Overcoming Operational Challenges to Ebola Case Investigation in Sierra Leone.

The Ebola virus disease (EVD) epidemic that hit West Africa in 2013 was the worst outbreak of EVD in recorded history. While much has been published regarding the international and national-level EVD responses, there is a dearth of literature on district-level coordination and operational structures, successes, and failures. This article seeks to understand how the EVD response unfolded at the district level, namely the challenges to operationalizing EVD surveillance over the course of the outbreak in Port Loko and Kambia districts of Sierra Leone. We present here GOAL Global's understanding of the fundamental challenges to case investigation operations during the EVD response, including environmental and infrastructural, sociocultural, and political and organizational challenges, with insight complemented by a survey of 42 case investigators. Major challenges included deficiencies in transportation and communication resources, low morale and fatigue among case investigators, mismanagement of data, mistrust among communities, and leadership challenges. Without addressing these operational challenges, technical surveillance solutions are difficult to implement and hold limited relevance, due to the poor quality and quantity of data being collected. The low prioritization of operational needs came at a high cost. To mediate this, GOAL addressed these operational challenges by acquiring critical transportation and communication resources to facilitate case investigation, including vehicles, boats, fuel, drivers, phones, and closed user groups; addressing fatigue and low morale by hiring more case investigators, making timely payments, arranging for time off, and providing meals and personal protective equipment; improving data tracking efforts through standard operating procedures, training, and mentorship to build higher-quality case histories and make it easier to access information; strengthening trust in communities by ensuring familiarity and consistency of case investigators; and improving operational leadership challenges through meetings and regular coordination, establishing an active surveillance strategy in Port Loko, and conducting an after-action review. Resolving or addressing these challenges was of primary importance, and requisite for the implementation of technical epidemiological complements to EVD case investigation.

Design and evaluation of a web-based decision support tool for district-level disease surveillance in a low-resource setting.

During the 2014 West African Ebola Virus outbreak it became apparent that the initial response to the outbreak was hampered by limitations in the collection, aggregation, analysis and use of data for intervention planning. As part of the post-Ebola recovery phase, IBM Research Africa partnered with the Port Loko District Health Management Team (DHMT) in Sierra Leone and GOAL Global, to design, implement and deploy a web-based decision support tool for district-level disease surveillance. This paper discusses the design process and the functionality of the first version of the system. The paper presents evaluation results prior to a pilot deployment and identifies features for future iterations. A qualitative assessment of the tool prior to pilot deployment indicates that it improves the timeliness and ease of using data for making decisions at the DHMT level.

Successful Implementation of a Multicountry Clinical Surveillance and Data Collection System for Ebola Virus Disease in West Africa: Findings and Lessons Learned.

BACKGROUND: The 2014 outbreak of Ebola virus disease (EVD) in West Africa was the largest ever recorded. Starting in September 2014, International Medical Corps (IMC) managed 5 Ebola treatment units (ETUs) in Liberia and Sierra Leone, which cumulatively cared for about 2,500 patients. We conducted a retrospective cohort study of patient data collected at the 5 ETUs over 1 year of operations. METHODS: To collect clinical and epidemiological data from the patient care areas, each chart was either manually copied across the fence between the high-risk zone and low-risk zone, imaged across the fence, or imaged in the high-risk zone. Each ETU's data were entered into a separate electronic database, and these were later combined into a single relational database. Lot quality assurance sampling was used to ensure data quality, with reentry of data with high error rates from imaged records. RESULTS: The IMC database contains records on 2,768 patient presentations, including 2,351 patient admissions with full follow-up data. Of the patients admitted, 470 (20.0%) tested positive for EVD, with an overall case fatality ratio (CFR) of 57.0% for EVD-positive patients and 8.1% for EVD-negative patients. Although more men were admitted than women (53.4% vs. 46.6%), a larger proportion of women were diagnosed EVD positive (25.6% vs. 15.2%). Diarrhea, red eyes, contact with an ill person, and funeral attendance were significantly more common in patients with EVD than in those with other diagnoses. Among EVD-positive patients, age was a significant predictor of mortality: the highest CFRs were among children under 5 (89.1%) and adults over 55 (71.4%). DISCUSSION: While several prior reports have documented the experiences of individual ETUs, this study is the first to present data from multiple ETUs across 2 countries run by the same organization with similar clinical protocols. Our experience demonstrates that even in austere settings under difficult conditions, it is possible for humanitarian organizations to collect high-quality clinical and epidemiologic data during a major infectious disease outbreak.