post-Ebola Periods Research Articles

Paediatric morbidity and mortality in Sierra Leone. Have things changed after the 2014/2015 Ebola outbreak?

Background:Sierra Leone was severely affected by the 2014/2015 Ebola outbreak which is likely to have had longer term repercussions on the health system including on paediatric morbidity and mortality. We thus assessed under-five morbidity and mortality for malaria, acute respiratory Infections (ARI)/pneumonia, watery diarrhoea and measles during the post-Ebola period in Sierra Leone and compared this with the pre- and intra-Ebola periods. Methods:This was a retrospective cross-sectional study using program data from the District Health Information system (DHIS2) and sourced from 14 districts in Sierra Leone. It included under-five children from 1,250 health facilities country-wide. Study periods included: before (June 1 st, 2013-April 30 th, 2014); during (June 1 st, 2014-April 30 th, 2015); and after Ebola (June 1 st, 2016-April 30 th, 2017). Results:Malaria, ARI/pneumonia and diarrhoea consultations declined during Ebola but recovered to pre-Ebola levels in the post-Ebola period. During the post-Ebola period, there was a highly significant reduction in case-fatality for the first three morbidities compared to the pre-Ebola period ( P<0.0001). Average number of measles cases increased from 48/month in the pre-Ebola period to 568/month (12-fold increase) post-Ebola. Although there was no difference in measles case-fatality between the pre- and post-Ebola periods, case-fatality post-Ebola was significantly lower than during Ebola (Relative Risk: 0.05, 95% confidence interval 0.02-0.15, P<0.0001). Conclusions:Consultations for under-five children at health facilities in Sierra Leone recovered to pre-Ebola levels and case-fatality for common childhood illnesses declined significantly. This is a change for the better. However, the high level of reported measles cases in the post-Ebola period indicates gaps in immune status and needs focused attention.

Staffing in public health facilities after the Ebola outbreak in rural Sierra Leone: How much has changed?

Background: The 2014-2015 Ebola outbreak in Sierra Leone led the Ministry of Health and Sanitation to set minimum standards of staffing (medical/non-medical) at the district level for the provision of basic essential health services (BPEHS). In one of the worst Ebola affected districts in Sierra Leone, we assessed staffing levels measured against these stipulated standards before, during, and 16 months after the Ebola outbreak. Methods: The study population included all health workers in 83 health facilities. We assessed staffing levels at three points in time: pre-Ebola (April 2014); the end of the outbreak (November 2015); and 16 months post-Ebola (March 2017). April 2014 was immediately prior to the Ebola outbreak and thus representative of the human resource situation before the outbreak. November 2015 was the month when Sierra Leone was declared Ebola-free, and thus reflects the end-situation after Ebola. March 2017 was two years since the launch of the BPEHS, and some progress should be expected. Results: Against recommended medical staff numbers during pre-, intra- and post-Ebola periods, deficits were 67%, 65% and 60% respectively. Similarly, against recommended non-medical staff numbers during pre-, intra- and post-Ebola periods, the deficit remained at 92% throughout. In the post-Ebola period, there was a deficit of 73% against 1,389 recommended health worker positions. Conclusions:Nothing has really changed in the state of human resources for health, and urgent measures are needed to rectify the situation and prevent a déjà vu in the advent of a new Ebola outbreak.

Paediatric morbidity and mortality in Sierra Leone. Have things changed after the 2014/2015 Ebola outbreak?

