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Setting: All health facility and community malnutrition screening programmes in Tonkolili, a rural Ebola-affected district in Sierra Leone. Objectives: Before the Ebola disease outbreak, Sierra Leone had set a goal to reduce the prevalence of severe acute malnutrition (SAM) in children aged

During the late phase of the large West-African Ebola virus disease (EVD) outbreak, the majority of patients were cared for in designated treatment centers. However, the preexisting healthcare infrastructure was already overwhelmed by the outbreak. This had a huge impact on other, non-EVD-related diseases, causing an unprecedented increase in morbidity and mortality, which most likely exceeded the toll due to EVD directly. Consequently, a crucial question is how to provide appropriate healthcare and safeguard functionality of a healthcare system that also serves patients not suspected or diagnosed to have EVD. Here, we report on the Lion Heart Medical Center's experience in Sierra Leone and note that a case definition of Ebola that is broader than those commonly applied may be better suited when it is necessary to identify atypically presenting, pauci-symptomatic cases.

Background During the West Africa Ebola outbreak, cultural practices have been described as hindering response efforts. The acceptance of control measures improved during the outbreak, but little is known about how and why this occurred. We conducted a qualitative study in two administrative districts of Sierra Leone to understand Ebola survivor, community, and health worker perspectives on Ebola control measures. We aimed to gain an understanding of community interactions with the Ebola response to inform future intervention strategies. Methodology/Principal findings Participants (25 survivors, 24 community members, and 16 health workers) were recruited purposively. A flexible participatory method gathered data through field notes and in-depth, topic-led interviews. These were analysed thematically with NVivo10© by open coding, constant comparison, and the principles of grounded theory. The primary theme, ‘when Ebola is real’, centred on denial, knowledge, and acceptance. Ebola was denied until it was experienced or observed first-hand and thus health promotion was more effective if undertaken by those directly exposed to Ebola rather than by mass media communication. Factors that enabled acceptance and engagement with control measures included: access to good, proximate care and prevention activities; seeing that people can survive infection; and the co-option of trusted or influential local leadership, with bylaws implemented by community leaders being strongly respected. All participants noted that dignity, respect, and compassion were key components of effective control measures. Conclusions Successful control approaches need strong community leadership, with the aim of achieving collective understanding between communities and health workers. Health promotion for communities at risk is best conducted through people who have had close interaction with or who have survived Ebola as opposed to reliance on broad mass communication strategies., Author summary The scale of the 2014–15 Ebola epidemic was unprecedented and led to over 11,000 deaths in Sierra Leone, Liberia and Guinea. What is distinct about the findings of this study is the knowledge gained from experiences and reflections of communities, health workers and Ebola survivors living in the midst of an outbreak of this magnitude. To this point cultural practices were seen to both spread the disease and hinder response efforts, yet little was known about how and why affected communities engaged with Ebola control measures. We talked with people to understand their perspectives with the aim of improving responses to future disease outbreaks. Our findings show people believed ‘Ebola is real’ and adapted to control measures when they were directly affected by the disease. Factors supporting acceptance of and adherence to controls were treatment quality; proximal care; first-hand observation that people can survive the disease; and the participation of local leaders and community knowledge in the response. Dignity, respect, and compassion were essential for control measures to be accepted and effective. Health messaging is best conducted at household level through local leaders or people who have experienced Ebola first-hand, rather than mass media which was the initial approach.

BACKGROUND During the 2014-16 Ebola virus disease (EVD) outbreak, the Magburaka Ebola Management Centre (EMC) operated by Medecins Sans Frontieres (MSF) in Tonkolili District, Sierra Leone, identified that available district maps lacked up-to-date village information to facilitate timely implementation of EVD control strategies. In January 2015, we undertook a survey in chiefdoms within the MSF EMC catchment area to collect mapping and village data. We explore the feasibility and cost to mobilise a local community for this survey, describe validation against existing mapping sources and use of the data to prioritise areas for interventions, and lessons learned. METHODS We recruited local people with self-owned Android smartphones installed with open-source survey software (OpenDataKit (ODK)) and open-source navigation software (OpenStreetMap Automated Navigation Directions (OsmAnd)). Surveyors were paired with local motorbike drivers to travel to eligible villages. The collected mapping data were validated by checking for duplication and comparing the village names against a pre-existing village name and location list using a geographic distance and text string-matching algorithm. RESULTS The survey teams gained sufficient familiarity with the ODK and OsmAnd software within 1-2 hours. Nine chiefdoms in Tonkolili District and three in Bombali District were surveyed within two weeks. Following de-duplication, the surveyors collected data from 891 villages with an estimated 127,021 households. The overall survey cost was €3,395; €3.80 per village surveyed. The MSF GIS team (MSF-OCG) created improved maps for the MSF Magburaka EMC team which were used to support surveillance, investigation of suspect EVD cases, hygiene-kit distribution and EVD survivor support. We shared the mapping data with OpenStreetMap, the local Ministry of Health and Sanitation and Sierra Leone District and National Ebola Response Centres. CONCLUSIONS Involving local community and using accessible technology allowed rapid implementation, at moderate cost, of a survey to collect geographic and essential village information, and creation of updated maps. These methods could be used for future emergencies to facilitate response.

