Ineffective responses to unlikely outbreaks: Hypothesis building in newly-emerging infectious disease outbreaks.

Over the last 30 years, there has been significant investment in research and infrastructure aimed at mitigating the threat of newly emerging infectious diseases (NEID). Core epidemiological processes, such as outbreak investigations, however, have received little attention and have proceeded largely unchecked and unimproved. Using ethnographic material from an investigation into a cryptic encephalitis outbreak in the Brong-Ahafo Region of Ghana in 2010-2013, in this paper we trace processes of hypothesis building and their relationship to the organizational structures of the response. We demonstrate how commonly recurring features of NEID investigations produce selective pressures in hypothesis building that favor iterations of pre-existing "exciting" hypotheses and inhibit the pursuit of alternative hypotheses, regardless of relative likelihood. These findings contribute to the growing anthropological and science and technology studies (STS) literature on the epistemic communities that coalesce around suspected NEID outbreaks and highlight an urgent need for greater scrutiny of core epidemiological processes.

Propagating Visions of a Forest Reservoir: A Supposed Zoonotic Outbreak in the Brong-Ahafo Region of Ghana.

When examined closely, the backgrounds of some of the most widely cited origin stories for zoonotic disease outbreaks have been found to be irreconcilable with empirical data. Stated simply, these explanatory landscapes do not appear to have existed. Here, I present a detailed case study of one such fictional landscape, that of a monkey-filled forest which was identified as the source of a suspected zoonotic outbreak in the Brong-Ahafo Region of Ghana in 2010. Taking my approach from cultural epidemiology, I elucidate the mechanisms by which this fictional landscape was constructed and transmitted among the professionals involved in the response.

Lockdowns, lives and livelihoods: the impact of COVID-19 and public health responses to conflict affected populations - a remote qualitative study in Baidoa and Mogadishu, Somalia.

BACKGROUND: Authorities in Somalia responded with drastic measures after the first confirmed COVID-19 case in mid-March 2020, closing borders, schools, limiting travel and prohibiting most group functions. However, the impact of the pandemic in Somalia thereafter remained unclear. This study employs a novel remote qualitative research method in a conflict-affected setting to look at how some of the most at-risk internally displaced and host populations were impacted by COVID-19, what determined their responses, and how this affected their health and socio-economic vulnerability. METHODS: We conducted a remote qualitative study, using Katikati, a 1-to-1 conversation management and analysis platform using short message service (SMS) developed by Lark Systems with Africa's Voices Foundation (AVF), for semi-structured interviews over three months with participants in Mogadishu and Baidoa. We recruited a gender balanced cohort across age groups, and used an analytical framework on the social determinants of health for a narrative analysis on major themes discussed, triangulating data with existing peer-reviewed and grey literature. RESULTS: The remote research approach demonstrated efficacy in sustaining trusted and meaningful conversations for gathering qualitative data from hard-to-reach conflict-affected communities. The major themes discussed by the 35 participants included health, livelihoods and education. Two participants contracted the disease, while others reported family or community members affected by COVID-19. Almost all participants faced a loss of income and/or education, primarily as a result of the strict public health measures. Some of those who were heavily affected economically but did not directly experienced disease, denied the pandemic. Religion played an important role in participants' beliefs in protection against and salvation from the disease. As lockdowns were lifted in August 2020, many believed the pandemic to be over. CONCLUSIONS: While the official COVID-19 burden has remained relatively low in Somalia, the impact to people's daily lives, income and livelihoods due to public health responses, has been significant. Participants describe those 'secondary' outcomes as the main impact of the pandemic, serving as a stark reminder of the need to broaden the public health response beyond disease prevention to include social and economic interventions to decrease people's vulnerability to future shocks.

Disaster displacement and zoonotic disease dynamics: The impact of structural and chronic drivers in Sindh, Pakistan.

