Validating the Delone and Mclean's model in a developing country's infectious disease pandemic context.

BACKGROUND: This study aimed at validating the updated DeLone and McLean's information systems success model (D&MISS) in a developing country's infectious disease pandemic preparedness and response context. The findings from this study are relevant to inform policies and actions for enhancing developing countries' the Health Information System's (HIS) performance, and specifically to improve their future pandemic readiness and response. The study sought to respond to a key research question: to what extent can the D&MISS model provide evidence to enhance the HIS's infectious disease pandemic readiness and response in developing countries? METHOD: A cross-sectional study design that involved a multi-stage probability sampling approach to select eligible healthcare workers was applied. Conducted in Nigeria and Liberia, 576 primary healthcare workers, out of the proposed 600, participated, representing a response rate of 96%. The D&MISS model served as the theoretical underpinning for this study, and nine hypothesized relationships were stated before the study based on the interconnectedness of the model's six dimensions. Structural Equation Modelling (SEM) data analysis using the Partial Least Square approach was used to determine if hypothesized relationships were supported. RESULTS: 70% of the observed variance in the Net Benefit construct was explained by the predictive influence of the Use and User Satisfaction constructs. The Use construct had a slightly more substantial predictive influence than the User Satisfaction construct. Eight of the nine hypothesized relationships were supported, except for the relationship between Information Quality and Use. The relationships between System Quality and Use and User Satisfaction and Net Benefit had the highest beta coefficient, statistically significant at p < 0.05. CONCLUSION AND RELEVANCE: The D&MISS model demonstrated its relevance in providing evidence on the gaps of the HISs regarding future pandemic preparedness and response. However, from a future research opportunity, its enhancement and modifications with context-specific dimensions peculiar to developing countries will improve its ability to provide more context-specific evidence to improve pandemic preparedness and response for developing countries.

Understanding the Effects of Trauma Exposure, Life Stress, Intimate Partner Violence, and Depression on Sexually Transmitted Infection Risk in Post-Conflict Liberia.

In sub-Saharan Africa, sexually transmitted infections (STIs) are a public health concern. The impact of STIs are exacerbated in post-conflict low- and middle-income countries, such as Liberia, where exposure to traumatic events is prevalent and access to mental health services are limited. Following a syndemics framework, this study used regression analyses to explore the independent, additive, and multiplicative effects of four psychosocial conditions (exposure to war-related traumatic events, intimate partner violence [IPV], stressful life events, and depressive symptoms) on self-reported STIs. Data were collected from 379 youth aged 18-30 years (n = 170 women; n = 179 men) in Montserrado County, Liberia. Results revealed that psychosocial variables correlated with each other and STI risk. In multivariable analysis, stressful life events, depressive symptoms, and IPV were statistically significant predictors of STI risk. We found support for an additive effect between the number of psychosocial conditions reported and STI risk, as well as a multiplicative effect (interaction) between IPV and depressive symptoms on STI risk. Our results suggest a synergy between experiencing psychosocial conditions and STI risk and point to the potential benefit of multi-level sexual health approaches that simultaneously address mental health and IPV among youth in Liberia.

Comprehensive knowledge about HIV/AIDS and associated factors among reproductive age women in Liberia.

