CDC Foundation and the Centers for Disease Control and Prevention. This project has also been funded in whole or in part with federal funds from the Frederick National Laboratory for Cancer Research, under Contract No. HHSN261200800001E. Declaration of Interests: The authors report no competing interests. Ethics Approval Statement: The study protocol was approved by the CDC and Liberia MoH Institutional Review Boards and Meharry Medical College (for hemoglobinopathy testing).

Care of the Self and the Ethos of Leadership in Times of Pandemic and Crisis

Foucault’s notion of the “care of the self ” is essential in preparing leaders for crisis situations. Crisis situations are characterized by insecurity, uncertainty, and disruption. Hence, it demands for leadership who will provide direction, inspiration, hope, and solution. Leaders must be prepared in encountering crisis situation as well as in the effective performance of crisis leadership tasks. Leadership preparation for crisis situation need not only scientific and technical know-how but also the development of one’s character, values, and moral conviction. Leaders must be guided by rational discourse, convictions, principles, and truth. Their actions and decisions must be consistent with truth, beliefs, values, and convictions.&#x0D; References&#x0D; &#x0D; Boin, A. et al., Leadership in Times of Crisis: A Framework for Assessment in International Review of Public Administration. Volume 18. No. 1. April 2013.&#x0D; Boin, A. and P. Hart, Public leadership in times of crisis: Mission impossible? in Public Administration Review. September/October 2003. Volume 63. Number 5.&#x0D; Boris, Vanessa. How Leaders at All Levels Are Taking on Change Management. April 8, 2020 @ https://www.harvardbusiness.org/how-leaders-at-all-levels-are-taking-on-change-management.&#x0D; Champoux-Paille, L. and Croteau, A. The reason why female leaders are excelling at managing the coronavirus. May 18, 2020 @ https://www.weforum.org/agenda/2020/05/why-women-leaders-are-excelling-during-the-coronavirus-pandemic.&#x0D; Foucault, Michel. Courage of Truth: Lectures at the College de France 1983-1984. New York: Palgrave Macmillan, 2008.&#x0D; ______________. The Hermeneutics of the Subject: Lectures at the College de France 1981-1982. Frederic Gros, ed. Graham Burchell, trans. New York: Palgrave Macmillan, 2005.&#x0D; ______________. The Care of the Self: The History of Sexuality, Robert Hurley, trans. (New York: Vintage Books, 1988)&#x0D; Foster, Deanna. Leading Through Uncertainty. March 12, 2020 @ https://www.harvardbusiness.org/leading-through-uncertainty.&#x0D; Kerrissey, M. and Edmondson. A. What Good Leadership Looks Like During This Pandemic. April 23, 2020 @ https://hbr.org/2020/04/what-good-leadership-looks-like-this-pandemic.&#x0D; Kraemer, Jr., Harry. From Values to Action: The Four Principles of Values-Based Leadership (San Francisco: Jossey-Bass, 2011.&#x0D; Kretchner, Henry. 3 Leadership Lessons from the Age of Coronavirus. August 12, 2020 @ https://weforum.org/agenda/2020/08/coronavirus-leadership-women-leaders-jacinda-arden.&#x0D; Lowney, Chris. Heroic Leadership: Best Practices from a 450-Year-Old Company that Changed the World. Chicago: Loyola Press, 2003.&#x0D; Nyenswah, T. et al. Leadership in Times of Crisis: The Example of Ebola Virus Disease in Liberia in Health Systems and Reform. 2(3): 194-207. 2016. ISSN: 2328-8604 print/2328-8620 online, DOI http://doi.org/10.1080/23288604.2016.1222793

Contextualizing Risk Perception and Trust in the Community-Based Response to Ebola Virus Disease in Liberia.

The 2014–15 Ebola Virus Disease (EVD) outbreaks in Western Africa became widespread in primarily three countries, Guinea, Liberia, and Sierra Leone. Unlike all previous outbreaks in Central and East Africa, which were confined to rural areas, the virus spread rapidly through West Africa as a result of transmission through high-density urban centres coupled with the effects of public distrust in outbreak response teams and local government officials. Objective: In this study, we examine the EVD epidemic in Liberia, the first country to implement a community-based response that led to changes in the trajectory of the epidemic. The focus on the role of community-based initiatives in outbreak response is often neglected in conventional epidemiological accounts. In this light, we consider the manner in which community-based strategies enabled a more effective response based on the establishment of better trust relations and an enhanced understanding of the risks that EVD posed for the community. Methodology: We conducted qualitative research in five distinct communities in Liberia three years after the outbreaks subsided. Data collection procedures consisted of semi-structured interviews and focus group discussions with residents. Results: We found that the implementation of a community-based response, which included the participation of Ebola survivors and local leaders, helped curb and ultimately end the EVD epidemic in Liberia. As community members became more directly involved in the EVD response, the level of trust between citizens, local officials, and non-governmental organization response teams increased. In turn, this led to greater acceptance in abiding to safety protocols, greater receptiveness to risk information, and changes in mobility patterns—all of which played a significant role in turning the tide of the epidemic.

