Lessons learned for surveillance system strengthening through capacity building and partnership engagement in post-Ebola Guinea, 2015-2019.

The 2014-2016 Ebola outbreak in Guinea revealed systematic weaknesses in the existing disease surveillance system, which contributed to delayed detection, underreporting of cases, widespread transmission in Guinea and cross-border transmission to neighboring Sierra Leone and Liberia, leading to the largest Ebola epidemic ever recorded. Efforts to understand the epidemic's scale and distribution were hindered by problems with data completeness, accuracy, and reliability. In 2017, recognizing the importance and usefulness of surveillance data in making evidence-based decisions for the control of epidemic-prone diseases, the Guinean Ministry of Health (MoH) included surveillance strengthening as a priority activity in their post-Ebola transition plan and requested the support of partners to attain its objectives. The U.S. Centers for Disease Control and Prevention (US CDC) and four of its implementing partners-International Medical Corps, the International Organization for Migration, RTI International, and the World Health Organization-worked in collaboration with the Government of Guinea to strengthen the country's surveillance capacity, in alignment with the Global Health Security Agenda and International Health Regulations 2005 objectives for surveillance and reporting. This paper describes the main surveillance activities supported by US CDC and its partners between 2015 and 2019 and provides information on the strategies used and the impact of activities. It also discusses lessons learned for building sustainable capacity and infrastructure for disease surveillance and reporting in similar resource-limited settings.

Evaluation of the first two Frontline cohorts of the field epidemiology training program in Guinea, West Africa.

BACKGROUND: The 2014-2016 Ebola virus disease outbreak in West Africa revealed weaknesses in the health systems of the three most heavily affected countries, including a shortage of public health professionals at the local level trained in surveillance and outbreak investigation. In response, the Frontline Field Epidemiology Training Program (FETP) was created by CDC in 2015 as a 3-month, accelerated training program in field epidemiology that specifically targets the district level. In Guinea, the first two FETP-Frontline cohorts were held from January to May, and from June to September 2017. Here, we report the results of a cross-sectional evaluation of these first two cohorts of FETP-Frontline in Guinea. METHODS: The evaluation was conducted in April 2018 and consisted of interviews with graduates, their supervisors, and directors of nearby health facilities, as well as direct observation of data reports and surveillance tools at health facilities. Interviews and site visits were conducted using standardized questionnaires and checklists. Qualitative data were coded under common themes and analyzed using descriptive statistics. RESULTS: The evaluation revealed a significant perception of improvement in all assessed skills by the graduates, as well as high levels of self-reported involvement in key activities related to data collection, analysis, and reporting. Supervisors highlighted improvements to systematic and quality case and summary reporting as key benefits of the FETP-Frontline program. At the health facility level, staff reported the training had resulted in improvements to information sharing and case notifications. Reported barriers included lack of transportation, available support personnel, and other resources. Graduates and supervisors both emphasized the importance of continued and additional training to solidify and retain skills. CONCLUSIONS: The evaluation demonstrated a strongly positive perceived benefit of the FETP-Frontline training on the professional activities of graduates as well as the overall surveillance system. However, efforts are needed to ensure greater gender equity and to recruit more junior trainee candidates for future cohorts. Moreover, although improvements to the surveillance system were observed concurrent with the completion of the two cohorts, the evaluation was not designed to directly measure impact on surveillance or response functions. Combined with the rapid implementation of FETP-Frontline around the world, this suggests an opportunity to develop standardized evaluation toolkits, which could incorporate metrics that would directly assess the impact of equitable field epidemiology workforce development on countries' abilities to prevent, detect, and respond to public health threats.

Implementing a DHIS2 Ebola virus disease module during the 2021 Guinea Ebola outbreak.

In 2017, the national agency for health security (L'Agence Nationale de Sécurité Sanitaire-ANSS) in Guinea implemented the District Health Information Software (DHIS2) as the Ministry of Health national surveillance system to capture and report aggregate disease data. During 2019, the ANSS started using DHIS2 Tracker to collect case-based (individual-level) data for epidemic-prone diseases. In 2020, the capability was expanded, and it was used during the COVID-19 pandemic to capture data relevant to the COVID-19 response. When an Ebola virus disease (EVD) outbreak was announced in February 2021, the Tracker module was updated, and enhanced functionalities were developed to meet the needs for the emerging epidemic. This novel EVD module has components to capture information on cases, contacts, alerts, laboratory and vaccinations and provides a centralised site for all EVD outbreak data. It has since been expanded for use with future viral haemorrhagic fever outbreaks.