Background: Sierra Leone was severely affected by the 2014/2015 Ebola outbreak which is likely to have had longer term repercussions on the health system including on paediatric morbidity and mortality. We thus assessed under-five morbidity and mortality for malaria, acute respiratory Infections (ARI)/pneumonia, watery diarrhoea and measles during the post-Ebola period in Sierra Leone and compared this with the pre- and intra-Ebola periods. Methods: This was a retrospective cross-sectional study using program data from the District Health Information system (DHIS2) and sourced from 14 districts in Sierra Leone. It included under-five children from 1,250 health facilities country-wide. Study periods included: before (June 1 st, 2013-April 30 th, 2014); during (June 1 st, 2014-April 30 th, 2015); and after Ebola (June 1 st, 2016-April 30 th, 2017). Results: Malaria, ARI/pneumonia and diarrhoea consultations declined during Ebola but recovered to pre-Ebola levels in the post-Ebola period. During the post-Ebola period, there was a highly significant reduction in case-fatality for the first three morbidities compared to the pre-Ebola period ( P<0.0001). Average number of measles cases increased from 48/month in the pre-Ebola period to 568/month (12-fold increase) post-Ebola. Although there was no difference in measles case-fatality between the pre- and post-Ebola periods, case-fatality post-Ebola was significantly lower than during Ebola (Relative Risk: 0.05, 95% confidence interval 0.02-0.15, P<0.0001). Conclusions: Consultations for under-five children at health facilities in Sierra Leone recovered to pre-Ebola levels and case-fatality for common childhood illnesses declined significantly. This is a change for the better. However, the high level of reported measles cases in the post-Ebola period indicates gaps in immune status and needs focused attention.

Staffing in public health facilities after the Ebola outbreak in rural Sierra Leone: How much has changed?

Background: The 2014-2015 Ebola outbreak in Sierra Leone led the Ministry of Health and Sanitation to set minimum standards of staffing (medical/non-medical) at the district level for the provision of basic essential health services (BPEHS). In one of the worst Ebola affected districts in Sierra Leone, we assessed staffing levels measured against these stipulated standards before, during, and 16 months after the Ebola outbreak. Methods: The study population included all health workers in 83 health facilities. We assessed staffing levels at three points in time: pre-Ebola (April 2014); the end of the outbreak (November 2015); and 16 months post-Ebola (March 2017). April 2014 was immediately prior to the Ebola outbreak and thus representative of the human resource situation before the outbreak. November 2015 was the month when Sierra Leone was declared Ebola-free, and thus reflects the end-situation after Ebola. March 2017 was two years since the launch of the BPEHS, and some progress should be expected. Results: Against recommended medical staff numbers during pre-, intra- and post-Ebola periods, deficits were 67%, 65% and 60% respectively. Similarly, against recommended non-medical staff numbers during pre-, intra- and post-Ebola periods, the deficit remained at 92% throughout. In the post-Ebola period, there was a deficit of 73% against 1,389 recommended health worker positions. Conclusions: Nothing has really changed in the state of human resources for health, and urgent measures are needed to rectify the situation and prevent a déjà vu in the advent of a new Ebola outbreak.

Malaria management in children with fever in rural Sierra Leone. Has anything changed after the Ebola outbreak?

Background: Sierra Leone is one of the highest malaria burden countries in the world and was severely affected by the 2014-15 Ebola outbreak. As fever is a common symptom of both malaria and Ebola, it might have affected the management of fever in children. Among under-fives in Koinadugu district, Sierra Leone, we determined fever cases that had malaria diagnostic testing and treated with Artemisinin-based Combination Therapy (ACT) during pre-Ebola, intra-Ebola and post-Ebola periods. Methods: The study population included all children under five with fever who presented to 68 primary healthcare facilities in Koinadugu district. Malaria management was in line with national guidelines. All individuals presenting with fever should be subjected to a malaria diagnostic test, which may involve a Rapid Diagnostic Test (RDT) or microscopy. Only confirmed malaria cases should receive ACTs. The study spanned pre-Ebola (June 1, 2013 – April 30, 2014), intra-Ebola (June 1, 2014 – April 30, 2015) and post-Ebola (June 1, 2016 – April 30 ,2017) periods. Data were sourced directly from routine morbidity registers available at each health facility. Results: In the 68 health facilities, fever cases increased from 43,245 pre-Ebola to 74,367 post-Ebola (1.7-fold increase). Diagnosed malaria ranged between 66% and 75%. Only 47% of malaria cases were treated during Ebola. ACT use was 95% pre-Ebola, 99% intra-Ebola and dropped to 71% post-Ebola. Post-Ebola, an average of 40 (59%) facilities had monthly stock-outs of ACT (range 28-45). Conclusion: What has changed since the Ebola outbreak is the increased utilisation of services for malaria. However, ACT stockouts are of concern, and this requires attention in order to ensure compliance with national malaria treatment guidelines.

Paediatric morbidity and mortality in Sierra Leone. Have things changed after the 2014/2015 Ebola outbreak?