Uncertainty Quantification of Stochastic Epidemic SIR Models Using B-spline Polynomial Chaos

Real-life epidemic situations are modeled using systems of differential equations (DEs) by considering deterministic parameters. However, in reality, the transmission parameters involved in such models experience a lot of variations and it is not possible to compute them exactly. In this paper, we apply B-spline wavelet-based generalized polynomial chaos (gPC) to analyze possible stochastic epidemic processes. A sensitivity analysis (SA) has been performed to investigate the behavior of randomness in a simple epidemic model. It has been analyzed that a linear B-spline wavelet basis shows accurate results by involving fewer polynomial chaos expansions (PCE) in comparison to cubic B-spline wavelets. We have carried out our developed method on two real outbreaks of diseases, firstly, influenza which affected the British boarding school for boys in North England in 1978, and secondly, Ebola in Liberia in 2014. Real data from the British Medical Journal (influenza) and World Health Organization (Ebola) has been incorporated into the Susceptible-Infected-Recovered (SIR) model. It has been observed that the numerical results obtained by the proposed method are quite satisfactory.

Understanding the Predictors that Contribute to Liberian Health Care Workers Feeling Protected From Ebola While at Work.

To assess Liberian health care workers' feelings around safety in returning to work in the setting of the Ebola virus disease outbreak of 2014-2015 after receiving infection prevention and control (IPC) training. Academic Consortium Combating Ebola in Liberia (ACCEL) training surveys were done at 21 public, Liberian hospitals to understand health care workers' attitudes surrounding Ebola and whether they felt safe while at work based on multiple factors. Logistic regression was used for analysis. We found that health care workers feeling safe at work during the Ebola outbreak was primarily predicted by the number of IPC/Ebola trainings received pre-ACCEL interventions. Health care workers felt increasingly safer and motivated to return to work as trainings approached 3 (OR 8, p-value < 0.001); however, more than 3 trainings resulted in decreased safety and motivation. In addition, health care workers who reported washing their hands before and after patient contact were 3.4 times more likely to understand how to protect themselves from Ebola. These results help to better understand the utility of repeated trainings on health care worker practice attitudes and the importance of IPC policies within hospitals, such as hand hygiene promotion and education, when coordinating humanitarian efforts.

Community engagement for health system resilience: evidence from Liberia's Ebola epidemic.

The importance of community engagement (CE) for health system resilience is established in theoretical and empirical literature. The practical dimensions of how to operationalize theory and implement its principles have been less explored, especially within low-resource crisis settings. It is therefore unclear how CE is drawn upon and how, if at all, it facilitates health system resilience in times of health system crises. To address this critical gap, we adapt and apply existing theoretical CE frameworks to analyse qualitative data from 92 in-depth interviews and 16 focus group discussions collected with health system stakeholders in Liberia in the aftermath of the 2014-15 Ebola outbreak. Health system stakeholders indicated that CE was a crucial contributing factor in addressing the Ebola epidemic in Liberia. Multiple forms of CE were used during the outbreak; however, only some forms were perceived as meaningful, such as the formation of community-based surveillance teams. To achieve meaningful CE, participants recommended that communities be treated as active participants in-as opposed to passive recipients of-health response efforts and that communication platforms for CE be established ahead of a crisis. Participant responses highlight that meaningful CE led to improved communication with and increased trust in health authorities and programming. This facilitated health system response efforts, leading to a fortuitous cycle of increased trust, improved communication and continued meaningful CE-all necessary conditions for health system resilience. This study refines our understanding of CE and demonstrates the ways in which meaningful CE and trust work together in mutually reinforcing and beneficial ways. These findings provide empirical evidence on which to base policies and programmes aimed at improving health system resilience in low-resource settings to more effectively respond to health system crises.

Reproductive health sequelae among women who survived Ebola virus disease in Liberia.

To estimate the incidence of failed pregnancy and menstrual irregularities among Liberian women who had survived Ebola virus disease (EVD) and to identify host-specific and disease-specific factors associated with these outcomes. A cross-sectional questionnaire-based study was conducted between August 10, 2016, and February 7, 2017. The study population comprised 111 women aged 18-45years who had survived EVD and were enrolled in the Longitudinal Liberian Ebola Survivor study based at the Eternal Love Winning Africa Hospital, Monrovia, Liberia. Self-reported data on outcomes related to pregnancy and menstrual changes since recovery from EVD were collected. In all, 29 (26.1%) of the participants had become pregnant since surviving EVD. Of the 23 women whose pregnancies continued to term, 10 (43.4%) reported live birth, 11 (47.8%) reported spontaneous abortion, and two (8.7%) reported stillbirth. Of the 105 women who reported having regular menstruation before EVD, 27 (29.0%) reported experiencing irregular menstruation for unknown reasons after EVD. In bivariate logistic models, no associations were found between failed pregnancy or irregular menstruation and any of the factors of interest. Adverse pregnancy outcomes and irregular menstruation were frequently reported among EVD survivors in Liberia.

