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During the 2018-2020 Ebola virus disease (EVD) outbreak in North Kivu province in the Democratic Republic of Congo, EVD was diagnosed in a patient who had received the recombinant vesicular stomatitis virus-based vaccine expressing a ZEBOV glycoprotein (rVSV-ZEBOV) (Merck). His treatment included an Ebola virus (EBOV)-specific monoclonal antibody (mAb114), and he recovered within 14 days. However, 6 months later, he presented again with severe EVD-like illness and EBOV viremia, and he died. We initiated epidemiologic and genomic investigations that showed that the patient had had a relapse of acute EVD that led to a transmission chain resulting in 91 cases across six health zones over 4 months. (Funded by the Bill and Melinda Gates Foundation and others.).

The tenth outbreak of Ebola virus disease (EVD) in North Kivu, the Democratic Republic of the Congo (DRC), was declared 8 days after the end of the ninth EVD outbreak, in the Equateur Province on August 1, 2018. With a total of 3,461 confirmed and probable cases, the North Kivu outbreak was the second largest outbreak after that in West Africa in 2014–2016, and the largest observed in the DRC. This outbreak was difficult to control because of multiple challenges, including armed conflict, population displacement, movement of contacts, community mistrust, and high population density. It took more than 21 months to control the outbreak, with critical innovations and systems put into place. We describe systems that were put into place during the EVD response in the DRC that can be leveraged for the response to the current COVID-19 global pandemic.

At the end of the 2013-2016 Ebola virus disease outbreak in Guinea, we implemented an alert system for early detection of Ebola resurgence among survivors. Survivors were asked to report health alerts in their household and provide body fluid specimens for laboratory testing. During April-September 2016, a total of 1,075 (88%) of 1,215 survivors participated in the system; follow up occurred at a median of 16 months after discharge (interquartile range 14-18 months). Of these, 784 acted as focal points and reported 1,136 alerts (including 4 deaths among survivors). A total of 372 (91%) of 408 eligible survivors had >1 semen specimen tested; of 817 semen specimens, 5 samples from 4 survivors were positive up to 512 days after discharge. No lochia (0/7) or breast milk (0/69) specimens tested positive. Our findings underscore the importance of long-term monitoring of survivors' semen samples in an Ebola-affected country.

Summary Background Women across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries. Methods We prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment. Findings 2016 labour observations and 2672 surveys were done. 838 (41·6%) of 2016 observed women and 945 (35·4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75·1%] of 253; survey: 295 [56·1%] of 526) or caesarean section (observation: 35 [13·4%] of 261; survey: 52 [10·8%] of 483), despite receiving these procedures. 133 (5·0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15–19 years) and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio [OR] 3·6, 95% CI 1·6–8·0) and younger women with some education (OR 1·6, 1·1–2·3) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity. Interpretation More than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context. Funding United States Agency for International Development and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO.

Summary Background A record number of people survived Ebola virus infection in the 2013–16 outbreak in west Africa, and the number of survivors has increased after subsequent outbreaks. A range of post-Ebola sequelae have been reported in survivors, but little is known about subsequent mortality. We aimed to investigate subsequent mortality among people discharged from Ebola treatment units. Methods From Dec 8, 2015, Surveillance Active en ceinture, the Guinean national survivors' monitoring programme, attempted to contact and follow-up all survivors of Ebola virus disease who were discharged from Ebola treatment units. Survivors were followed up until Sept 30, 2016, and deaths up to this timepoint were recorded. Verbal autopsies were done to gain information about survivors of Ebola virus disease who subsequently died from their closest family members. We calculated the age-standardised mortality ratio compared with the general Guinean population, and assessed risk factors for mortality using survival analysis and a Cox proportional hazards regression model. Findings Of the 1270 survivors of Ebola virus disease who were discharged from Ebola treatment units in Guinea, information was retrieved for 1130 (89%). Compared with the general Guinean population, survivors of Ebola virus disease had a more than five-times increased risk of mortality up to Dec 31, 2015 (age-standardised mortality ratio 5·2 [95% CI 4·0–6·8]), a mean of 1 year of follow-up after discharge. Thereafter (ie, from Jan 1–Sept 30, 2016), mortality did not differ between survivors of Ebola virus disease and the general population. (0·6 [95% CI 0·2–1·4]). Overall, 59 deaths were reported, and the cause of death was tentatively attributed to renal failure in 37 cases, mostly on the basis of reported anuria. Longer stays (ie, equal to or longer than the median stay) in Ebola treatment units were associated with an increased risk of late death compared with shorter stays (adjusted hazard ratio 2·62 [95% CI 1·43–4·79]). Interpretation Mortality was high in people who recovered from Ebola virus disease and were discharged from Ebola treatment units in Guinea. The finding that survivors who were hospitalised for longer during primary infection had an increased risk of death, could help to guide current and future survivors' programmes and in the prioritisation of funds in resource-constrained settings. The role of renal failure in late deaths after recovery from Ebola virus disease should be investigated. Funding WHO, International Medical Corps, and the Guinean Red Cross.

Understanding risk factors for Ebola transmission is key for effective prediction and design of interventions. We used data on 860 cases in 129 chains of transmission from the latter half of the 2013–2016 Ebola epidemic in Guinea. Using negative binomial regression, we determined characteristics associated with the number of secondary cases resulting from each infected individual. We found that attending an Ebola treatment unit was associated with a 38% decrease in secondary cases (incidence rate ratio (IRR) = 0.62, 95% confidence interval (CI): 0.38, 0.99) among individuals that did not survive. Unsafe burial was associated with a higher number of secondary cases (IRR = 1.82, 95% CI: 1.10, 3.02). The average number of secondary cases was higher for the first generation of a transmission chain (mean = 1.77) compared with subsequent generations (mean = 0.70). Children were least likely to transmit (IRR = 0.35, 95% CI: 0.21, 0.57) compared with adults, whereas older adults were associated with higher numbers of secondary cases. Men were less likely to transmit than women (IRR = 0.71, 95% CI: 0.55, 0.93). This detailed surveillance data set provided an invaluable insight into transmission routes and risks. Our analysis highlights the key role that age, receiving treatment, and safe burial played in the spread of EVD.