Background:Sierra Leone was severely affected by the 2014/2015 Ebola outbreak and is likely to have had longer term repercussions on the health system including on paediatric morbidity and mortality. We thus assessed under-five morbidity and mortality for malaria, acute respiratory Infections (ARI)/pneumonia, watery diarrhoea and measles during the post-Ebola period in Sierra Leone and compared this with the pre- and intra-Ebola periods. Methods:This was a retrospective cross-sectional study using program data from the District Health Information system (DHIS2) and sourced from 14 districts in Sierra Leone. It included under-five children from 1,200 health facilities country-wide. Study periods included: before (June 1 st, 2013-April 30 th, 2014); during (June 1 st, 2014-April 30 th, 2015); and after Ebola (June 1 st, 2016-April 30 th, 2017). Results:Malaria, ARI/pneumonia and diarrhoea consultations declined during Ebola but recovered to pre-Ebola levels in the post-Ebola period. During the post-Ebola period, there was a highly significant reduction in case-fatality for the first three morbidities compared to the pre-Ebola period (P<0.0001). Average number of measles cases increased from 48/month in the pre-Ebola period to 568/month (12-fold increase) post-Ebola. Although there was no difference in measles case-fatality between the pre- and post-Ebola periods, case-fatality post-Ebola was significantly lower than during Ebola (Relative Risk: 0.05, 95% confidence interval 0.02-0.15, P<0.0001). Conclusions:Consultations for under-five children at health facilities in Sierra Leone recovered to pre-Ebola levels and case-fatality for common childhood illnesses declined significantly. This is a change for the better. However, the high level of reported measles cases in the post-Ebola period indicates gaps in immune status and needs focused attention.

Staffing in public health facilities after the Ebola outbreak in rural Sierra Leone: How much has changed?

Background: The 2014-2015 Ebola outbreak in Sierra Leone led the Ministry of Health and Sanitation to set minimum standards of staffing (medical/non-medical) at the district level for the provision of basic essential health services (BPEHS). In one of the worst Ebola affected districts in Sierra Leone, we assessed staffing levels measured against these stipulated standards before, during, and 16 months after the Ebola outbreak. Methods: The study population included all health workers in 83 health facilities. We assessed staffing levels at three points in time: pre-Ebola (April 2014); the end of the outbreak (November 2015); and 16 months post-Ebola (March 2017). April 2014 was immediately prior to the Ebola outbreak and thus representative of the human resource situation before the outbreak. November 2015 was the month when Sierra Leone was declared Ebola-free, and thus reflects the end-situation after Ebola. March 2017 was two years since the launch of the BPEHS, and some progress should be expected. Results: Against recommended medical staff numbers during pre-, intra- and post-Ebola periods, deficits were 67%, 65% and 60% respectively. Similarly, against recommended non-medical staff numbers during pre-, intra- and post-Ebola periods, the deficit remained at 92% throughout. In the post-Ebola period, there was a deficit of 73% against 1,389 recommended health worker positions. Conclusions: Nothing has really changed in the state of human resources for health, and urgent measures are needed to rectify the situation and prevent a déjà vu in the advent of a new Ebola outbreak.

Analyzing the Effects of the Ebola Virus Disease Outbreak on Maternal and Child Health Services in the Health District of Beyla, Guinea

While more efforts were needed to enhance maternal and child health services in Guinea, the country experienced the worst and longest Ebola virus disease outbreak in 2014. The aim of this study was to analyze the effects of the 2014 Ebola virus disease outbreak on antenatal care visits, institutional deliveries and vaccine coverage among children aged 0 to 11 months in the health district of Beyla in Guinea. This was an ecological study based on aggregated data from the public health facilities of the district health of Beyla, that covered three distinct periods related to the Ebola virus disease outbreak: pre-Ebola (February 1^st 2013 to January 31^st 2014), intra-Ebola (February 1^st 2014 to January 31^st 2015) and post-Ebola (February 1^st 2015 to December 31^st 2015). Antenatal care visits, institutional deliveries and vaccination coverage of children aged 0 to 11 months significantly decreased during the intra and post-Ebola periods. The average of antenatal care visits (third visit or more) declined from 123% (pre-Ebola period) to 85% and 65% during the intra and post-Ebola periods respectively. Institutional deliveries declined from 40% to 35% then to 30% respectively (p < 0.001). Also, the average of vaccination coverage declined from 86% to 65% then to 56% respectively for BCG (p < 0.001), from 90% to 50% then to 52% for Pentavalent-3 (p < 0.001), and from 84% to 33% then to 48% for Oral Polio vaccine (third dose) (p < 0.001). Ebola virus disease outbreak led to persistent decrease in antenatal care visits, institutional deliveries and vaccination coverages among children aged 0 to 11 months in the district health of Beyla intra and post Ebola outbreak. Further studies, using qualitative research methods, that explore perceptions of communities and women will better guide health response during outbreak, strengthen health systems and prevent future Ebola outbreak in Guinea.