INTRODUCTION: Acquired Immune Deficiency Syndrome (AIDS) continues to be a deadly pandemic and a serious threat to public health. Globally, reproductive age women are more likely to be infected with Human Immunodeficiency Virus (HIV). Comprehensive knowledge about HIV/AIDS is pivotal in the fight against AIDS. However, comprehensive HIV/AIDS knowledge is low in Sub-Saharan African (SSA) nations including Liberia, which contributes to the high incidence of HIV in these nations. This study assessed the level of comprehensive knowledge about HIV/AIDS and its associated factors among reproductive age women in Liberia. METHODS: The prevalence and associated factors of comprehensive knowledge about HIV/AIDS among reproductive age women in Liberia were determined using secondary data analysis of 2019-2020 Liberia Demographic and Health Surveys (LDHS). Comprehensive knowledge about HIV/AIDS was a composite variable computed from six variables available in the Demographic and Health Survey (DHS). The study included 7,621 reproductive age women in weighted samples. A generalized linear mixed model with robust error variance was used. For the variables included in the final model, adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) were calculated. RESULTS: The prevalence of comprehensive HIV/AIDS knowledge among Liberian women aged 15-49 was 33.5%. Women's age and education, and distance to health facility were positively associated with comprehensive knowledge about HIV/AIDS among Liberian reproductive age women. In contrast, community poverty level was negatively associated with comprehensive knowledge about HIV/AIDS. CONCLUSION AND RECOMMENDATIONS: This study demonstrates that the prevalence of good comprehensive HIV/AIDS knowledge was relatively low among reproductive age women in Liberia. Hence, health practitioners and policymakers should strengthen HIV/AIDS sensitization programmes to increase women's knowledge about HIV/AIDS.

Sharps injuries among healthcare workers in Liberia and Ghana: a cross-sectional survey.

There are little data on sharps injuries among healthcare workers in West Africa despite the region's high rate of hepatitis B and human immunodeficiency virus. The purpose of this study is to investigate healthcare workers' history of sharps injuries in Liberia and Ghana. An electronic cross-sectional survey was conducted among healthcare workers in Liberia and Ghana from February to June 2022. A link to the survey was texted to participants through professional association membership lists, including nursing, midwifery, and physician assistant organizations in both Liberia and Ghana and a physician organization in Ghana only. Five hundred and nine participants reported an average of 1.8 injuries per year in Liberia and 1.1 in Ghana (P ≤ .01); 15.1% of healthcare workers reported three or more injuries in the past year. Liberia had a higher proportion of frequently injured workers (P = .01). Frequently injured workers were evenly distributed across worker types. Workers in this region are vulnerable to sharps injuries. A frequently injured subset of workers likely has distinctive risk factors and would benefit from further investigation and intervention.

Risk Factors for Ebola Virus Persistence in Semen of Survivors in Liberia.

BACKGROUND: Long-term persistence of Ebola virus (EBOV) in immunologically privileged sites has been implicated in recent outbreaks of Ebola virus disease (EVD) in Guinea and the Democratic Republic of Congo. This study was designed to understand how the acute course of EVD, convalescence, and host immune and genetic factors may play a role in prolonged viral persistence in semen. METHODS: A cohort of 131 male EVD survivors in Liberia were enrolled in a case-case study. "Early clearers" were defined as those with 2 consecutive negative EBOV semen test results by real-time reverse-transcription polymerase chain reaction (rRT-PCR) ≥2 weeks apart within 1 year after discharge from the Ebola treatment unit or acute EVD. "Late clearers" had detectable EBOV RNA by rRT-PCR >1 year after discharge from the Ebola treatment unit or acute EVD. Retrospective histories of their EVD clinical course were collected by questionnaire, followed by complete physical examinations and blood work. RESULTS: Compared with early clearers, late clearers were older (median, 42.5 years; P < .001) and experienced fewer severe clinical symptoms (median 2, P = .006). Late clearers had more lens opacifications (odds ratio, 3.9 [95% confidence interval, 1.1-13.3]; P = .03), after accounting for age, higher total serum immunoglobulin G3 (IgG3) titers (P = .005), and increased expression of the HLA-C*03:04 allele (0.14 [.02-.70]; P = .007). CONCLUSIONS: Older age, decreased illness severity, elevated total serum IgG3 and HLA-C*03:04 allele expression may be risk factors for the persistence of EBOV in the semen of EVD survivors. EBOV persistence in semen may also be associated with its persistence in other immunologically protected sites, such as the eye.

Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards.