Summary: Background: Amid efforts to improve the quality of care for women and neonates during childbirth, there is growing interest in the experience of care, including respectful care practices. However, there is little research on the prevalence of practices that might constitute mistreatment of neonates. This study aims to describe the care received by neonates up to 2 h after birth in a sample of three countries in west Africa. Methods: Data from this multicountry, facility-based, observational study were collected on 15 neonatal care practices across nine facilities in Ghana, Guinea, and Nigeria, as part of WHO's wider multicountry study on how women are treated during childbirth. Women were eligible if they were admitted to the participating health facilities for childbirth, in early established labour or active labour, aged 15 years or older, and provided written informed consent on behalf of themselves and their neonate. All labour observations were continuous, one-to-one observations of women and neonates by independent data collectors. Descriptive statistics and multivariate logistic regressions were used to examine associations between these neonatal care practices, maternal and neonate characteristics, and maternal mistreatment. Early neonate deaths, stillbirths, and higher order multiple births were excluded from analysis. Findings: Data collection took place from Sept 19, 2016, to Feb 26, 2017, in Nigeria; from Aug 1, 2017, to Jan 18, 2018, in Ghana; and from July 1 to Oct 30, 2017, in Guinea. We included data for 362 women–neonate dyads (356 [98%] with available data for neonatal care practices) in Nigeria, 760 (749 [99%]) in Ghana, and 558 (522 [94%]) in Guinea. Delayed cord clamping was done for most neonates (1493 [91·8%] of 1627); other practices, such as skin-to-skin contact, were less commonly done (1048 [64·4%]). During the first 2 h after birth, separation of the mother and neonate occurred in 844 (51·9%) of 1627 cases; and was more common for mothers who were single (adjusted odds ratio [AOR; adjusting for country, maternal age, education, marital status, neonate weight at birth, and neonate sex] 1·8, 95% CI 1·3–2·6) than those who were married or cohabiting. Lack of maternal education was associated with increased likelihood of neonates not receiving recommended breastfeeding practices. Neonates with a low birthweight (

BackgroundEvidence has shown the benefits of labour companions during childbirth. Few studies have documented the relationship between the absence of labour companions and mistreatment of women during childbirth in low-income and middle-income countries using a standardised tool.MethodsWe conducted a secondary analysis of the WHO multi-country study on how women are treated during childbirth, where a cross-sectional community survey was conducted with women up to 8 weeks after childbirth in Ghana, Guinea, Nigeria and Myanmar. Descriptive analysis and multivariable logistic regression were used to examine whether labour companionship was associated with various types of mistreatment.ResultsOf 2672 women, about half (50.4%) reported the presence of a labour companion. Approximately half (49.6%) of these women reported that the timing of support was during labour and after childbirth and most of the labour companions (47.0%) were their family members. Across Ghana, Guinea and Nigeria, women without a labour companion were more likely to report physical abuse, non-consented medical procedures and poor communication compared with women with a labour companion. However, there were country-level variations. In Guinea, the absence of labour companionship was associated with any physical abuse, verbal abuse, or stigma or discrimination (adjusted OR (AOR) 3.6, 1.9–6.9) and non-consented vaginal examinations (AOR 3.2, 1.6–6.4). In Ghana, it was associated with non-consented vaginal examinations (AOR 2.3, 1.7–3.1) and poor communication (AOR 2.0, 1.3–3.2). In Nigeria, it was associated with longer wait times (AOR 0.6, 0.3–0.9).ConclusionLabour companionship is associated with lower levels of some forms of mistreatment that women experience during childbirth, depending on the setting. Further work is needed to ascertain how best to implement context-specific labour companionship to ensure benefits while maintaining women’s choices and autonomy.

Background Despite the predictive role of body weight variation in treatment outcome in multidrug-resistant tuberculosis (MDR-TB), few corroborating data are available. We studied weight variation in patients with MDR-TB to identify groups of weight change and to determine factors that influence these changes. Methods We analyzed patients with rifampicin resistance who were treated with an MDR-TB treatment regimen between June 07, 2016 and June 22, 2018 at three major drug-resistant TB centers in Guinea. Patients were seen monthly until the end of treatment. Clinical outcome was the body mass index (BMI). We used a linear mixed model to analyze trajectories of BMI and a latent class mixed model to identify groups of BMI trajectories. Results Of 232 patients treated for MDR-TB during the study period, 165 were analyzed. These patients had a total of 1387 visits, with a median of 5 visits (interquartile range, 3–8 visits). Monthly BMI increase was 0.24 (SE 0.02) per kg/m2. Factors associated with faster BMI progression were success of MDR-TB treatment (0.24 [SE 0.09] per kg/m2; p = 0.0205) and absence of lung cavities on X-ray (0.18 [0.06] per kg/m2; p = 0.0068). Two groups of BMI change were identified: rapid BMI increase (n = 121; 85%) and slow BMI increase (n = 22; 15%). Patients in the slow BMI increase group were mostly female (68%) had no history of TB treatment (41%), had a positive HIV infection (59%), and had a more severe clinical condition at baseline, characterized by a higher frequency of symptoms including depression (18%), dyspnea (68%), poor adherence to MDR-TB treatment (64%), lower platelet count, and higher SGOT. These patients also had a longer time to initial culture conversion (log-rank test: p = 0.0218). Conclusion Quantitative BMI data on patients with MDR-TB treated with a short regimen allowed the identification of subgroups of patients with different trajectories of BMI and emphasized the usefulness of BMI as a biomarker for the monitoring of MDR-TB treatment outcome.