Influence of Ebola on tuberculosis case finding and treatment outcomes in Liberia.

Setting: National Leprosy and Tuberculosis (TB) Control Programme, Liberia. Objectives: To assess TB case finding, including human immunodeficiency virus (HIV) associated interventions and treatment outcomes, before (January 2013-March 2014), during (April 2014-June 2015) and after (July-December 2015) the Ebola virus disease outbreak. Design: A cross-sectional study and retrospective cohort analysis of outcomes. Results: The mean quarterly numbers of individuals with presumptive TB and the proportion diagnosed as smear-positive were: pre-Ebola (n = 7032, 12%), Ebola (n = 6147, 10%) and post-Ebola (n = 6795, 8%). For all forms of TB, stratified by category and age group, there was a non-significant decrease in the number of cases from the pre-Ebola to the Ebola and post-Ebola periods. There were significant decreases in numbers of cases with smear-positive pulmonary TB (PTB) from the pre-Ebola period (n = 855), to the Ebola (n = 640, P < 0.001) and post-Ebola (n = 568, P < 0.001) periods. The proportions of patients tested for HIV, found to be HIV-positive and started on antiretroviral therapy decreased as follows: pre-Ebola (respectively 72%, 15% and 34%), Ebola (69%, 14% and 30%) and post-Ebola (68%, 12% and 26%). Treatment success rates among TB patients were: 80% pre-Ebola, 69% Ebola (P < 0.001) and 73% post-Ebola (P < 0.001). Loss to follow-up was the main contributing adverse outcome. Conclusion: The principal negative effects of Ebola were the significant decreases in diagnoses of smear-positive PTB, the declines in HIV testing and antiretroviral therapy uptake and poor treatment success. Ways to prevent these adverse effects from recurring in the event of another Ebola outbreak need to be found.

Influence of the 2014-2015 Ebola outbreak on the vaccination of children in a rural district of Guinea.

Setting: All health centres in Macenta District, rural Guinea. Objective: To compare stock-outs of vaccines, vaccine stock cards and the administration of various childhood vaccines across the pre-Ebola, Ebola and post-Ebola virus disease periods. Design: This was an ecological study. Results: Similar levels of stock-outs were observed for all vaccines (bacille Calmette-Guérin [BCG], pentavalent, polio, measles, yellow fever) in the pre-Ebola and Ebola periods (respectively 2760 and 2706 facility days of stock-outs), with some variation by vaccine. Post-Ebola, there was a 65-fold reduction in stock-outs compared to pre-Ebola. Overall, 24 facility-months of vaccine stock card stock-outs were observed during the pre-Ebola period, which increased to 65 facility-months of stock-outs during the Ebola outbreak period; no such stock-out occurred in the post-Ebola period. Apart from yellow fever and measles, vaccine administration declined universally during the peak outbreak period (August-November 2014). Complete cessation of vaccine administration for BCG and a prominent low for polio (86% decrease) were observed in April 2014, corresponding to vaccine stock-outs. Post-Ebola, overall vaccine administration did not recover to pre-Ebola levels, with the highest gaps seen in polio and pentavalent vaccines, which had shortages of respectively 40% and 38%. Conclusion: These findings highlight the need to sustain vaccination activities in Guinea so that they remain resilient and responsive, irrespective of disease outbreaks.

Knockdown and recovery of malaria diagnosis and treatment in Liberia during and after the 2014 Ebola outbreak.