Assessing the effects of modeling the spectrum of clinical symptoms on the dynamics and control of Ebola

Mathematical modelers have attempted to capture the dynamics of Ebola transmission and to evaluate the effectiveness of control measures, as well as to make predictions about ongoing outbreaks. Many of their models consider only infections with typical symptoms, but Ebola presents clinically in a more complicated way. Even the most common symptom, fever, is not experienced by 13% of patients. This suggests that infected individuals could be asymptomatic or have moderately symptomatic infections as reported during previous Ebola outbreaks. To account crudely for the spectrum of clinical symptoms that characterizes Ebola infection, we developed a model including moderate and severe symptoms. Our model captures the dynamics of the recent outbreak of Ebola in Liberia. Our estimate of the basic reproduction number is 1.83 (CI: 1.72, 1.86), consistent with the WHO response team’s estimate using early outbreak case data. We also estimate the effectiveness of interventions using observations before and after their introduction. As the final epidemic size is linked to the timing of interventions in an exponential fashion, a simple empirical formula is provided to guide policy-making. It suggests that early implementation could significantly decrease final size. We also compare our model to one with typical symptoms by excluding moderate ones. The model with only typical symptoms overestimates the basic reproduction number and effectiveness of control measures, and exaggerates changes in peak size attributable to the timing of interventions. In addition, uncertainty about how moderate symptoms affect the basic reproduction number is considered, and PRCC (Partial rank correlation coefficient) is used to analyze the global sensitivity of relevant parameters. Possible control strategies are evaluated through numerical simulations and sensitivity analysis, indicating that simultaneously strengthening contact-tracing and effectiveness of isolation in hospital would be most effective. In this study, we show that asymptomatic Ebola infections may have implications for policy-making.

Reproductive health sequelae among women who survived Ebola virus disease in Liberia

Reproductive health sequelae among women who survived Ebola virus disease in Liberia

“To Save the Community”: Carework as Citizenship during Liberia's Ebola Outbreak and Zambia's AIDS Crisis

“To Save the Community”: Carework as Citizenship during Liberia's Ebola Outbreak and Zambia's AIDS Crisis

Stigma and Ebola survivorship in Liberia: Results from a longitudinal cohort study.

BackgroundSurvivors of the 2014–2016 West Africa Ebola epidemic have been reported to suffer high levels of stigmatization after return to their communities. We sought to characterize the stigma encountered by a cohort of Ebola survivors in Liberia over time.MethodsEbola-related stigma was assessed from June 2015 to August 2017 in 299 adolescent and adult Liberian Ebola Survivor Cohort participants at three month intervals using adapted HIV stigma scales scored from 0 to 10 according to the proportion of answers indicating stigmatization.FindingsThe median time from Ebola Virus Disease (EVD) to study entry was 393 days (IQR 336–492). Participants (43% female) had a median age of 31 (IQR 25–40) years. Mean self-reported stigma levels were greater at baseline (6.28 ± 0.15 [IQR: 4.38–8.75]) compared to the first post-baseline visit (0.60 ± 0.10 [IQR: 0–0]; p<0.0001). During follow-up, stigma levels were stable. Baseline stigma significantly increased during enrollment and following clusters of Ebola re-emergence in Liberia. Survivors encountered primarily enacted and perceived external stigma rather than internalized stigma.ConclusionsEbola-related stigma was prevalent among Liberian survivors more than a year after EVD recovery. Self-reported stigma was greater in the period before cohort enrollment; however, some degree of stigmatization persisted years after EVD. Transient rises in stigma were observed following episodic Ebola re-emergence of EVD in Liberia. During future EVD outbreaks, enhanced public health interventions designed to prevent and mitigate Ebola-related stigma that is enacted and external should be implemented to support survivor recovery and community re-integration.

Discrete stochastic analogs of Erlang epidemic models

ABSTRACTErlang differential equation models of epidemic processes provide more realistic disease-class transition dynamics from susceptible (S) to exposed (E) to infectious (I) and removed (R) categories than the ubiquitous SEIR model. The latter is itself is at one end of the spectrum of Erlang SEIR models with concatenated E compartments and concatenated I compartments. Discrete-time models, however, are computationally much simpler to simulate and fit to epidemic outbreak data than continuous-time differential equations, and are also much more readily extended to include demographic and other types of stochasticity. Here we formulate discrete-time deterministic analogs of the Erlang models, and their stochastic extension, based on a time-to-go distributional principle. Depending on which distributions are used (e.g. discretized Erlang, Gamma, Beta, or Uniform distributions), we demonstrate that our formulation represents both a discretization of Erlang epidemic models and generalizations thereof. We consider the challenges of fitting SEIR models and our discrete-time analog to data (the recent outbreak of Ebola in Liberia). We demonstrate that the latter performs much better than the former; although confining fits to strict SEIR formulations reduces the numerical challenges, but sacrifices best-fit likelihood scores by at least 7%.