The 2014–2016 Ebola virus (EBOV) disease outbreak affected over 29000 people and left behind the biggest cohort (over 17000 individuals) of Ebola survivors in history. Although the persistence of EBOV in body fluids of survivors was reported before the recent outbreak, new evidence revealed that the virus can be detected up to 18 months in the semen, which represents the biggest risk of Ebola resurgence in affected communities. In this study, we review the knowledge on the Ebola flare-ups that occurred after the peak of the 2014–2016 Ebola epidemic in West Africa.

Background By the end of the 2013–2016 West African Ebola Virus Disease (EVD) outbreaks, a total of 3814 cases (probable and confirmed) and 2544 deaths were reported in Guinea. Clearly, surveillance activities aiming at stopping human-to-human transmission have been the breakthrough of EVD outbreak management, but their application has been at times easier said than done. This article presents five confirmed or probable EVD cases that arose in Conakry towards the end of the Guinea epidemic, which demonstrate flaws in surveillance and follow-up. Case presentation For case 1, safe burial requirements were not followed. For cases 1 and 2, negative Polymerase Chain Reaction (PCR) results were interpreted as no infection. For the first case, the sample may have not been taken properly while for the second the disease was possibly at its early stage. Case 3 was stopped at a border health checkpoint and despite her high temperature she was allowed to continue the bus journey. For case 4, an oral swab sample was supposedly taken after death but could not be found for retrospective testing. Despite characteristic symptomatology, case 5 was not identified as a suspect case for as long as 3 weeks. Conclusion In epidemic contexts, health systems must be able to track all samples of suspect cases and deaths, regardless of their laboratory results. Social mobilization in communities and training in health care facilities must be strengthened at the tail of an outbreak, to avoid the natural slackening of disease surveillance, in particular for long-lasting and deadly epidemics.

The ongoing Ebola outbreak in the eastern Democratic Republic of the Congo is facing unprecedented levels of insecurity and violence. We evaluate the likely impact in terms of added transmissibility and cases of major security incidents in the Butembo coordination hub. We also show that despite this additional burden, an adapted response strategy involving enlarged ring vaccination around clusters of cases and enhanced community engagement managed to bring this main hotspot under control.

In 2015, favipiravir was administered on a compassionate-use basis to patients with Ebola virus disease in Guinea. This study reveals a trend toward improved survival in favipiravir-treated patients; however, the effect of treatment was not statistically significant, except for its influence on survival time., Background In 2015, the laboratory at the Ebola treatment center in Coyah, Guinea, confirmed Ebola virus disease (EVD) in 286 patients. The cycle threshold (Ct) of an Ebola virus–specific reverse transcription–polymerase chain reaction assay and 13 blood chemistry parameters were measured on admission and during hospitalization. Favipiravir treatment was offered to patients with EVD on a compassionate-use basis. Methods To reduce biases in the raw field data, we carefully selected 163 of 286 patients with EVD for a retrospective study to assess associations between potential risk factors, alterations in blood chemistry findings, favipiravir treatment, and outcome. Results The case-fatality rate in favipiravir-treated patients was lower than in untreated patients (42.5% [31 of 73] vs 57.8% [52 of 90]; P = .053 by univariate analysis). In multivariate regression analysis, a higher Ct and a younger age were associated with survival (P < .001), while favipiravir treatment showed no statistically significant effect (P = .11). However, Kaplan-Meier analysis indicated a longer survival time in the favipiravir-treated group (P = .015). The study also showed characteristic changes in blood chemistry findings in patients who died, compared with survivors. Conclusions Consistent with the JIKI trial, this retrospective study revealed a trend toward improved survival in favipiravir- treated patients; however, the effect of treatment was not statistically significant, except for its influence on survival time.

Summary Background The real-time generation of information about pathogen genomes has become a vital goal for transmission analysis and characterisation in rapid outbreak responses. In response to the recently established genomic capacity in the Democratic Republic of the Congo, we explored the real-time generation of genomic information at the start of the 2018 Ebola virus disease (EVD) outbreak in North Kivu Province. Methods We used targeted-enrichment sequencing to produce two coding-complete Ebola virus genomes 5 days after declaration of the EVD outbreak in North Kivu. Subsequent sequencing efforts yielded an additional 46 genomes. Genomic information was used to assess early transmission, medical countermeasures, and evolution of Ebola virus. Findings The genomic information demonstrated that the EVD outbreak in the North Kivu and Ituri Provinces was distinct from the 2018 EVD outbreak in Equateur Province of the Democratic Republic of the Congo. Primer and probe mismatches to Ebola virus were identified in silico for all deployed diagnostic PCR assays, with the exception of the Cepheid GeneXpert GP assay. Interpretation The first two coding-complete genomes provided actionable information in real-time for the deployment of the rVSVΔG-ZEBOV-GP Ebola virus envelope glycoprotein vaccine, available therapeutics, and sequence-based diagnostic assays. Based on the mutations identified in the Ebola virus surface glycoprotein (GP12) observed in all 48 genomes, deployed monoclonal antibody therapeutics (mAb114 and ZMapp) should be efficacious against the circulating Ebola virus variant. Rapid Ebola virus genomic characterisation should be included in routine EVD outbreak response procedures to ascertain efficacy of medical countermeasures. Funding Defense Biological Product Assurance Office.