Implementation of DHIS2 for Disease Surveillance in Guinea: 2015-2020.

A robust epidemic-prone disease surveillance system is a critical component of public health infrastructure and supports compliance with the International Health Regulations (IHR). One digital health platform that has been implemented in numerous low- and middle-income countries is the District Health Information System Version 2 (DHIS2). In 2015, in the wake of the Ebola epidemic, the Ministry of Health in Guinea established a strategic plan to strengthen its surveillance system, including adoption of DHIS2 as a health information system that could also capture surveillance data. In 2017, the DHIS2 platform for disease surveillance was piloted in two regions, with the aim of ensuring the timely availability of quality surveillance data for better prevention, detection, and response to epidemic-prone diseases. The success of the pilot prompted the national roll-out of DHIS2 for weekly aggregate disease surveillance starting in January 2018. In 2019, the country started to also use the DHIS2 Tracker to capture individual cases of epidemic-prone diseases. As of February 2020, for aggregate data, the national average timeliness of reporting was 72.2%, and average completeness 98.5%; however, the proportion of individual case reports filed was overall low and varied widely between diseases. While substantial progress has been made in implementation of DHIS2 in Guinea for use in surveillance of epidemic-prone diseases, much remains to be done to ensure long-term sustainability of the system. This paper describes the implementation and outcomes of DHIS2 as a digital health platform for disease surveillance in Guinea between 2015 and early 2020, highlighting lessons learned and recommendations related to the processes of planning and adoption, pilot testing in two regions, and scale up to national level.

Leveraging Partnerships to Maximize Global Health Security Improvements in Guinea, 2015-2019.

In response to the 2014-2016 West Africa Ebola virus disease (EVD) outbreak, a US congressional appropriation provided funds to the US Centers for Disease Control and Prevention (CDC) to support global health security capacity building in 17 partner countries, including Guinea. The 2014 funding enabled CDC to provide more than 300 deployments of personnel to Guinea during the Ebola response, establish a country office, and fund 11 implementing partners through cooperative agreements to support global health security engagement efforts in 4 core technical areas: workforce development, surveillance systems, laboratory systems, and emergency management. This article reflects on almost 4 years of collaboration between CDC and its implementing partners in Guinea during the Ebola outbreak response and the recovery period. We highlight examples of collaborative synergies between cooperative agreement partners and local Guinean partners and discuss the impact of these collaborations in strengthening the above 4 core capacities. Finally, we identify the key elements of the successful collaborations, including communication and information sharing as a core cooperative agreement activity, a flexible funding mechanism, and willingness to adapt to local needs. We hope these observations can serve as guidance for future endeavors seeking to establish strong and effective partnerships between government and nongovernment organizations providing technical and operational assistance.

Long-distance effects of epidemics: Assessing the link between the 2014 West Africa Ebola outbreak and U.S. exports and employment.

Although the economic consequences of epidemic outbreaks to affected areas are often well documented, little is known about how these might carry over into the economies of unaffected regions. In the absence of direct pathogen transmission, global trade is one mechanism through which geographically distant epidemics could reverberate to unaffected countries. This study explores the link between global public health events and U.S. economic outcomes by evaluating the role of the 2014 West Africa Ebola outbreak in U.S. exports and exports-supported U.S. jobs, 2005-2016. Estimates were obtained using difference-in-differences models where sub-Saharan Africa countries were assigned to treatment and comparison groups based on their Ebola transmission status, with controls for observed and unobserved time-variant factors that may independently influence trends in trade. Multiple model specification checks were performed to ensure analytic robustness. The year of peak transmission, 2014, was estimated to result in $1.08 billion relative reduction in U.S. merchandise exports to Ebola-affected countries, whereas estimated losses in exports-supported U.S. jobs exceeded 1,200 in 2014 and 11,000 in 2015. These findings suggest that remote disruptions in health security might play a role in U.S. economic indicators, demonstrating the interconnectedness between global health and aspects of the global economy and informing the relevance of health security efforts.