Projected increases in human and animal displacement driven by climate change, disasters and related environmental degradation will have significant implications to global health. Pathways for infectious disease transmission including zoonoses, diseases transmitted between animals and humans, are complex and non-linear. While forced migration is considered an important driver for the spread of zoonoses, actual disease dynamics remain under researched. This paper presents the findings of a case study investigating how disaster displacement affected zoonotic disease transmission risk following the 2010 'superfloods' in Sindh province, Pakistan. We interviewed 30 key informants and 17 household members across 6 rural communities between March and November 2019, supported by observational studies and a review of secondary data. Results were analysed using the ecosocial theoretical framework. Buffalo, cattle and goats were often the only moveable asset, therefore livestock was an important consideration in determining displacement modality and destination location, and crowded locations were avoided to protect human and animal health. Meanwhile however, livestock was rarely included in the humanitarian response, resulting in communities and households fragmenting according to the availability of livestock provisions. We found that rather than a driver for disease, displacement acted as a process affecting community, household and individual zoonotic disease risk dynamics, based on available resources and social networks before, during and after displacement, rooted in the historical, political and socio-economic context. We conclude that in rural Sindh, disaster displaced populations' risk of zoonoses is the result of changes in dynamics rooted in pre-existing structural and chronic inequalities, making people more or less vulnerable to disease through multiple interlinked pathways. Our findings have implications for policy makers and humanitarian responders assisting displaced populations dependent on livestock, with a call to integrate livestock support in humanitarian policies and responses for health, survival and recovery.

Estimating undetected Ebola spillovers.

The preparedness of health systems to detect, treat, and prevent onward transmission of Ebola virus disease (EVD) is central to mitigating future outbreaks. Early detection of outbreaks is critical to timely response, but estimating detection rates is difficult because unreported spillover events and outbreaks do not generate data. Using three independent datasets available on the distributions of secondary infections during EVD outbreaks across West Africa, in a single district (Western Area) of Sierra Leone, and in the city of Conakry, Guinea, we simulated realistic outbreak size distributions and compared them to reported outbreak sizes. These three empirical distributions lead to estimates for the proportion of detected spillover events and small outbreaks of 26% (range 8-40%, based on the full outbreak data), 48% (range 39-62%, based on the Sierra Leone data), and 17% (range 11-24%, based on the Guinea data). We conclude that at least half of all spillover events have failed to be reported since EVD was first recognized. We also estimate the probability of detecting outbreaks of different sizes, which is likely less than 10% for single-case spillover events. Comparing models of the observation process also suggests the probability of detecting an outbreak is not simply the cumulative probability of independently detecting any one individual. Rather, we find that any individual's probability of detection is highly dependent upon the size of the cluster of cases. These findings highlight the importance of primary health care and local case management to detect and contain undetected early stage outbreaks at source.

Facility-based surveillance for emerging infectious diseases; diagnostic practices in rural West African hospital settings: observations from Ghana.

The aim of this study was to better understand the effectiveness of Integrated Disease Surveillance and Response (IDSR) facility-based surveillance in detecting newly emerging infectious diseases (EIDs) in rural West African settings. A six-month ethnographic study was undertaken in 2012 in the Techiman Municipality of the Brong-Ahafo Region of Ghana, aimed at documenting the trajectories of febrile illness cases of unknown origin occurring within four rural communities. Particular attention was paid to where these trajectories involved the use of formal healthcare facilities and the diagnostic practices that occurred there. Seventy-six participants were enrolled in the study, and 24 complete episodes of illness were documented. While participants routinely used hospital treatment when confronted with enduring or severe illness, the diagnostic process within clinical settings meant that an unusual diagnosis, such as an EID, was unlikely to be considered. Facility-based surveillance is unlikely to be effective in detecting EIDs due to a combination of clinical care practices and the time constraints associated with individual episodes of illness, particularly in the resource-limited settings of rural West Africa, where febrile illness due to malaria is common and specific diagnostic assays are largely unavailable. The success of the 'One Health' approach to EIDs in West Africa is predicated on characterization of accurately diagnosed disease burdens. To this end, we must address inefficiencies in the dominant approaches to EID surveillance and the weaknesses of health systems in the region generally.This article is part of the themed issue 'One Health for a changing world: zoonoses, ecosystems and human well-being'.