BACKGROUND: Accurate surveillance of population access to essential surgery is key for strategic healthcare planning. This study aimed to estimate population access to surgical facilities meeting standards for safe surgery equipment, specialized surgical personnel, and bellwether capability, cesarean delivery, emergency laparotomy, and long-bone fracture fixation and to evaluate the validity of using these standards to describe the full breadth of essential surgical care needs in Liberia. METHOD: An observational study of surgical facilities was conducted in Liberia between 20 September and 8 November 2018. Facility data were combined with geospatial data and analysed in an online visualization platform. RESULTS: Data were collected from 51 of 52 surgical facilities. Nationally, 52.9 per cent of the population (2 392 000 of 4 525 000 people) had 2-h access to their closest surgical facility, whereas 41.1 per cent (1 858 000 people) and 48.6 per cent (2 199 000 people) had 2-h access to a facility meeting the personnel and equipment standards respectively. Six facilities performed all bellwether procedures; 38.7 per cent of the population (1 751 000 people) had 2-h access to one of these facilities. Bellwether-capable facilities were more likely to perform other essential surgical procedures (OR 3.13, 95 per cent c.i. 1.28 to 7.65; P = 0.012). These facilities delivered a median of 13.0 (i.q.r. 11.3-16.5) additional essential procedures. CONCLUSION: Population access to essential surgery is limited in Liberia; strategies to reduce travel times ought to be part of healthcare policy. Policymakers should also be aware that bellwether capability might not be a valid proxy for the full breadth of essential surgical care in low-income settings.

Durable wall lining for malaria control in Liberia: results of a cluster randomized trial.

BACKGROUND: Malaria control in Liberia depends upon universal coverage with pyrethroid-impregnated long-lasting insecticidal nets (LLINs). Despite regular mass distribution, LLIN coverage and usage is patchy. Pyrethroid resistance in malaria vectors may further reduce LLIN efficacy. Durable Wall Lining (DWL), a novel material treated with two non-pyrethroid class insecticides, was designed to be installed onto the surface of inner walls, and cover openings and ceiling surfaces of rural houses. OBJECTIVES: AIM: To determine the malaria control efficacy of DWL. PRIMARY OBJECTIVE: To determine if DWL has an additional protective effect in an area of pyrethroid resistance. SECONDARY OBJECTIVES: To compare surface bio-availability of insecticides and entomological effectiveness over the study duration. DESIGN: A cluster randomized trial. PARTICIPANTS: Children aged 2-59 months. CONTROL ARM: 50 houses per 20 clusters, all of which received LLIN within the previous 12 months. ACTIVE ARM: 50 houses per 20 experimental clusters, all of which received LLINs with the previous 12 months, and had internal walls and ceilings lined with DWL. RANDOMISATION: Cluster villages were randomly allocated to control or active arms, and paired on 4 covariates. MAIN OUTCOME MEASURES: PRIMARY MEASURE: Prevalence of infection with P. falciparum in children aged 2 to 59 months. SECONDARY MEASURE: Surface bioavailability and entomological effectiveness of DWL active ingredients. RESULTS: Plasmodium falciparum prevalence in active clusters after 12 months was 34.6% compared to 40.1% in control clusters (p = 0.052). The effect varied with elevation and was significant (RR = 1.3, p = 0.022) in 14 pairs of upland villages. It was not significant (RR = 1.3, p = 0.344) in 6 pairs of coastal villages. Pooled risk ratio (RR) was calculated in SAS (Cary, NC, USA) using the Cochran-Mantel-Haenszel (CMH) test for upland and coastal cluster pairs. DWL efficacy was sustained at almost 100% for 12 months. CONCLUSIONS: Findings indicate that DWL is a scalable and effective malaria control intervention in stable transmission areas with pyrethroid-resistant vectors, where LLIN usage is difficult to achieve, and where local housing designs include large gable and eve openings. Trial registration ClinicalTrials.gov identifier: NCT02448745 (19 May 2015): https://clinicaltrials.gov/ct2/show/NCT02448745.

Determinants of incomplete childhood hepatitis B vaccination in Sierra Leone, Liberia, and Guinea: Analysis of national surveys (2018-2020).