Assessing health systems in Guinea for prevention and control of priority zoonotic diseases: A One Health approach.

To guide One Health capacity building efforts in the Republic of Guinea in the wake of the 2014-2016 Ebola virus disease (EVD) outbreak, we sought to identify and assess the existing systems and structures for zoonotic disease detection and control. We partnered with the government ministries responsible for human, animal, and environmental health to identify a list of zoonotic diseases - rabies, anthrax, brucellosis, viral hemorrhagic fevers, trypanosomiasis and highly pathogenic avian influenza - as the country's top priorities. We used each priority disease as a case study to identify existing processes for prevention, surveillance, diagnosis, laboratory confirmation, reporting and response across the three ministries. Results were used to produce disease-specific systems "maps" emphasizing linkages across the systems, as well as opportunities for improvement. We identified brucellosis as a particularly neglected condition. Past efforts to build avian influenza capabilities, which had degraded substantially in less than a decade, highlighted the challenge of sustainability. We observed a keen interest across sectors to reinvigorate national rabies control, and given the regional and global support for One Health approaches to rabies elimination, rabies could serve as an ideal disease to test incipient One Health coordination mechanisms and procedures. Overall, we identified five major categories of gaps and challenges: (1) Coordination; (2) Training; (3) Infrastructure; (4) Public Awareness; and (5) Research. We developed and prioritized recommendations to address the gaps, estimated the level of resource investment needed, and estimated a timeline for implementation. These prioritized recommendations can be used by the Government of Guinea to plan strategically for future One Health efforts, ideally under the auspices of the national One Health Platform. This work demonstrates an effective methodology for mapping systems and structures for zoonotic diseases, and the benefit of conducting a baseline review of systemic capabilities prior to embarking on capacity building efforts.

Creating a National Specimen Referral System in Guinea: Lessons From Initial Development and Implementation.

In the wake of the 2014-2016, West Africa Ebola virus disease (EVD) outbreak, the Government of Guinea recognized an opportunity to strengthen its national laboratory system, incorporating capacity and investments developed during the response. The Ministry of Health (MOH) identified creation of a holistic, safe, secure, and timely national specimen referral system as a priority for improved detection and confirmation of priority diseases, in line with national Integrated Disease Surveillance and Response guidelines. The project consisted of two parts, each led by different implementing partners working collaboratively together and with the Ministry of Health: the development and approval of a national specimen referral policy, and pilot implementation of a specimen referral system, modeled on the policy, in three prefectures. This paper describes the successful execution of the project, highlighting the opportunities and challenges of building sustainable health systems capacity during and after public health emergencies, and provides lessons learned for strengthening national capabilities for surveillance and disease diagnosis.

Sensitivity and Specificity of Suspected Case Definition Used during West Africa Ebola Epidemic.

Rapid early detection and control of Ebola virus disease (EVD) is contingent on accurate case definitions. Using an epidemic surveillance dataset from Guinea, we analyzed an EVD case definition developed by the World Health Organization (WHO) and used in Guinea. We used the surveillance dataset (March-October 2014; n = 2,847 persons) to identify patients who satisfied or did not satisfy case definition criteria. Laboratory confirmation determined cases from noncases, and we calculated sensitivity, specificity and predictive values. The sensitivity of the defintion was 68.9%, and the specificity of the definition was 49.6%. The presence of epidemiologic risk factors (i.e., recent contact with a known or suspected EVD case-patient) had the highest sensitivity (74.7%), and unexplained deaths had the highest specificity (92.8%). Results for case definition analyses were statistically significant (p<0.05 by χ2 test). Multiple components of the EVD case definition used in Guinea contributed to improved overall sensitivity and specificity.

Operational evaluation of rapid diagnostic testing for Ebola Virus Disease in Guinean laboratories.

