Sustainable strategies for Ebola virus disease outbreak preparedness in Africa: a case study on lessons learnt in countries neighbouring the Democratic Republic of the Congo.

BACKGROUND: From May 2018 to September 2022, the Democratic Republic of Congo (DRC) experienced seven Ebola virus disease (EVD) outbreaks within its borders. During the 10th EVD outbreak (2018-2020), the largest experienced in the DRC and the second largest and most prolonged EVD outbreak recorded globally, a WHO risk assessment identified nine countries bordering the DRC as moderate to high risk from cross border importation. These countries implemented varying levels of Ebola virus disease preparedness interventions. This case study highlights the gains and shortfalls with the Ebola virus disease preparedness interventions within the various contexts of these countries against the background of a renewed and growing commitment for global epidemic preparedness highlighted during recent World Health Assembly events. MAIN TEXT: Several positive impacts from preparedness support to countries bordering the affected provinces in the DRC were identified, including development of sustained capacities which were leveraged upon to respond to the subsequent coronavirus disease 2019 (COVID-19) pandemic. Shortfalls such as lost opportunities for operationalizing cross-border regional preparedness collaboration and better integration of multidisciplinary perspectives, vertical approaches to response pillars such as surveillance, over dependence on external support and duplication of efforts especially in areas of capacity building were also identified. A recurrent theme that emerged from this case study is the propensity towards implementing short-term interventions during active Ebola virus disease outbreaks for preparedness rather than sustainable investment into strengthening systems for improved health security in alignment with IHR obligations, the Sustainable Development Goals and advocating global policy for addressing the larger structural determinants underscoring these outbreaks. CONCLUSIONS: Despite several international frameworks established at the global level for emergency preparedness, a shortfall exists between global policy and practice in countries at high risk of cross border transmission from persistent Ebola virus disease outbreaks in the Democratic Republic of Congo. With renewed global health commitment for country emergency preparedness resulting from the COVID-19 pandemic and cumulating in a resolution for a pandemic preparedness treaty, the time to review and address these gaps and provide recommendations for more sustainable and integrative approaches to emergency preparedness towards achieving global health security is now.

Predictive ability of symptomatology in COVID-19 during Active case search in Lagos State, Nigeria.

BACKGROUND: In April 2020, a community-based active case search surveillance system of coronavirus disease 2019 (COVID-19) was developed by the emergency outbreak committee in Lagos State. This followed the evidence of community transmission of coronavirus disease in the twenty Local Government Areas in Lagos State. This study assessed the value of respiratory and other symptoms in predicting positive SARS-CoV-2 using reverse transcription-polymerase chain reaction (RT-PCR). It is hoped that if symptoms are predictive, they can be used in screening before testing. METHODS: Communities were included based on the alerts from community members through the rumour alert system set up by the state. All members of the households of the communities from where the alert came were eligible. Household members who declined to participate were excluded from the study. A standardised interviewer-administered electronic investigation form was used to collect sociodemographic information, clinical details and history for each possible case. Data was analysed to see the extent of agreement or correlation between reported symptoms and the results of PCR testing for SARS-COV-2. RESULTS: A total of 12,739 persons were interviewed. The most common symptoms were fever, general weakness, cough and difficulty in breathing. Different symptoms recorded different levels of sensitivity as follows: fever, 28.9%; cough, 21.7%; general body weakness, 10.9%; and sore throat, 10.9%. Sensitivity and specificity for fever, the most common symptom, were 28.3% and 50.2%, respectively, while similar parameters for general body weakness, the next most common symptom, were 10.9% and 73.2%, respectively. CONCLUSION: From these findings, the predictive ability of symptoms for COVID-19 diagnosis was extremely weak. It is unlikely that symptoms alone will suffice to predict COVID-19 in a patient. An additional measure, such as confirmatory test by RT-PCR testing, is necessary to confirm the disease.

Analyses of the performance of the Ebola virus disease alert management system in South Sudan: August 2018 to November 2019.