Les envenimations ophidiennes constituent un probleme de sante publique en Afrique, entrainant 20 000 deces annuels. Cette mortalite traduit les difficultes de prise en charge des complications en particuliers hemorragiques. Nous rapportons le cas de Mr SL 35 ans, agriculteur, victime d'une morsure de vipere entrainant un syndrome hemorragique, suivi d'un abdomen aigu d'installation progressive. L'echographie objectivait un epanchement de grande abondance, dont la ponction ramenait du sang incoagulable. Devant la reconstitution de l'hemoperitoine apres trois doses de serum antivenimeux et la coagulation des prelevements sur tube sec, une laparotomie exploratrice etait realisee a J9. Elle a retrouve un hematome retro peritoneal bombant dans le meso-colon et qui s'ecoulait dans la cavite peritoneale. Le geste a consiste a une evacuation de 1500ml de sang, et un toilettage au serum physiologique. Les suites operatoires ont ete simples. Le patient etait transfere en secteur d'hospitalisation de chirurgie a J3 post operatoire puis sortie d'hopital a J19.

In October 2015, a new case of Ebola virus disease in Guinea was detected. Case investigation, serology, and whole-genome sequencing indicated possible transmission of the virus from an Ebola virus disease survivor to another person and then to the case-patient reported here. This transmission chain over 11 months suggests slow Ebola virus evolution.

Objectives The objective of the study was to present the findings of an audit tool aimed at assessing contact tracing activities during an Ebola outbreak. Methods The tool was based on Ebola guidelines and observations in the field. It was composed of 38 indicators covering contact tracing preparatives, resources, procedures and results. Results All contact tracing teams were assessed in Boke and Conakry prefectures (24 supervisors, 22 community workers, 442 contacts) between 1 July and 10 August 2015. Contact lists had less than a 40% accomplishment rate. 7% of the contacts were not seen by community workers or supervisors. 'No touch policy' was fully respected. Conclusion Audit checklist helped to systematically identify critical issues related to contact tracing.

Publisher's version (útgefin grein), [No abstract available], The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Background The PR1MaC study was conducted to evaluate the integration of Chronic Disease Prevention and Management services into primary care practices and was reported effective. The aim of this study was to further explore the effects of the PR1MaC intervention on patients and their family. Methods We conducted a qualitative study embedded in a randomized controlled trial. The trial was implemented in eight primary health care practices in the Saguenay region, Quebec, Canada. The interdisciplinary patient-centred team-based intervention included self-management support and a motivational approach. We conducted focus groups and semi-directed individual interviews with patients, family members and healthcare professionals. Results Perceived positive effects can be grouped into six major themes: awareness, improved knowledge, improved motivation and empowerment, adoption of healthy behaviours, improvement of health status and improvement of quality of life. On the negative side, some participants reported lack of sustainability of newly acquired benefits in the months following the intervention. Conclusions Integrating chronic disease prevention and management services into primary care settings had impacts on patients and their family members. These findings are consistent with findings that were reported in the quantitative study. Further studies should address longterm sustainabilility in terms of benefits for the patients. Trial registration ClinicalTrials.gov, no.: NCT01319656. Electronic supplementary material The online version of this article (10.1186/s12875-018-0898-z) contains supplementary material, which is available to authorized users.

Background Efforts to improve maternal health are increasingly focused on improving the quality of care provided to women at health facilities, including the promotion of respectful care and eliminating mistreatment of women during childbirth. A WHO-led multi-country research project aims to develop and validate two tools (labor observation and community survey) to measure how women are treated during facility-based childbirth. This paper describes the development process for these measurement tools, and how they were implemented in a multi-country study (Ghana, Guinea, Myanmar and Nigeria). Methods An iterative mixed-methods approach was used to develop two measurement tools. Methodological development was conducted in four steps: (1) initial tool development; (2) validity testing, item adjustment and piloting of paper-based tools; (3) conversion to digital, tablet-based tools; and (4) data collection and analysis. These steps included systematic reviews, primary qualitative research, mapping of existing tools, item consolidation, peer review by key stakeholders and piloting. Results The development, structure, administration format, and implementation of the labor observation and community survey tools are described. For the labor observations, a total of 2016 women participated: 408 in Nigeria, 682 in Guinea, and 926 in Ghana. For the community survey, a total of 2672 women participated: 561 in Nigeria, 644 in Guinea, 836 in Ghana, and 631 in Myanmar. Of the 2016 women who participated in the labor observations, 1536 women (76.2%) also participated in the community survey and have linked data: 779 in Ghana, 425 in Guinea, and 332 in Nigeria. Conclusions An important step to improve the quality of maternity care is to understand the magnitude and burden of mistreatment across contexts. Researchers and healthcare providers in maternal health are encouraged to use and implement these tools, to inform the development of more women-centered, respectful maternity healthcare services. By measuring the prevalence of mistreatment of women during childbirth, we will be able to design and implement programs and policies to transform maternity services. Electronic supplementary material The online version of this article (10.1186/s12874-018-0603-x) contains supplementary material, which is available to authorized users.

The 2017 plague outbreak in Madagascar was unprecedented in the African region, resulting in 2417 cases (498 confirmed, 793 probable and 1126 suspected) and 209 deaths by the end of the acute urban pneumonic phase of the outbreak. The Health Emergencies Programme of the WHO Regional Office for Africa together with the WHO Country Office and WHO Headquarters assisted the Ministry of Public Health of Madagascar in the rapid implementation of plague prevention and control measures while collecting and analysing quantitative and qualitative data to inform immediate interventions. We document the key findings of the evidence available to date and actions taken as a result. Based on the four goals of operational research – effective dissemination of results, peer-reviewed publication, changes to policy and practice and improvements in programme performance and health – we evaluate the use of evidence to inform response to the outbreak and describe lessons learned for future outbreak responses in the WHO African region. This article may not be reprinted or reused in any way in order to promote any commercial products or services.