Between August-December 2014, Ebola Virus Disease (EVD) patients from Tonkolili District were referred for care to two Médecins Sans Frontières (MSF) Ebola Management Centres (EMCs) outside the district (distant EMCs). In December 2014, MSF opened an EMC in Tonkolili District (district EMC). We examined the effect of opening a district-based EMC on time to admission and number of suspect cases dead on arrival (DOA), and identified factors associated with fatality in EVD patients, residents in Tonkolili District. Residents of Tonkolili district who presented between 12 September 2014 and 23 February 2015 to the district EMC and the two distant EMCs were identified from EMC line-lists. EVD cases were confirmed by a positive Ebola PCR test. We calculated time to admission since the onset of symptoms, case-fatality and adjusted Risk Ratios (aRR) using Binomial regression. Of 249 confirmed Ebola cases, 206 (83%) were admitted to the distant EMCs and 43 (17%) to the district EMC. Of them 110 (45%) have died. Confirmed cases dead on arrival (n = 10) were observed only in the distant EMCs. The median time from symptom onset to admission was 6 days (IQR 4,8) in distant EMCs and 3 days (IQR 2,7) in the district EMC (p3 days after symptom onset) in the distant compared with the district EMC, but were less likely (aRR = 0.8; 95%CI 0.6–1.0) to have a high viral load (cycle threshold ≤22). A fatal outcome was associated with a high viral load (aRR 2.6; 95%CI 1.8–3.6) and vomiting at first presentation (aRR 1.4; 95%CI 1.0–2.0). The opening of a district EMC was associated with earlier admission of cases to appropriate care facilities, an essential component of reducing EVD transmission. High viral load and vomiting at admission predicted fatality. Healthcare providers should consider the location of EMCs to ensure equitable access during Ebola outbreaks.

Background During December 2014–February 2015, an Ebola outbreak in a village in Kono district, Sierra Leone, began following unsafe funeral practices after the death of a person later confirmed to be infected with Ebola virus. In response, disease surveillance officers and community health workers, in collaboration with local leadership and international partners, conducted 1 day of active surveillance and health education for all households in the village followed by ongoing outreach. This study investigated the impact of these interventions on the outbreak. Methods Fifty confirmed Ebola cases were identified in the village between December 1, 2014 and February 28, 2015. Data from case investigations, treatment facility and laboratory records were analyzed to characterize the outbreak. The reproduction number (R) was estimated by fitting to the observed distribution of secondary cases. The impact of the active surveillance and health education was evaluated by comparing two outcomes before and after the day of the interventions: 1) the number of days from symptom onset to case-patient isolation or death and 2) a reported epidemiologic link to a prior Ebola case. Results The case fatality ratio among the 50 confirmed Ebola cases was 64.0 %. Twenty-three cases occurred among females (46.0 %); the mean age was 39 years (median: 37 years; range: 5 months to 75 years). Forty-three (87.8 %) cases were linked to the index case; 30 (61.2 %) were either at the funeral of Patient 1 or had contact with him while he was ill. R was 0.93 (95 % CI: 0.15–2.3); excluding the funeral, R was 0.29 (95 % CI: 0.11–0.53). The mean number of days in the community after onset of Ebola symptoms decreased from 4.0 days (median: 3 days; 95 % CI: 3.2–4.7) before the interventions to 2.9 days (median: 2 days; 95 % CI: 1.6–4.3) afterward. An epidemiologic link was reported in 47.6 % of case investigations prior to and 100 % after the interventions. Conclusions Initial case investigation and contact tracing were hindered by delayed reporting and under-reporting of symptomatic individuals from the community. Active surveillance and health education contributed to quicker identification of suspected cases, interrupting further transmission.