South Sudan implemented Ebola virus disease preparedness interventions aiming at preventing and rapidly containing any importation of the virus from the Democratic Republic of Congo starting from August 2018. One of these interventions was a surveillance system which included an Ebola alert management system. This study analyzed the performance of this system. A descriptive cross-sectional study of the Ebola virus disease alerts which were reported in South Sudan from August 2018 to November 2019 was conducted using both quantitative and qualitative methods. As of 30 November 2019, a total of 107 alerts had been detected in the country out of which 51 (47.7%) met the case definition and were investigated with blood samples collected for laboratory confirmation. Most (81%) of the investigated alerts were South Sudanese nationals. The alerts were identified by health workers (53.1%) at health facilities, at the community (20.4%) and by screeners at the points of entry (12.2%). Most of the investigated alerts were detected from the high-risk states of Gbudwe (46.9%), Jubek (16.3%) and Torit (10.2%). The investigated alerts commonly presented with fever, bleeding, headache and vomiting. The median timeliness for deployment of Rapid Response Team was less than one day and significantly different between the 6-month time periods (K-W = 7.7567; df = 2; p = 0.0024) from 2018 to 2019. Strengths of the alert management system included existence of a dedicated national alert hotline, case definition for alerts and rapid response teams while the weaknesses were occasional inability to access the alert toll-free hotline and lack of transport for deployment of the rapid response teams which often constrain quick response. This study demonstrates that the Ebola virus disease alert management system in South Sudan was fully functional despite the associated challenges and provides evidence to further improve Ebola preparedness in the country.

What did we learn from preparing for cross-border transmission of Ebola virus disease into a complex humanitarian setting - The Republic of South Sudan?

BACKGROUND: Following the West Africa Ebola virus disease (EVD) outbreak (2013-2016), WHO developed a preparedness checklist for its member states. This checklist is currently being applied for the first time on a large and systematic scale to prepare for the cross border importation of the ongoing EVD outbreak in the Democratic Republic of Congo hence the need to document the lessons learnt from this experience. This is more pertinent considering the complex humanitarian context and weak health system under which some of the countries such as the Republic of South Sudan are implementing their EVD preparedness interventions. MAIN TEXT: We identified four main lessons from the ongoing EVD preparedness efforts in the Republic South Sudan. First, EVD preparedness is possible in complex humanitarian settings such as the Republic of South Sudan by using a longer-term health system strengthening approach. Second, the Republic of South Sudan is at risk of both domestic and cross border transmission of EVD and several other infectious disease outbreaks hence the need for an integrated and sustainable approach to outbreak preparedness in the country. Third, a phased and well-prioritized approach is required for EVD preparedness in complex humanitarian settings given the costs associated with preparedness and the difficulties in the accurate prediction of outbreaks in such settings. Fourth, EVD preparedness in complex humanitarian settings is a massive undertaking that requires effective and decentralized coordination. CONCLUSION: Despite a very challenging context, the Republic of South Sudan made significant progress in its EVD preparedness drive demonstrating that it is possible to rapidly scale up preparedness efforts in complex humanitarian contexts if appropriate and context-specific approaches are used. Further research, systematic reviews and evaluation of the ongoing preparedness efforts are required to ensure comprehensive documentation and application of the lessons learnt for future EVD outbreak preparedness and response efforts.

Clinical presentation, case management and outcomes for the first 32 COVID-19 patients in Nigeria.

INTRODUCTION: Success in curtailing the pandemic coronavirus disease (COVID-19) depends largely on a sound understanding of the epidemiologic and clinical profile of cases in a population as well as the case management approach. This study documents the presenting characteristics, treatment modalities and outcomes of the first 32 COVID-19 patients in Nigeria. METHODS: This retrospective study used medical records of the first 32 patients admitted and discharged from the Mainland Hospital, Lagos State, southwest Nigeria between February 27 and April 6, 2020. The outcomes of interest were death, promptness of admission process and duration of hospitalization. RESULTS: The mean age of the patients was 38.1 years (SD: 15.5) and 66% were male. Three-quarters (75%) of the patients presented in moderately severe condition while 16% were asymptomatic. The most common presenting symptoms were fever (59%) and dry cough (44%). The mean time between a positive test result and admission was 1.63 days (SD: 1.31). Almost all (97%) the patients were treated with lopinavir-ritonavir with no recorded death. The median duration of hospital stay was 12 days (IQR: 9-13.5). CONCLUSION: In this preliminary analysis of the first COVID-19 cases in Nigeria, clinical presentation was mild to moderate with no mortality. Processes to improve promptness of admission and reduce hospital stay are required to enhance the response to COVID-19 in Nigeria.