Vaccination against hepatitis B virus (HBV) is effective at preventing vertical transmission. Sierra Leone, Liberia, and Guinea are hyperendemic West African countries; yet, childhood vaccination coverage is suboptimal, and the determinants of incomplete vaccination are poorly understood. We analyzed national survey data (2018-2020) of children aged 4-35 months to assess complete HBV vaccination (receiving 3 doses of the pentavalent vaccine) and incomplete vaccination (receiving <3 doses). Statistical analysis was conducted using the complex sample command in SPSS (version 28). Multivariate logistic regression was used to identify determinants of incomplete immunization. Overall, 11,181 mothers were analyzed (4,846 from Sierra Leone, 2,788 from Liberia, and 3,547 from Guinea). Sierra Leone had the highest HBV childhood vaccination coverage (70.3%), followed by Liberia (64.6%) and Guinea (39.3%). Within countries, HBV vaccination coverage varied by socioeconomic characteristics and healthcare access. In multivariate regression analysis, factors that were significantly associated with incomplete vaccination in at least one country included sex of the child, Muslim mothers, lower household wealth index, <4 antenatal visits, home delivery, and distance to health facility vaccination (all p < 0.05). Understanding and addressing modifiable determinants of incomplete vaccination will be essential to help achieve the 2030 viral hepatitis elimination goals.

Modelling mass drug administration strategies for reducing scabies burden in Monrovia, Liberia.

Scabies is a parasitic infestation with high global burden. Mass drug administrations (MDAs) are recommended for communities with a scabies prevalence of >10%. Quantitative analyses are needed to demonstrate the likely effectiveness of MDA recommendations. In this study, we developed an agent-based model of scabies transmission calibrated to demographic and epidemiological data from Monrovia. We used this model to compare the effectiveness of MDA scenarios for achieving scabies elimination and reducing scabies burden, as measured by time until recrudescence following delivery of an MDA and disability-adjusted-life-years (DALYs) averted. Our model showed that three rounds of MDA delivered at six-month intervals and reaching 80% of the population could reduce prevalence below 2% for three years following the final round, before recrudescence. When MDAs were followed by increased treatment uptake, prevalence was maintained below 2% indefinitely. Increasing the number of and coverage of MDA rounds increased the probability of achieving elimination and the number of DALYs averted. Our results suggest that acute reduction of scabies prevalence by MDA can support a transition to improved treatment access. This study demonstrates how modelling can be used to estimate the expected impact of MDAs by projecting future epidemiological dynamics and health gains under alternative scenarios.

The lasting influence of Ebola: a qualitative study of community-level behaviors, trust, and perceptions three years after the 2014-16 Ebola epidemic in Liberia.

The majority of disease transmission during the 2014-16 West Africa Ebola epidemic was driven by community-based behaviors that proved difficult to change in a social paradigm of misinformation, denial, and deep-seated distrust of government representatives and institutions. In Liberia, perceptions and beliefs about Ebola during and since the epidemic can provide insights useful to public health strategies aimed at improving community preparedness. In this 2018 study, we conducted nine focus groups with Liberians from three communities who experienced Ebola differently, to evaluate behaviors, attitudes, and trust during and after the epidemic. Focus group participants reported that some behaviors adopted during Ebola have persisted (e.g. handwashing and caretaking practices), while others have reverted (e.g. physical proximity and funeral customs); and reported ongoing distrust of the government and denial of the Ebola epidemic. These findings suggest that a lack of trust in the biomedical paradigm and government health institutions persists in Liberia. Future public health information campaigns may benefit from community engagement addressed at understanding beliefs and sources of trust and mistrust in the community to effect behavior change and improve community-level epidemic preparedness.

Documenting the development, adoption and pre-ebola implementation of Liberia's integrated disease surveillance and response (IDSR) strategy.

