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Guinea, Liberia, Sierra Leone

Ebola : the results of nine months of operational research

Operational Research News 
From September 2014 onwards, MSF started publishing field research studies describing various aspects of its Ebola emergency programs, and whose results led to multiple implications for Ebola interventions in West Africa.

    On Friday 29th May, MSF organizes the Operational Research Day in Brussels, a medical conference whose afternoon will be devoted to research on Ebola programs. The presentations and discussions will address amongst other things the medical care, community perception, tracking Ebola survivors, and control of the infection chain. For if the program or follow the live discussion, click here.


    1. Hospitalization

    Patients come from all levels of society and of all age groups. The only risk factors for death that could be identified were age (the young and the elderly) and a high viral load. In Kailahun (Sierra Leone), most of the patients presented late, on average five days after symptom onset, which was likely a major driver of the epidemic in the district. On average, half of our patients did not survive Ebola, however there was a substantial variation in mortality over time and across treatment centres, requiring further investigation.

    Pregnant women deserve close attention in an Ebola case management centre (CMC), and cases were described in the three Ebola-affected countries in West Africa. In contrast with previous outbreaks, where almost all Ebola-infected pregnant women died, survival of more than thirty pregnant women was documented. However, most pregnancies ended with stillbirths, and no neonates born to women cured from Ebola survived longer than two days.

    Foetuses, amniotic fluid, breastmilk and the placenta were highly positive for Ebola virus, even one month after the mother is cured. One case of a pregnant woman testing positive for Ebola virus prior to symptom onset was described. These observations carried important implications for infection control:

    • pregnancy tests should be offered to all female Ebola patients of childbearing age
    • termination of pregnancy should be offered
    • all pregnant women surviving Ebola should deliver in an Ebola treatment centre with strict infection control measures
    • breastfeeding among survivors should be discouraged
    • the general message of “no infectiousness prior to symptoms” should be treated with caution, in particular among pregnant women.

    Available publications :

        - Ebola virus disease in West Africa – clinical manifestations and management
        - Ebola outbreak in rural West Africa: epidemiology, clinical features and outcomes
        - The contribution of Ebola viral load at admission and other patient characteristics to mortality in a Médecins Sans Frontières (MSF) Ebola Case Management Centre (CMC), Kailahun, Sierra Leone, June –October, 2014
        - Patient characteristics and risk of mortality in the MSF Ebola Management Centres (EMCs) during the West African Ebola outbreak - Preliminary Analysis
        - Blood, birthing and body fluids: Delivering and staying alive in an Ebola Management Centre
        - Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014
        - Lactating mothers infected with Ebola virus: EBOV RT-PCR of blood only may be insufficient

    2. Survivors

    MSF assessed the mental health burden among Ebola survivors from the MSF treatment centres in Kailahun and ELWA 3 in Monrovia. Stigma in the community was frequently described, and considerable psychological consequences existed. The pattern of post-traumatic stress reactions resembled that found in survivors of war or natural disasters. Qualitative research in Monrovia showed how survivors found themselves caught between two identities: presented as the ‘heroes’ and ‘success stories’ of the epidemic by humanitarian agencies, and at the same time facing stigma, loss and fear in their communities.

    Male survivors in particular became the targets of anger and discrimination out of fears that they could still transmit the Ebola virus through sexual intercourse, and individual male survivors were seen as a threat to the wellbeing of whole communities. Only one case described in Monrovia suggested infection through sexual intercourse with a survivor five months after discharge. This case carried multiple implications for public health recommendations, while underscoring the need for clear communication around Ebola survivors, and for assistance to survivors, their families and communities through outreach activities and support to survivors’ organisations.

    Approximately one third of the Ebola suspects admitted to a treatment centre are tested negative and return home after admission; some of them subsequently return and test positive. In Kailahun, MSF assessed whether such readmissions could be due to exposure in the centre. All readmitted patients had at least one high-risk exposure during their incubation period other than their first admission, suggesting that the suspect area of the treatment centre was probably not the main source of infection for these patients.

    Available publications :

        - Describing readmissions to an Ebola case management centre, Sierra Leone, 2014
        - Post-traumatic stress reactions in Ebola patient survivors in Sierra Leone
        - What Does It Mean To Be A Survivor? The Identity and Stigmatisation of Ebola Survivors in Monrovia, Liberia
        - Possible Sexual Transmission of Ebola Virus — Liberia, 2015

    3. Community perceptions

    Community perceptions of the MSF interventions and different responses are crucial to the success of the interventions.

    Anthropological research in Liberia showed the total disruption of social networks, family ties and solidarities. The top-down decision on mandatory cremation for all Ebola-related deaths in Liberia fed the mistrust and sense of abandonment within the communities. Similarly, enforced quarantine of households and individuals, combined with mismanagement of the supporting measures (food provision, health monitoring, etc.) led to a widening divide between aid agencies and the population, and in general the enforced nature of such measures undermined their efficacy, with unsafe burials occurring illegally, and evasion or escape from the quarantine observed frequently. It is crucial for the Ebola intervention to restore transparency, trust and mutual help in the communities.

    The perceptions of the ELWA 3 centre in Monrovia changed over time. Community members initially showed resistance and fear due to transmission risks, but over time saw a perceived benefit of having a centre nearby providing treatment and support.  They also saw the centre as a resource from which they could benefit as a community. Ongoing engagement with the local community and transparency of treatment centres is essential to build trust and gain acceptance.

    Finally, perceptions of the therapeutic treatment trials in which MSF was involved were assessed. There was a high general acceptability of trials and new drugs amongst the community, and people expressed their desperation for a way of treating Ebola. An early, clear and straight-forward communication policy was seen as essential to engage the general population. Health-care workers should be actively engaged in this process, since they function as important informal sources of information for their communities. Transparency is essential to empower and inform local populations, which is necessary to minimize rumours that could have a detrimental effect on research acceptance.

    Available publications:

       - State-enforced Ebola containment measures in Liberia: a view from the communities

    4. Transmission in the community and triage at the Ebola center

    MSF documented the transmission chains of the start of the outbreak in Guéckédou, Guinea, and in Bo district, Sierra Leone.

    In Bo district, Sierra Leone, preparedness was started before the first case arrived in the district, but the control over the situation was quickly lost due to the magnitude of the outbreak and the shortage of human resources in the field. Unsafe funerals, hospital transmission, and household contacts were identified as the main drivers of the outbreak early on, but documentation of transmission became sparse as control over the outbreak was lost.

    Triaging suspect Ebola cases in high and low risk categories may prevent infection while waiting for test results in the suspect area of a treatment centre. Accommodation of patients in single compartments instead of wards until they receive their test result, or grouping patients by their risk of transmission, may be the best strategy to reduce the risk of nosocomial infection.

    Available publications:

        - Emergence of Zaire Ebola Virus Disease in Guinea
        - Is there added value in separating admitted Ebola patients into suspect and highly suspect wards pending laboratory confirmation?