Lessons learned for surveillance system strengthening through capacity building and partnership engagement in post-Ebola Guinea, 2015–2019

The 2014–2016 Ebola outbreak in Guinea revealed systematic weaknesses in the existing disease surveillance system, which contributed to delayed detection, underreporting of cases, widespread transmission in Guinea and cross-border transmission to neighboring Sierra Leone and Liberia, leading to the largest Ebola epidemic ever recorded. Efforts to understand the epidemic's scale and distribution were hindered by problems with data completeness, accuracy, and reliability. In 2017, recognizing the importance and usefulness of surveillance data in making evidence-based decisions for the control of epidemic-prone diseases, the Guinean Ministry of Health (MoH) included surveillance strengthening as a priority activity in their post-Ebola transition plan and requested the support of partners to attain its objectives. The U.S. Centers for Disease Control and Prevention (US CDC) and four of its implementing partners—International Medical Corps, the International Organization for Migration, RTI International, and the World Health Organization—worked in collaboration with the Government of Guinea to strengthen the country's surveillance capacity, in alignment with the Global Health Security Agenda and International Health Regulations 2005 objectives for surveillance and reporting. This paper describes the main surveillance activities supported by US CDC and its partners between 2015 and 2019 and provides information on the strategies used and the impact of activities. It also discusses lessons learned for building sustainable capacity and infrastructure for disease surveillance and reporting in similar resource-limited settings

Estimating the number of secondary Ebola cases resulting from an unsafe burial and risk factors for transmission during the West Africa Ebola epidemic

<div><p>Background</p><p>Safely burying Ebola infected individuals is acknowledged to be important for controlling Ebola epidemics and was a major component of the 2013–2016 West Africa Ebola response. Yet, in order to understand the impact of safe burial programs it is necessary to elucidate the role of unsafe burials in sustaining chains of Ebola transmission and how the risk posed by activities surrounding unsafe burials, including care provided at home prior to death, vary with human behavior and geography.</p><p>Methodology/Principal findings</p><p>Interviews with next of kin and community members were carried out for unsafe burials in Sierra Leone, Liberia and Guinea, in six districts where the Red Cross was responsible for safe and dignified burials (SDB). Districts were randomly selected from a district-specific sampling frame comprised of villages and neighborhoods that had experienced cases of Ebola. An average of 2.58 secondary cases were potentially generated per unsafe burial and varied by district (range: 0–20). Contact before and after death was reported for 142 (46%) contacts. Caregivers of a primary case were 2.63 to 5.92 times more likely to become EVD infected compared to those with post-mortem contact only. Using these estimates, the Red Cross SDB program potentially averted between 1,411 and 10,452 secondary EVD cases, reducing the epidemic by 4.9% to 36.5%.</p><p>Conclusions/Significance</p><p>SDB is a fundamental control measure that limits community transmission of Ebola; however, for those individuals having contact before and after death, it was impossible to ascertain the exposure that caused their infection. The number of infections prevented through SDB is significant, yet greater impact would be achieved by early hospitalization of the primary case during acute illness.</p></div

Reported illness after contact with the primary case and timing of contact as reported by key informants.

<p>Reported illness after contact with the primary case and timing of contact as reported by key informants.</p

Number of safe and dignified burials carried out by the Red Cross by country and the number of those deaths that were EVD positive.

<p>Number of safe and dignified burials carried out by the Red Cross by country and the number of those deaths that were EVD positive.</p

Estimates and uncertainty in the number of secondary cases caused by an unsafe burial, by district.

<p>Boxes enclose the interquartile range of each estimate (extending from the 25th percentile to the 75th percentile). The thick horizontal lines within each box correspond to the median. Capped vertical lines encompass the total range of variability in the estimate.</p

Reported cases in the WHO patient database and burials over time in Sierra Leone (left), Liberia (center) and Guinea (right).

<p>Colored dots show reported cases from the WHO patient database. Dotted lines show the total number of recorded burials carried out. Solid lines show estimates of the number of burials of EVD casualties, reconstructed from laboratory testing of swab samples collected from community deaths.</p

Estimates and uncertainty in the number of secondary cases caused by an unsafe burial, pooled across districts, for baseline and ceiling estimates.

<p>Thick horizontal lines show median estimate, boxes enclose the interquartile range in the estimate (between the 25^th and 75^th percentile) across primary cases and districts. Capped vertical lines encompass the total range of variability in the estimate.</p

Types of contact with primary cases as reported by key informants by country and district.

<p>Types of contact with primary cases as reported by key informants by country and district.</p

Population and area estimates for the districts where unsafe burials were investigated.

<p>Population and area estimates for the districts where unsafe burials were investigated.</p

Description of reported primary case contacts as described by key informants by country and district.

<p>Description of reported primary case contacts as described by key informants by country and district.</p