Background\ud \ud On May 8, 2018, the Government of the Democratic Republic of the Congo reported an outbreak of Ebola virus disease in Équateur Province in the northwest of the country. The remoteness of most affected communities and the involvement of an urban centre connected to the capital city and neighbouring countries makes this outbreak the most complex and high risk ever experienced by the Democratic Republic of the Congo. We provide early epidemiological information arising from the ongoing investigation of this outbreak.\ud Methods\ud \ud We classified cases as suspected, probable, or confirmed using national case definitions of the Democratic Republic of the Congo Ministère de la Santé Publique. We investigated all cases to obtain demographic characteristics, determine possible exposures, describe signs and symptoms, and identify contacts to be followed up for 21 days. We also estimated the reproduction number and projected number of cases for the 4-week period from May 25, to June 21, 2018.\ud Findings\ud \ud As of May 30, 2018, 50 cases (37 confirmed, 13 probable) of Zaire ebolavirus were reported in the Democratic Republic of the Congo. 21 (42%) were reported in Bikoro, 25 (50%) in Iboko, and four (8%) in Wangata health zones. Wangata is part of Mbandaka, the urban capital of Équateur Province, which is connected to major national and international transport routes. By May 30, 2018, 25 deaths from Ebola virus disease had been reported, with a case fatality ratio of 56% (95% CI 39–72) after adjustment for censoring. This case fatality ratio is consistent with estimates for the 2014–16 west African Ebola virus disease epidemic (p=0·427). The median age of people with confirmed or probable infection was 40 years (range 8–80) and 30 (60%) were male. The most commonly reported signs and symptoms in people with confirmed or probable Ebola virus disease were fever (40 [95%] of 42 cases), intense general fatigue (37 [90%] of 41 cases), and loss of appetite (37 [90%] of 41 cases). Gastrointestinal symptoms were frequently reported, and 14 (33%) of 43 people reported haemorrhagic signs. Time from illness onset and hospitalisation to sample testing decreased over time. By May 30, 2018, 1458 contacts had been identified, of which 746 (51%) remained under active follow-up. The estimated reproduction number was 1·03 (95% credible interval 0·83–1·37) and the cumulative case incidence for the outbreak by June 21, 2018, is projected to be 78 confirmed cases (37–281), assuming heterogeneous transmissibility.\ud Interpretation\ud \ud The ongoing Ebola virus outbreak in the Democratic Republic of the Congo has similar epidemiological features to previous Ebola virus disease outbreaks. Early detection, rapid patient isolation, contact tracing, and the ongoing vaccination programme should sufficiently control the outbreak. The forecast of the number of cases does not exceed the current capacity to respond if the epidemiological situation does not change. The information presented, although preliminary, has been essential in guiding the ongoing investigation and response to this outbreak.

Objective: Objectives of this study were to calculate the rate of stillbirth in the Regional Hospital Kindia maternity and describe the sociodemographic profile of pregnant women that gave birth to stillborn children. Methodology: This was a prospective descriptive type study on all stillbirths (mother and newborn) received in the Regional Kindia hospital maternity over a period of 12 months from 1 January to 31 December 2012 on a continuous series of 139 cases of stillbirth. Result: The stillbirth rates found in our study are diverse and higher in the group of women with the following characteristics: high maternal age (75‰ in women 40 years or more), lower level study (88.98‰), low socio-economic level (52.16‰), the unmarried status (54.01‰), medical evacuation (95.23‰), multiparity (97.56‰), poor prenatal care (110.56‰). New born males were most affected (64.03‰), as well as those from a full-term pregnancy (79.86‰) and those with normal birth weight (82.73‰). Morphologically, most newborns were not macerated (71.94‰), the rate was higher in case of breech presentation (87.37‰). In case of associated maternal morbidities, the rate of stillbirth was 205.81‰. Conclusion: The high rate of stillbirth in our series is the result of poor management of pregnancy and labor, the low purchasing power of the population, a low level of education F.B. Diallo (*) · I.S. Balde · A. Diallo · I. Conte Service de gyneco-obstetrique, Universite de Conakry, CHU Ignace Deen, BP 1819 Conakry, Guinee e-mail : bindiallo223@hotmail.com B.S. Diallo · O. Balde · A. Beavogui Service de gyneco-obstetrique Donka B. Diallo Maternite hopital regional de Kindia Rev. Med. Perinat. (2015) 7:187-191 DOI 10.1007/s12611-015-0324-x

On 11 May 2015, the Dubréka prefecture, Guinea, reported nine laboratory-confirmed cases of Ebola virus disease (EVD). None could be epidemiologically linked to cases previously reported in the prefecture. We describe the epidemiological and molecular investigations of this event. We used the Dubréka EVD registers and the Ebola treatment centre’s (ETC) records to characterise chains of transmission. Real-time field Ebola virus sequencing was employed to support epidemiological results. An epidemiological cluster of 32 cases was found, of which 27 were laboratory confirmed, 24 were isolated and 20 died. Real-time viral sequencing on 12 cases demonstrated SL3 lineage viruses with sequences differing by one to three nt inside a single phylogenetic cluster. For isolated cases, the average time between symptom onset and ETC referral was 2.8 days (interquartile range (IQR): 1–4). The average time between sample collection and molecular results’ availability was 3 days (IQR: 2–5). In an area with scarce resources, the genetic characterisation supported the outbreak investigations in real time, linking cases where epidemiological investigation was limited and reassuring that the responsible strain was already circulating in Guinea. We recommend coupling thorough epidemiological and genomic investigations to control EVD clusters.