BACKGROUND: Rapid Diagnostic Tests (RDTs) for Ebola Virus Disease (EVD) at the point of care have the potential to increase access and acceptability of EVD testing and the speed of patient isolation and secure burials for suspect cases. A pilot program for EVD RDTs in high risk areas of Guinea was introduced in October 2015. This paper presents concordance data between EVD RDTs and PCR testing in the field as well as an assessment of the acceptability, feasibility, and quality assurance of the RDT program. METHODS AND FINDINGS: Concordance data were compiled from laboratory surveillance databases. The operational measures of the laboratory-based EVD RDT program were evaluated at all 34 sentinel sites in Guinea through: (1) a technical questionnaire filled by the lab technicians who performed the RDTs, (2) a checklist filled by the evaluator during the site visits, and (3) direct observation of the lab technicians performing the quality control test. Acceptability of the EVD RDT was good for technicians, patients, and families although many technicians (69.8%) expressed concern for their safety while performing the test. The feasibility of the program was good based on average technician knowledge scores (6.6 out of 8) but basic infrastructure, equipment, and supplies were lacking. There was much room for improvement in quality assurance of the program. CONCLUSIONS: The implementation of new diagnostics in weak laboratory systems requires general training in quality assurance, biosafety and communication with patients in addition to specific training for the new test. Corresponding capacity building in terms of basic equipment and a long-term commitment to transfer supervision and quality improvement to national public health staff are necessary for successful implementation.

Ebola Response Impact on Public Health Programs, West Africa, 2014-2017.

Events such as the 2014-2015 West Africa epidemic of Ebola virus disease highlight the importance of the capacity to detect and respond to public health threats. We describe capacity-building efforts during and after the Ebola epidemic in Liberia, Sierra Leone, and Guinea and public health progress that was made as a result of the Ebola response in 4 key areas: emergency response, laboratory capacity, surveillance, and workforce development. We further highlight ways in which capacity-building efforts such as those used in West Africa can be accelerated after a public health crisis to improve preparedness for future events.

Knowledge, Attitudes, and Practices Related to Ebola Virus Disease at the End of a National Epidemic - Guinea, August 2015.

Health communication and social mobilization efforts to improve the public's knowledge, attitudes, and practices (KAP) regarding Ebola virus disease (Ebola) were important in controlling the 2014-2016 Ebola epidemic in Guinea (1), which resulted in 3,814 reported Ebola cases and 2,544 deaths.* Most Ebola cases in Guinea resulted from the washing and touching of persons and corpses infected with Ebola without adequate infection control precautions at home, at funerals, and in health facilities (2,3). As the 18-month epidemic waned in August 2015, Ebola KAP were assessed in a survey among residents of Guinea recruited through multistage cluster sampling procedures in the nation's eight administrative regions (Boké, Conakry, Faranah, Kankan, Kindia, Labé, Mamou, and Nzérékoré). Nearly all participants (92%) were aware of Ebola prevention measures, but 27% believed that Ebola could be transmitted by ambient air, and 49% believed they could protect themselves from Ebola by avoiding mosquito bites. Of the participants, 95% reported taking actions to avoid getting Ebola, especially more frequent handwashing (93%). Nearly all participants (91%) indicated they would send relatives with suspected Ebola to Ebola treatment centers, and 89% said they would engage special Ebola burial teams to remove corpses with suspected Ebola from homes. Of the participants, 66% said they would prefer to observe an Ebola-affected corpse from a safe distance at burials rather than practice traditional funeral rites involving corpse contact. The findings were used to guide the ongoing epidemic response and recovery efforts, including health communication, social mobilization, and planning, to prevent and respond to future outbreaks or sporadic cases of Ebola.

Implementation of broad screening with Ebola rapid diagnostic tests in Forécariah, Guinea.

BACKGROUND: Laboratory-enhanced surveillance is critical for rapidly detecting the potential re-emergence of Ebola virus disease. Rapid diagnostic tests (RDT) for Ebola antigens could expand diagnostic capacity for Ebola virus disease. OBJECTIVES: The Guinean National Coordination for Ebola Response conducted a pilot implementation to determine the feasibility of broad screening of patients and corpses with the OraQuick® Ebola RDT. METHODS: The implementation team developed protocols and trained healthcare workers to screen patients and corpses in Forécariah prefecture, Guinea, from 15 October to 30 November 2015. Data collected included number of consultations, number of fevers reported or measured, number of tests performed for patients or corpses and results of confirmatory RT-PCR testing. Data on malaria RDT results were collected for comparison. Feedback from Ebola RDT users was collected informally during supervision visits and forums. RESULTS: There were 3738 consultations at the 15 selected healthcare facilities; 74.6% of consultations were for febrile illness. Among 2787 eligible febrile patients, 2633 were tested for malaria and 1628 OraQuick® Ebola RDTs were performed. A total of 322 OraQuick® Ebola RDTs were conducted on corpses. All Ebola tests on eligible patients were negative. CONCLUSIONS: Access to Ebola testing was expanded by the implementation of RDTs in an emergency situation. Feedback from Ebola RDT users and lessons learned will contribute to improving quality for RDT expansion.