BACKGROUND: In the immediate aftermath of a 14-year civil conflict that disrupted the health system, Liberia adopted the internationally recommended integrated disease surveillance and response (IDSR) strategy in 2004. Despite this, Liberia was among the three West African countries ravaged by the worst Ebola epidemic in history from 2014 to 2016. This paper describes successes, failures, strengths, and weaknesses in the development, adoption, and implementation of IDSR following the civil war and up until the outbreak of Ebola, from 2004 to early 2014. METHODS: We reviewed 112 official Government documents and peer-reviewed articles and conducted 29 in-depth interviews with key informants from December 2021 to March 2022 to gain perspectives on IDSR in the post-conflict and pre-Ebola era in Liberia. We assessed the core and supportive functions of IDSR, such as notification of priority diseases, confirmation, reporting, analysis, investigation, response, feedback, monitoring, staff training, supervision, communication, and financial resources. Data were triangulated and presented via emerging themes and in-depth accounts to describe the context of IDSR introduction and implementation, and the barriers surrounding it. RESULTS: Despite the adoption of the IDSR framework, Liberia failed to secure the resources-human, logistical, and financial-to support effective implementation over the 10-year period. Documents and interview reports demonstrate numerous challenges prior to Ebola: the surveillance system lacked key components of IDSR including laboratory testing capacity, disease reporting, risk communication, community engagement, and staff supervision systems. Insufficient financial support and an abundance of vertical programs further impeded progress. In-depth accounts by donors and key governmental informants demonstrate that although the system had a role in detecting Ebola in Liberia, it could not respond effectively to control the disease. CONCLUSION: Our findings suggest that post-war, Liberia's health system intended to prioritize epidemic preparedness and response with the adoption of IDSR. However, insufficient investment and systems development meant IDSR was not well implemented, leaving the country vulnerable to the devastating impact of the Ebola epidemic.

Perceived impacts of COVID-19 responses on routine health service delivery in Liberia and UK: cross-country lessons for resilient health systems for equitable service delivery during pandemics.

BACKGROUND: COVID-19 has caused significant public health problems globally, with catastrophic impacts on health systems. This study explored the adaptations to health services in Liberia and Merseyside UK at the beginning of the COVID-19 pandemic (January-May 2020) and their perceived impact on routine service delivery. During this period, transmission routes and treatment pathways were as yet unknown, public fear and health care worker fear was high and death rates among vulnerable hospitalised patients were high. We aimed to identify cross-context lessons for building more resilient health systems during a pandemic response. METHODS: The study employed a cross-sectional qualitative design with a collective case study approach involving simultaneous comparison of COVID-19 response experiences in Liberia and Merseyside. Between June and September 2020, we conducted semi-structured interviews with 66 health system actors purposively selected across different levels of the health system. Participants included national and county decision-makers in Liberia, frontline health workers and regional and hospital decision-makers in Merseyside UK. Data were analysed thematically in NVivo 12 software. RESULTS: There were mixed impacts on routine services in both settings. Major adverse impacts included diminished availability and utilisation of critical health services for socially vulnerable populations, linked with reallocation of health service resources for COVID-19 care, and use of virtual medical consultation in Merseyside. Routine service delivery during the pandemic was hampered by a lack of clear communication, centralised planning, and limited local autonomy. Across both settings, cross-sectoral collaboration, community-based service delivery, virtual consultations, community engagement, culturally sensitive messaging, and local autonomy in response planning facilitated delivery of essential services. CONCLUSION: Our findings can inform response planning to assure optimal delivery of essential routine health services during the early phases of public health emergencies. Pandemic responses should prioritise early preparedness, with investment in the health systems building blocks including staff training and PPE stocks, address both pre-existing and pandemic-related structural barriers to care, inclusive and participatory decision-making, strong community engagement, and effective and sensitive communication. Multisectoral collaboration and inclusive leadership are essential.

Assessing the cost-effectiveness of integrated case management of Neglected Tropical Diseases in Liberia.