Background Human Ebola infection is characterized by a paralysis of the immune system. A signature of αβ T cells in fatal Ebola infection has been recently proposed, while the involvement of innate immune cells in the protection/pathogenesis of Ebola infection is unknown. Aim of this study was to analyze γδ T and NK cells in patients from the Ebola outbreak of 2014–2015 occurred in West Africa, and to assess their association with the clinical outcome. Methodology/Principal findings Nineteen Ebola-infected patients were enrolled at the time of admission to the Ebola Treatment Centre in Guinea. Patients were divided in two groups on the basis of the clinical outcome. The analysis was performed by using multiparametric flow cytometry established by the European Mobile Laboratory in the field. A low frequency of Vδ2 T-cells was observed during Ebola infection, independently from the clinical outcome. Moreover, Vδ2 T-cells from Ebola patients massively expressed CD95 apoptotic marker, suggesting the involvement of apoptotic mechanisms in Vδ2 T-cell loss. Interestingly, Vδ2 T-cells from survivors expressed an effector phenotype and presented a lower expression of the CTLA-4 exhaustion marker than fatalities, suggesting a role of effector Vδ2 T-cells in the protection. Furthermore, patients with fatal Ebola infection were characterized by a lower NK cell frequency than patients with non fatal infection. In particular, both CD56bright and CD56dim NK frequency were very low both in fatal and non fatal infections, while a higher frequency of CD56neg NK cells was associated to non-fatal infections. Finally, NK activation and expression of NKp46 and CD158a were independent from clinical outcome. Conclusions/Significances Altogether, the data suggest that both effector Vδ2 T-cells and NK cells may play a role in the complex network of protective response to EBOV infection. Further studies are required to characterize the protective effector functions of Vδ2 and NK cells., Author summary Human Ebola infection presents a high lethality rate and is characterized by a paralysis of the immune response. The definition of the protective immune profile during Ebola infection represents a main challenge useful in vaccine and therapy design. In particular, the protective/pathogenetic involvement of innate immune cells during Ebola infection in humans remains to be clarified. Nineteen Ebola-infected patients were enrolled at the time of admission to the Ebola Treatment Center in Guinea, and the profiling of innate immunity was correlated with the clinical outcome. Our results show that both effector Vδ2 T-cells and NK cells were associated with survival, suggesting their involvement in the complex network of protective response to EBOV infection.

Background The international impact, rapid widespread transmission, and reporting delays during the 2014 Ebola outbreak in West Africa highlighted the need for a global, centralized database to inform outbreak response. The World Health Organization and Emerging and Dangerous Pathogens Laboratory Network addressed this need by supporting the development of a global laboratory database. Methods Specimens were collected in the affected countries from patients and dead bodies meeting the case definitions for Ebola virus disease. Test results were entered in nationally standardized spreadsheets and consolidated onto a central server. Results From March 2014 through August 2016, 256343 specimens tested for Ebola virus disease were captured in the database. Thirty-one specimen types were collected, and a variety of diagnostic tests were performed. Regular analysis of data described the functionality of laboratory and response systems, positivity rates, and the geographic distribution of specimens. Conclusion With data standardization and end user buy-in, the collection and analysis of large amounts of data with multiple stakeholders and collaborators across various user-access levels was made possible and contributed to outbreak response needs. The usefulness and value of a multifunctional global laboratory database is far reaching, with uses including virtual biobanking, disease forecasting, and adaption to other disease outbreaks.

Background Reducing maternal morbidity and mortality remains a key health challenge in Guinea. Anecdotal evidence suggests that women in Guinea are subjected to mistreatment during childbirth in health facilities, but limited research exists on this topic. This study was conducted to better understand the social norms and the acceptability of four scenarios of mistreatment during childbirth, from the perspectives of women and service providers. Methods This study used qualitative methods including in-depth interviews (IDIs) and focus group discussions (FGDs) with women of reproductive age, midwives, nurses and doctors. This study was conducted in one urban area (Mamou) and one peri-urban area (Pita) in Guinea. Participants were presented with four scenarios of mistreatment during childbirth, including a provider: (1) slapping a woman; (2) verbally abusing a woman; (3) refusing to help a woman; and (4) forcing a woman to give birth on the floor. Data were collected in local languages (Pular and Malinké) and French, and transcribed and analyzed in French. We used a thematic analysis approach and manually coded the data using a codebook developed for the project. Results A total of 40 IDIs and eight FGDs were conducted with women of reproductive age, 5 IDIs with doctors, and 13 IDIs with midwives. Most women were not accepting of any of the scenarios, unless the action was perceived to be used to save the life of the mother or child. However, they perceived a woman’s disobedience and uncooperativeness to contribute to her poor treatment. Women reacted to this mistreatment by accepting poor treatment, refusal to use the same hospital, revenge against the provider or complaints to hospital management. Service providers were accepting of mistreatment when women were disobedient, uncooperative, or to save the life of the baby. Conclusions This is the first known study on mistreatment of women during childbirth to be conducted in Guinea. Both women and service providers were accepting of mistreatment during childbirth under certain conditions. Any approach to preventing and eliminating mistreatment during childbirth must consider these important contextual and social norms and develop a comprehensive intervention that addresses root causes. Further research is needed on how to measure mistreatment during childbirth in Guinea.

