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Impact of Ebola on the Epidemiology of other Infectious Diseases in West Africa
National Academy of Sciences, Washington DC,
Frank Mahoney MD, December 2017
Outline • Impact of Ebola on health work force and
provision of health services
• Changes in the epidemiology of priority diseases
• Lessons learned on Ebola in urban settings
Arrival of Patrick Sawyer in Nigeria
July 17 oDiplomat being monitored in
Monrovia o Left hospital AMA
July 20: Arrived in Lagos
Admitted to local hospital
with diagnosis of malaria
July 23 o EVD confirmed o IMS activated
July 25: Patient died
72 health care workers and airport staff exposed
Case Investigation of HCW who took care of Patrick Sawyer
“I had 1st contact with Mr Sawyer on July 21 after I was called by the nurse.” On getting to the patient, I discovered his IV line was by his side and picked it up with bare hands to hang on the drip stand. I called the nurse to assist the patient to toilet. I had a cut on my hand and did not remember to wash my hands until much later in the shift”
*Ebola among HCWs in Liberia, Sierra Leone, and Guinea 2014-15
Country Total no. HCW infections
No. where outcome is known
No. HCW deaths
% mortality
Liberia 288 220 157 71% Sierre Leone
328 219 152 69%
Guinea 199 196 109 56% Total 815 635 418 66%
*http://www.who.int/csr/resources/publications/ebola/health-worker-infections/en/
Number of probable and confirmed Ebola infections among HCWs (and proportion of total infections among HCWs) in Guinea, Sierra
Leone and Liberia, 2014 to March 2015
http://www.who.int/csr/resources/publications/ebola/health-worker-infections/en/
Impact of Ebola infection among health care workers in W. Africa, 2014-15
Health system • Closure of many facilities • Limited provision of services • Concerns about managing
patients with febrile illness and/or hemorrhage
Community • Fear of getting infected in
health care setting • Decreased utilization of
services
Geographic distribution of Ebola among HCWs in West Africa, 2014-15
*Average monthly consultations for children under-five before and during the Ebola outbreak in Sierra Leone, 2014-15
Morbidities
Pre-Ebola1 During Ebola2 % reduction or increase
Total visits
Avg per month
Total visits
Avg per month
Malaria 998,068 89,915 724,881 65,898 27% ARI/ Pneumonia
717,345 65,213 521,860 47,442 27%
AWD 200,006 18,812 124,100 11,282 38% Measles 525 48 962 87 80%
1. 1 June 2013–30 April 2014 2. 1 June 2014–30 April 2015 *Adapted from T. Sesay et al Public Health Action, VOL 7 supplement 1 , 21 JUNE 2017
Ref Country Setting Key findings Barden-O’Fallon et al1
Guinea Hospitals PHCs
Decrease in HIV testing Decrease in penta 1 and penta 3 Decrease in visits AWD and ARI
Elston et al2 SL 15 facilities
Decrease in outpatient visits
Cisse et al3 Guinea Hospital Decrease in visits Decrease in ARV compliance
Leuenberger et al4
Guinea MTFs - 40% outpatient visits - 46% HIV testing - 47% enrollment in HIV care - 53% new dx of TB
Studies documenting impact of Ebola outbreak on health care delivery in West Africa, 2014-15
1 .PLOS Currents Outbreaks. 2015 Aug 4 . Edition 1. doi: 10.1371/currents.outbreaks. 2. J Public Health (Oxf). 2016 Dec 2;38(4):673-678. 3. Abstract 1077: Procedings of the conference on retroviruses and opportuntistic infections, Seattle, 2015. 4. Abstract 103LB: Procedings of the conference on retroviruses and opportuntistic infections, Seattle, 2015
Population-based surveys assessing health care utilization during and after Ebola outbreak, Liberia
Ref: Morse et al BMJ Glob Health. 2016 May 18;1(1):e000007. doi: 10.1136/bmjgh-2015-000007. eCollection 2016.