BACKGROUND: In 2017, Liberia became one of the first countries in the African region to develop and implement a national strategy for integrated case management of Neglected Tropical Diseases (CM-NTDs), specifically Buruli ulcer, leprosy, lymphatic filariasis morbidities, and yaws. Implementing this plan moves the NTD program from many countries' fragmented (vertical) disease management. This study explores to what extent an integrated approach offers a cost-effective investment for national health systems. METHODS: This study is a mixed-method economic evaluation that explores the cost-effectiveness of the integrated CM-NTDs approach compared to the fragmented (vertical) disease management. Primary data were collected from two integrated intervention counties and two non-intervention counties to determine the relative cost-effectiveness of the integrated program model vs. fragmented (vertical) care. Data was sourced from the NTDs program annual budgets and financial reports for integrated CM-NTDs and Mass Drug Administration (MDA) to determine cost drivers and effectiveness. RESULTS: The total cost incurred by the integrated CM-NTD approach from 2017 to 2019 was US$ 789,856.30, with the highest percentage of costs for program staffing and motivation (41.8%), followed by operating costs (24.8%). In the two counties implementing fragmented (vertical) disease management, approximately US$ 325,000 was spent on the diagnosis of 84 persons and the treatment of twenty-four persons suffering from NTDs. While 2.5 times as much was spent in integrated counties, 9-10 times more patients were diagnosed and treated. CONCLUSIONS: The cost of a patient being diagnosed under the fragmented (vertical) implementation is five times higher than integrated CM-NTDs, and providing treatment is ten times as costly. Findings indicate that the integrated CM-NTDs strategy has achieved its primary objective of improved access to NTD services. The success of implementing an integrated CM-NTDs approach in Liberia, presented in this paper, demonstrates that NTD integration is a cost-minimizing solution.

'The solution is we need to have a centre': a study on diabetes in Liberia.

In Liberia, one of the poorest nations in sub-Saharan Africa, the burden of diabetes is a growing concern. The high mortality and morbidity associated with diabetes have significant implications for individuals, families and society at large. The aim of this critical hermeneutic study was to explore what it is like to live with diabetes in Liberia. We recruited 10 participants from Monrovia, Liberia to partake in this study. Photovoice, a well-established participatory data collection approach was used to gather images and stories that represented participants' everyday experiences of living with diabetes. Three major themes were uncovered, highlighting the strengths, challenges and solutions related to living with diabetes in Liberia: strengths-engagement in diabetes self-management practices, focused on participants' commitment to engage in diabetes self-management practices despite the socioeconomic challenges they experienced; challenges-lack of social and economic support, focused on limited access to food, diabetes medications and supplies and diabetes education; and solutions-centre for diabetes education, care and support, focused on participants' recommendations for a community-based diabetes centre, a single point of access for meeting the needs of people with diabetes. A strong commitment to prioritize diabetes on Liberia's national health agenda and increased resources for diabetes care is needed to address the challenges experienced by people living with this chronic disease in Liberia.

Rumour spread and control during the West African Ebola epidemic in Liberia.

The severity of the 2014-15 West African Ebola epidemic in Liberia was coupled with widespread misunderstanding of the virus among citizens and the proliferation of rumours. Rumour control during outbreaks is imperative to reduce the public's fears about a disease. In Liberia, a tracker system was developed to detect rumours as quickly as possible through SMS (short message service) text messaging. This study focused on assessing rumour circulation in newspapers and on radio and rumour control over time. It relied on a content analysis of SMS messages from the 'DeySay' tracker, print and audio communications of newspapers, and radio programmes, in the time frame between January 2014 and March 2015. The findings show that more rumours appeared in newspapers but were more likely to be overtly characterised as such on the radio. DeySay accurately predicted rumours before they appeared on the radio and in newspapers, supporting its usefulness in future health epidemics.

Flattening the curve: voluntary association participation and the 2013-16 West Africa Ebola epidemic.

To what extent does voluntary association participation correlate with reduced Ebola duration in districts of Guinea, Liberia, and Sierra Leone during the epidemic in West Africa in 2013-16? This study, the first cross-national quantitative analysis of Ebola outcomes across these countries, answers this question by investigating how social capital influences epidemic outcomes. Ebola virus disease struck along the borders of three countries with similar levels of human development as well as cultural practices, yet resulted in different outcomes. This study examines the role of social trust, political trust, voluntary association participation, religious organisation membership, and community meeting attendance in explaining international policy failure to reduce Ebola outcomes. Overall, in districts with a culture of raising issues and participating in voluntary and religious organisations, Ebola duration rates were lower. These findings have implications not only for health crisis response, but also for disaster response and the provision of international aid to civil society.