Background The ongoing West African Ebola epidemic began in December 2013 in Guinea, probably from a single zoonotic introduction. As a result of ineffective initial control efforts, an Ebola outbreak of unprecedented scale emerged. As of 4 May 2015, it had resulted in more than 19,000 probable and confirmed Ebola cases, mainly in Guinea (3,529), Liberia (5,343), and Sierra Leone (10,746). Here, we present analyses of data collected during the outbreak identifying drivers of transmission and highlighting areas where control could be improved. Methods and Findings Over 19,000 confirmed and probable Ebola cases were reported in West Africa by 4 May 2015. Individuals with confirmed or probable Ebola (“cases”) were asked if they had exposure to other potential Ebola cases (“potential source contacts”) in a funeral or non-funeral context prior to becoming ill. We performed retrospective analyses of a case line-list, collated from national databases of case investigation forms that have been reported to WHO. These analyses were initially performed to assist WHO’s response during the epidemic, and have been updated for publication. We analysed data from 3,529 cases in Guinea, 5,343 in Liberia, and 10,746 in Sierra Leone; exposures were reported by 33% of cases. The proportion of cases reporting a funeral exposure decreased over time. We found a positive correlation (r = 0.35, p < 0.001) between this proportion in a given district for a given month and the within-district transmission intensity, quantified by the estimated reproduction number (R). We also found a negative correlation (r = −0.37, p < 0.001) between R and the district proportion of hospitalised cases admitted within ≤4 days of symptom onset. These two proportions were not correlated, suggesting that reduced funeral attendance and faster hospitalisation independently influenced local transmission intensity. We were able to identify 14% of potential source contacts as cases in the case line-list. Linking cases to the contacts who potentially infected them provided information on the transmission network. This revealed a high degree of heterogeneity in inferred transmissions, with only 20% of cases accounting for at least 73% of new infections, a phenomenon often called super-spreading. Multivariable regression models allowed us to identify predictors of being named as a potential source contact. These were similar for funeral and non-funeral contacts: severe symptoms, death, non-hospitalisation, older age, and travelling prior to symptom onset. Non-funeral exposures were strongly peaked around the death of the contact. There was evidence that hospitalisation reduced but did not eliminate onward exposures. We found that Ebola treatment units were better than other health care facilities at preventing exposure from hospitalised and deceased individuals. The principal limitation of our analysis is limited data quality, with cases not being entered into the database, cases not reporting exposures, or data being entered incorrectly (especially dates, and possible misclassifications). Conclusions Achieving elimination of Ebola is challenging, partly because of super-spreading. Safe funeral practices and fast hospitalisation contributed to the containment of this Ebola epidemic. Continued real-time data capture, reporting, and analysis are vital to track transmission patterns, inform resource deployment, and thus hasten and maintain elimination of the virus from the human population., In this retrospective observational study, Christophe Fraser and colleagues analyze the exposure patterns associated with Ebola transmission during the 2013-2016 epidemic in West Africa., Author Summary Why Was This Study Done? Knowing how and from whom individuals acquire infection can help inform the response to limit the impact of an epidemic; this study presents updated versions of analyses initially performed to assist the international response during the 2013–2016 Ebola epidemic in West Africa. Over 19,000 individuals with confirmed or probable Ebola (“cases”) were reported in West Africa by 4 May 2015. Cases were asked whether they had exposure to potential Ebola cases (“potential source contacts”) in a funeral or non-funeral context prior to becoming ill. What Did the Researchers Do and Find? We analysed data from 3,529 cases in Guinea, 5,343 in Liberia, and 10,746 in Sierra Leone; exposures were reported by 33% of cases. Non-funeral exposures were strongly peaked around the time of death of the contact. There was evidence of super-spreading, with only 20% of cases accounting for at least 73% of new infections. What Do These Findings Mean? Safe funeral practices and fast hospitalisation contributed to the containment of this Ebola epidemic. The data are highly detailed despite the challenging circumstances in the three countries; however, the analyses were limited by data quality, mostly missing data and incorrect entries. In light of viral persistence in reservoirs, it is vital to maintain active surveillance and analysis of Ebola outbreaks to avoid and contain future outbreaks.

SummaryThe 2013-2016 epidemic of Ebola virus disease in West Africa was of unprecedented magnitude, duration and impact. Extensive collaborative sequencing projects have produced a large collection of over 1600 Ebola virus genomes, representing over 5% of known cases, unmatched for any single human epidemic. In this comprehensive analysis of this entire dataset, we reconstruct in detail the history of migration, proliferation and decline of Ebola virus throughout the region. We test the association of geography, climate, administrative boundaries, demography and culture with viral movement among 56 administrative regions. Our results show that during the outbreak viral lineages moved according to a classic ‘gravity’ model, with more intense migration between larger and more proximate population centers. Notably, we find that despite a strong attenuation of international dispersal after border closures, localized cross-border transmission beforehand had already set the seeds for an international epidemic, rendering these measures relatively ineffective in curbing the epidemic. We use this empirical evidence to address why the epidemic did not spread into neighboring countries, showing that although these regions were susceptible to developing significant outbreaks, they were also at lower risk of viral introductions. Finally, viral genome sequence data uniquely reveals this large epidemic to be a heterogeneous and spatially dissociated collection of transmission clusters of varying size, duration and connectivity. These insights will help inform approaches to intervention in such epidemics in the future.