Attitudes about vaccines to prevent Ebola virus disease in Guinea at the end of a large Ebola epidemic: Results of a national household survey.

INTRODUCTION: In 2014-2016, an Ebola epidemic devastated Guinea; more than 3800 cases and 2500 deaths were reported to the World Health Organization. In August 2015, as the epidemic waned and clinical trials of an experimental, Ebola vaccine continued in Guinea and neighboring Sierra Leone, we conducted a national household survey about Ebola-related knowledge, attitudes, and practices (KAP) and opinions about "hypothetical" Ebola vaccines. METHODS: Using cluster-randomized sampling, we selected participants aged 15+ years old in Guinea's 8 administrative regions, which had varied cumulative case counts. The questionnaire assessed socio-demographic characteristics, experiences during the epidemic, Ebola-related KAP, and Ebola vaccine attitudes. To assess the potential for Ebola vaccine introduction in Guinea, we examined the association between vaccine attitudes and participants' characteristics using categorical and multivariable analyses. RESULTS: Of 6699 persons invited to participate, 94% responded to at least 1 Ebola vaccine question. Most agreed that vaccines were needed to fight the epidemic (85.8%) and that their family would accept safe, effective Ebola vaccines if they became available in Guinea (84.2%). These measures of interest and acceptability were significantly more common among participants who were male, wealthier, more educated, and lived with young children who had received routine vaccines. Interest and acceptability were also significantly higher among participants who understood Ebola transmission modes, had witnessed Ebola response teams, knew Ebola-affected persons, believed Ebola was not always fatal, and would access Ebola treatment centers. In multivariable analyses of the majority of participants living with young children, interest and acceptability were significantly higher among those living with vaccinated children than among those living with unvaccinated children. DISCUSSION: The high acceptability of hypothetical vaccines indicates strong potential for introducing Ebola vaccines across Guinea. Strategies to build public confidence in use of Ebola vaccines should highlight any similarities with safe, effective vaccines routinely used in Guinea.

Assessments of Ebola knowledge, attitudes and practices in Forécariah, Guinea and Kambia, Sierra Leone, July-August 2015.

The border region of Forécariah (Guinea) and Kambia (Sierra Leone) was of immense interest to the West Africa Ebola response. Cross-sectional household surveys with multi-stage cluster sampling procedure were used to collect random samples from Kambia (n = 635) in July 2015 and Forécariah (n = 502) in August 2015 to assess public knowledge, attitudes and practices related to Ebola. Knowledge of the disease was high in both places, and handwashing with soap and water was the most widespread prevention practice. Acceptance of safe alternatives to traditional burials was significantly lower in Forécariah compared with Kambia. In both locations, there was a minority who held discriminatory attitudes towards survivors. Radio was the predominant source of information in both locations, but those from Kambia were more likely to have received Ebola information from community sources (mosques/churches, community meetings or health workers) compared with those in Forécariah. These findings contextualize the utility of Ebola health messaging during the epidemic and suggest the importance of continued partnership with community leaders, including religious leaders, as a prominent part of future public health protection.This article is part of the themed issue 'The 2013-2016 West African Ebola epidemic: data, decision-making and disease control'.

Risk factors for long-term post-traumatic stress disorder among medical rescue workers appointed to the 2008 Wenchuan earthquake response in China.