Bivariate mapping of intimate partner violence prevalence and its correlates in Liberia by county: Results from the 2019-2020 Demographic and Health Survey.

Intimate partner violence (IPV) is a global public health concern and requires nuanced health policy response for effective addressal at the subnational level. Using the nationally and county level representative data from the 2019-20 Demographic and Health Survey of Liberia, the prevalence of IPV was computed for each of the sixteen Liberian counties in 15 - 49-year-old women. Additionally, prevalence of IPV acceptance and having parental IPV were also computed. Prevalence of each of the three metrics were mapped by county, in addition to bivariate mapping of the three attributes. Results demonstrate wide chasms in prevalence at the county level. Several countries with high prevalence of one metric were correlated with the high prevalence of the other two metrics, and vice versa. Albeit nuanced differences in associations at the county level were also observed. Findings auger for nuanced health policy measures to address IPV more effectively in Liberia.

Quantifying Population Burden and Effectiveness of Decentralized Surveillance Strategies for Skin-Presenting Neglected Tropical Diseases, Liberia.

We evaluated programmatic approaches for skin neglected tropical disease (NTD) surveillance and completed a robust estimation of the burden of skin NTDs endemic to West Africa (Buruli ulcer, leprosy, lymphatic filariasis morbidity, and yaws). In Maryland, Liberia, exhaustive case finding by community health workers of 56,285 persons across 92 clusters identified 3,241 suspected cases. A total of 236 skin NTDs (34.0 [95% CI 29.1-38.9]/10,000 persons) were confirmed by midlevel healthcare workers trained using a tailored program. Cases showed a focal and spatially heterogeneous distribution. This community health worker‒led approach showed a higher skin NTD burden than prevailing surveillance mechanisms, but also showed high (95.1%) and equitable population coverage. Specialized training and task-shifting of diagnoses to midlevel health workers led to reliable identification of skin NTDs, but reliability of individual diagnoses varied. This multifaceted evaluation of skin NTD surveillance strategies quantifies benefits and limitations of key approaches promoted by the 2030 NTD roadmap of the World Health Organization.

A Longitudinal Study of Ebola Sequelae in Liberia.

BACKGROUND: Multiple health problems have been reported in survivors of Ebola virus disease (EVD). Attribution of these problems to the disease without a control group for analysis is difficult. METHODS: We enrolled a cohort of EVD survivors and their close contacts and prospectively collected data on symptoms, physical examination findings, and laboratory results. A subset of participants underwent ophthalmologic examinations. Persistence of Ebola virus (EBOV) RNA in semen samples from survivors was determined. RESULTS: A total of 966 EBOV antibody-positive survivors and 2350 antibody-negative close contacts (controls) were enrolled, and 90% of these participants were followed for 12 months. At enrollment (median time to baseline visit, 358 days after symptom onset), six symptoms were reported significantly more often among survivors than among controls: urinary frequency (14.7% vs. 3.4%), headache (47.6% vs. 35.6%), fatigue (18.4% vs. 6.3%), muscle pain (23.1% vs. 10.1%), memory loss (29.2% vs. 4.8%), and joint pain (47.5% vs. 17.5%). On examination, more survivors than controls had abnormal abdominal, chest, neurologic, and musculoskeletal findings and uveitis. Other than uveitis (prevalence at enrollment, 26.4% vs. 12.1%; at year 1, 33.3% vs. 15.4%), the prevalence of these conditions declined during follow-up in both groups. The incidence of most symptoms, neurologic findings, and uveitis was greater among survivors than among controls. EBOV RNA was detected in semen samples from 30% of the survivors tested, with a maximum time from illness to detection of 40 months. CONCLUSIONS: A relatively high burden of symptoms was seen in all participants, but certain symptoms and examination findings were more common among survivors. With the exception of uveitis, these conditions declined in prevalence during follow-up in both groups. Viral RNA in semen persisted for a maximum of 40 months. (Funded by the National Institute of Allergy and Infectious Diseases and the National Eye Institute; PREVAIL III ClinicalTrials.gov number, NCT02431923.).