Setting: The malaria-endemic country of Liberia, before, during and after the 2014 Ebola outbreak. Objective: To describe the consequences of the Ebola outbreak on Liberia's National Malaria Programme and its post-Ebola recovery. Design: A retrospective cross-sectional study using routine countrywide programme data. Results: Malaria caseloads decreased by 47% during the Ebola outbreak and by 11% after, compared to the pre-Ebola period. In those counties most affected by Ebola, a caseload reduction of >20% was sustained for 12 consecutive months, while this lasted for only 4 consecutive months in the counties least affected by Ebola. Linear regression of monthly proportions of confirmed malaria cases-as a proxy indicator of programme performance-over the pre- and post-Ebola periods indicated that the malaria programme could require 26 months after the end of the acute phase of the Ebola outbreak to recover to pre-Ebola levels. Conclusions: The differential persistence of reduced caseloads in the least- and most-affected counties, all of which experienced similar emergency measures, suggest that factors other than Ebola-related security measures played a key role in the programme's reduced performance. Clear guidance on when to abandon the emergency measures after an outbreak may be needed to ensure faster recovery of malaria programme performance.

Management of malaria in children with fever in rural Sierra Leone in relation to the 2014-2015 Ebola outbreak.

Setting: Sixty-eight primary health facilities, Koinadugu District, rural Sierra Leone. Objectives: Sierra Leone, a country with one of the highest burdens of malaria, was severely affected by the 2014-2015 Ebola virus disease outbreak. In under-five children, we compared trends in the completeness of malaria reports sent to the district office during the pre-Ebola, Ebola and post-Ebola periods, including the number of children with reported fever, malaria diagnostic testing performed and treatment for malaria initiated with artemisinin-based combination therapy (ACT). Design: A cross-sectional study. Results: Of 1904 expected malaria reports, 1289 (68%) were received. Completeness of reporting was 61% pre-Ebola, increased to 88% during the outbreak and dropped to 44% post-Ebola (P = 0.003). Total malaria testing (n = 105 558) exceeded the number of fever cases (n = 105 320). Pre-Ebola, 75% (n = 43 245) of all reported fever cases received malaria treatment, dropping to 34% (n = 50 453) during the Ebola outbreak. Of 36 804 confirmed malaria cases during Ebola, 17 438 (47%) were treated, significantly fewer than in the pre-Ebola period (96%, P < 0.001). Of the fever cases, 95% in both the pre- and post-Ebola periods received ACT, a rate that increased to 99% during the Ebola outbreak. Conclusion: Pre-existing gaps in malaria reporting worsened after the Ebola outbreak. Reassuringly, malaria testing matched fever cases, although only half of all confirmed cases received treatment during the outbreak, possibly explained by outbreak-related operational difficulties. These findings could be useful to guide health systems strengthening and recovery.

The influence of the Ebola outbreak on presumptive and active tuberculosis in Bombali District, Sierra Leone.

Setting: Bombali District, rural Sierra Leone. Objective: To compare the number of patients with presumptive tuberculosis (TB), the number of patients registered with TB (including testing for the human immunodeficiency virus [HIV] and initiation on antiretroviral therapy [ART]) and treatment outcomes during the pre-Ebola, Ebola and post-Ebola disease outbreak periods between 2013 and 2016. Design: This was a cross-sectional study and retrospective cohort analysis of treatment outcomes. Results: The mean monthly number of patients with presumptive TB before, during and post-Ebola was respectively 169, 145 and 210. The mean monthly number of registered TB cases was respectively 57, 57 and 96. Smear-positive TB was the most frequent type of TB, at 75%, 66% and 77%. The proportion of TB patients tested for HIV was 82% pre-Ebola, 74% Ebola and 99% post-Ebola. The proportion of HIV-positive patients with TB initiated on ART was respectively 46%, 85% and 100%. Treatment success among TB patients was 71% in the pre-Ebola period and 89% in the Ebola period (P < 0.001). Conclusion: During the Ebola outbreak, there were decreases in the number of presumptive TB patients and in the proportions of patients diagnosed with smear-positive TB and tested for HIV. The initiation of ART in HIV-infected TB patients and treatment outcomes remained acceptable. Pre-emptive actions are needed to maintain adequate control activities in future outbreaks.