This study aims to determine the risk factors for clinically-significant post-traumatic stress disorder (PTSD) among Chinese medical rescue workers one year after the response to the Wenchuan earthquake on 12 May 2008. A sample of 337 medical workers who performed response work within the first three months of the event completed an online questionnaire, which included information on demographics, social support, the management and organisation of the disaster response, and an assessment of PTSD. Symptoms consistent with PTSD were prevalent in 17 per cent of the rescue workers. Those who developed PTSD symptoms were more likely to have been injured, experienced a water shortage, been disconnected from family and friends during the response, and have passive coping styles and neurotic personalities. Factors that cannot be changed easily, such as personality traits, should be evaluated prior to deployment to ensure that rescue workers at higher risk of PTSD are provided with adequate support before and during deployment.

Notes from the Field: Baseline Assessment of the Use of Ebola Rapid Diagnostic Tests--Forécariah, Guinea, October-November 2015.

The Ebola virus disease (Ebola) epidemic in West Africa began in Guinea in early 2014. The reemergence of Ebola and risk of ongoing, undetected transmission continues because of the potential for sexual transmission and other as yet unknown transmission pathways. On March 17, 2016, two new cases of Ebola in Guinea were confirmed by the World Health Organization. This reemergence of Ebola in Guinea is the first since the original outbreak in the country was declared over on December 29, 2015. The prefecture of Forécariah, in western Guinea, was considerably affected by Ebola in 2015, with an incidence rate of 159 cases per 100,000 persons. Guinea also has a high prevalence of malaria; in a nationwide 2012 survey, malaria prevalence was reported to be 44% among healthy children aged ≤5 years. Malaria is an important reason for seeking health care; during 2014, 34% of outpatient consultations were related to malaria.

Evaluation of a National Call Center and a Local Alerts System for Detection of New Cases of Ebola Virus Disease - Guinea, 2014-2015.

The epidemic of Ebola virus disease (Ebola) in West Africa began in Guinea in late 2013 (1), and on August 8, 2014, the World Health Organization (WHO) declared the epidemic a Public Health Emergency of International Concern (2). Guinea was declared Ebola-free on December 29, 2015, and is under a 90 day period of enhanced surveillance, following 3,351 confirmed and 453 probable cases of Ebola and 2,536 deaths (3). Passive surveillance for Ebola in Guinea has been conducted principally through the use of a telephone alert system. Community members and health facilities report deaths and suspected Ebola cases to local alert numbers operated by prefecture health departments or to a national toll-free call center. The national call center additionally functions as a source of public health information by responding to questions from the public about Ebola. To evaluate the sensitivity of the two systems and compare the sensitivity of the national call center with the local alerts system, the CDC country team performed probabilistic record linkage of the combined prefecture alerts database, as well as the national call center database, with the national viral hemorrhagic fever (VHF) database; the VHF database contains records of all known confirmed Ebola cases. Among 17,309 alert calls analyzed from the national call center, 71 were linked to 1,838 confirmed Ebola cases in the VHF database, yielding a sensitivity of 3.9%. The sensitivity of the national call center was highest in the capital city of Conakry (11.4%) and lower in other prefectures. In comparison, the local alerts system had a sensitivity of 51.1%. Local public health infrastructure plays an important role in surveillance in an epidemic setting.

Ebola Virus Disease--Sierra Leone and Guinea, August 2015.

The Ebola virus disease (Ebola) outbreak in West Africa began in late 2013 in Guinea (1) and spread unchecked during early 2014. By mid-2014, it had become the first Ebola epidemic ever documented. Transmission was occurring in multiple districts of Guinea, Liberia, and Sierra Leone, and for the first time, in capital cities (2). On August 8, 2014, the World Health Organization (WHO) declared the outbreak to be a Public Health Emergency of International Concern (3). Ministries of Health, with assistance from multinational collaborators, have reduced Ebola transmission, and the number of cases is now declining. While Liberia has not reported a case since July 12, 2015, transmission has continued in Guinea and Sierra Leone, although the numbers of cases reported are at the lowest point in a year. In August 2015, Guinea and Sierra Leone reported 10 and four confirmed cases, respectively, compared with a peak of 526 (Guinea) and 1,997 (Sierra Leone) in November 2014. This report details the current situation in Guinea and Sierra Leone, outlines strategies to interrupt transmission, and highlights the need to maintain public health response capacity and vigilance for new cases at this critical time to end the outbreak.