Summary Background During the 2014–2015 Ebola Virus Disease (EVD) outbreak in N'Zerekore, Forested Guinea, modes of transmission remained unexamined for a number of new cases. We used network visualization to investigate EVD transmission chains (TC) in seven sub-prefectures of N'Zerekore in order to adapt outbreak response. Methods Between August 2014 and February 2015, the EVD outbreak response team including the World Health Organization (WHO) and local health authorities routinely collected information among new cases regarding hospital visits, cases within a household, participation in burials, as well as dates of symptom onset, serial intervals (SI) and exposure to EVD. SI's were defined as the interval between symptom onset in an index case and symptom onset in a secondary case infected by that index case. Cases who reported hospital visits, contact with a case in the household or participating in burials were attributed to these exposures. Results We identified seven TC (two urban and five rural) gathering characteristics of 109 probable/confirmed cases. Overall, 61% (66 cases, SI range: 7–20 days) were household related, 32% (35 cases, SI range 8–30 days) were household or burial related and 7% (8 cases, SI range: 4–20 days) were hospital-related. In the urban chains (18 cases, SI range: 7–20 days), 12 cases were household related and 6 cases were hospital related, none where household or burial related. In the rural chains (84 cases, SI range: 7–30 days), 60% (50 cases) were household related, 1% (1 case) was hospital related and 39% (34 cases) were household or burial related. No cases reported multiple exposures. Conclusions Network visualization during field response is crucial in enhancing local control strategies, refining outbreak response and aiding rapid response teams in insuring psychosocial and socio-economic recovery. Urban settings need to focus on reducing hospital EVD transmission whereas rural settings should focus on raising awareness of transmission within a household and safeguarding EVD burials.

BACKGROUND During the Ebola outbreak in Guinea, community resistance obstructed case investigation and response. We investigated a cluster of Ebola cases that were hiding in the forest, refusing external help, to identify sociocultural determinants related to community resistance. METHODS Participant observation, interviews and focus group discussions were carried out. RESULTS Most villagers feared the Ebola treatment centre (ETC) as there was the belief that people were killed in ETCs for organ trade. Four survivors accompanied back to the village from the ETC shared their experiences and reassured their neighbours. Subsequently, community compliance with contact tracing improved, leading to the timely detection of cases. CONCLUSIONS Engaging Ebola virus disease survivors improved community compliance. Understanding the sociocultural context and community perceptions may improve community engagement and prevent Ebola virus transmission.

Background. A unit of the European Mobile Laboratory (EMLab) consortium was deployed to the Ebola virus disease (EVD) treatment unit in Guéckédou, Guinea, from March 2014 through March 2015. Methods. The unit diagnosed EVD and malaria, using the RealStar Filovirus Screen reverse transcriptionpolymerase chain reaction (RT-PCR) kit and a malaria rapid diagnostic test, respectively. Results. The cleaned EMLab database comprised 4719 samples from 2741 cases of suspected EVD from Guinea. EVD was diagnosed in 1231 of 2178 hospitalized patients (57%) and in 281 of 563 who died in the community (50%). Children aged 74 years (90%) and low in patients aged 1019 years (40%). On admission, RT-PCR analysis of blood specimens from patients who died in the hospital yielded a lower median cycle threshold (Ct) than analysis of blood specimens from survivors (18.1 vs 23.2). Individuals who died in the community had a median Ct of 21.5 for throat swabs. Multivariate logistic regression on 1047 data sets revealed that low Ct values, ages of

Despite the magnitude of the Ebola virus disease (EVD) outbreak in West Africa, there is still a fundamental lack of knowledge about the pathophysiology of EVD 1 . In particular, very little is known about human immune responses to Ebola virus (EBOV) 2,3 . Here, we have for the first time evaluated the physiology of the human T cell immune response in EVD patients at the time of admission at the Ebola Treatment Center (ETC) in Guinea, and longitudinally until discharge or death. Through the use of multiparametric flow cytometry established by the European Mobile Laboratory in the field, we have identified an immune signature that is unique in EVD fatalities. Fatal EVD was characterized by high percentage of CD4 and CD8 T cells expressing the inhibitory molecules cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death-1 (PD-1), which was correlated with elevated inflammatory markers and high virus load. Conversely, surviving individuals showed significantly lower expression of CTLA-4 and PD-1 as well as lower inflammation despite comparable overall T cell activation. Concommittant with virus clearance, survivors mounted a robust EBOV-specific T cell response. Our findings suggest that dysregulation of the T cell response is a key component of EVD pathophysiology.

Background Every woman is entitled to respectful care during childbirth; so it is concerning to hear of informal reports of mistreatment during childbirth in Guinea. This study sought to explore the perceptions and experiences of mistreatment during childbirth, from the perspectives of women and service providers, and the analysis presents findings according to a typology of mistreatment during childbirth. Methods This study used qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) and was conducted with four groups of participants: women of reproductive age, midwives, doctors, and administrators. The study took place in two sites in Guinea, an urban area (Mamou) and peri-urban (Pita). Data collection was conducted in two health facilities for providers and administrators, and in the health facility catchment area for women. Data were collected in local languages (Pular and Malinké), then transcribed and analyzed in French. We used a thematic analysis approach and coded transcripts manually. Results A total of 64 IDIs and eight FGDs were conducted and are included in this analysis, including 40 IDIs and eight FGDs with women of reproductive age, 5 IDIs with doctors, 13 IDIs with midwives, and 6 IDIs with administrators. Participants described their own personal experiences, experiences of women in their communities and perceptions regarding mistreatment during childbirth. Results were organized according to a typology of mistreatment during childbirth, and included instances of physical abuse, verbal abuse, abandonment and neglect. Women described being slapped by providers, yelled at for noncompliance with provider requests, giving birth on the floor and without skilled attendance in the health facility. Poor physical conditions of health facilities and health workforce constraints contributed to experiences of mistreatment. Conclusions These results are important because they demonstrate that the mistreatment of women during childbirth exists in Guinea and occurs in multiple forms. These data should be used by the Ministry of Health and other stakeholders to develop strategies to reduce and prevent the mistreatment of women during childbirth.