Outline • Impact of Ebola on health work force and
provision of health services
• Changes in the epidemiology of priority diseases
• Lessons learned on Ebola in urban settings
Modeling the impact of the Ebola outbreak on Malaria disease burden1 in Guinea, Liberia, and Sierra Leone
Country Total estimated malaria deaths
No. of excess deaths attributed to outbreak
% change in attributable mortality rates
Guinea 12,825 4,275 48% Liberia 2,573 788 54% Sierra Leone 4,860 1,755 50% Total 20,258 6,818
1 Based on estimate of 50% reduction in treatment coverage, among children < 5 years of age
Adapted from: Parpla, et al. Emerging Infectious Diseases vol 22 No. 3 march 2016
Modeling the impact of Ebola outbreak on HIV disease burden in Guinea, Liberia, and Sierra Leone
Disease Total estimated HIV deaths*
No. of excess deaths attributed to outbreak
% change in attributable mortality rates
Guinea 5,151 713 16% Liberia 1,198 155 13% Sierra Leone 2,621 223 13% Total 8,970 1091 1 Based on 50% reduction in ART coverage among persons 15 to 49 years of age
Adapted from: Parpla, et al. Emerging Infectious Diseases vol 22 No. 3 march 2016
Modeling the impact of Ebola outbreak on TB disease burden1 in Guinea, Liberia, and Sierra Leone
Country Total estimated TB deaths
No. of excess deaths attributed to outbreak
% change in attributable mortality rates
Guinea 3,463 1,281 51% Liberia 1,553 592 59% Sierra Leone 2,164 841 59%
7,180 2,714 1 Based on 50% reduction in treatment coverage for both drug susceptible and resistant TB
Adapted from: Parpla, et al. Emerging Infectious Diseases vol 22 No. 3 march 2016
Modeling the impact of the Ebola outbreak on Malaria disease burden1 in Guinea, Liberia, and Sierra Leone
1 Based on estimate of absence in clinical treatment in 2015
Walker et al Lancet Infect Dis. 2015 July ; 15(7): 825–832. doi:10.1016/S1473-3099(15)70124-6
Increase in untreated malaria • 45% (95% CI 43–49) in Guinea, • 88% (83–93) in Sierra Leone, • 140% (135–147) in Liberia in 2014. Disease burden • 3·5 million (95% CI 2·6 million to 4·9 million) additional
untreated cases • 10 900 (5700–21 400) additional malaria-attributable deaths.
Country
DTP3 Measles vaccine (MCV1) Pre-Ebola
Ebola Diff Pre-Ebola
Ebola Diff
2013 2014 2013 2014 Liberia 89% 63% -26% 74% 58% -16% Guinea 90% 60% -30% 90% 62% -28% Sierra Leone
92% 83% -9% 85% 80% -5%
Source: WHO-UNICEF best estimates of vaccination coverage
Impact of Ebola Outbreak on DTP3 and Measles Vaccination Coverage in Liberia, Guinea and Sierra Leone, 2013 versus 2014
Estimated Measles-Susceptibility Among Liberians ≤20 Years of Age
Post-Ebola measles outbreaks in Guinea and Liberia, 2015
* Suk JE et al EID: Vol 22 No. 6 2016.
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Suspect measles cases in Liberia, 2014-15
Suspect cases in Lola Guinea, 2014-15
Outline • Impact of Ebola on health work force and
provision of health services
• Changes in the epidemiology of priority diseases
• Lessons learned on Ebola in urban settings
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Case
cou
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EPI Week
Suspect and Probable Ebola Case Counts by Week, March to Mid-September, Liberia ‘14
Doubling of cases every 2 weeks
Lofa outbreak, March 13- Apr 6
Confirmed EVD death in Monrovia
Experience with Quarantine for Ebola in West Point, Liberia
Evolution of Strategy in Liberia, Aug 2015
• Context – Monsterrado county
overwhelmed w cases – Not enough ETU beds – People dying in the streets – Models predicting disaster
• Debate among responders – ETU model of care vs home care vs transit centers…. – Concerns about managing patients in health care
system • Development of strategy
– Meetings convened by WHO/CDC /MSF and partners in late Aug/early Sept
Key Elements in Liberian Strategy, Aug 2014
• Early identification and isolation of suspect patients – Intensified surveillance – Contact tracing – Clinical management in
dedicated treatment centers
• Safe transport • Preventing transmission in the health care setting • Safe burials
What the strategy did not include…
• Treatment within the existing health care system
• Home health care – Distribution of home care
kits • WASH
– Distribution of hygiene kits • Involuntary quarantine of infected
households or neighborhoods
Challenges with building new ETUs
• Cost – ~ 1 Million for 100 beds
• Human resources – 400 HCWs per 100 bed ETU – Few NGOs w experience
• Training – 3 weeks (2 weeks cold, 1 week hot)
• O&M – Expensive
• Community acceptance
Ebola Isolation Ward, Lagos
• Hospital ward not in use
• Improvised wash stations
• Mentoring of clinical staff by persons w previous ETU experience
Opening of Island Clinic ETU, Liberia 2014
• Facility – Renovated hospital – WHO supported – Government managed
• Capacity – 100 Bed
• Opening – 21st Sept – Filled within hours of
opening – 200+ admissions in first
week
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50
150
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Bed
capa
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Num
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f cas
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Epidemiologic week of admission
Bong
Lofa
Margibi
Montserrado*
Nimba
bed capacity
EW3 BNG IC
EW2
June July September August October November
Training of burial teams
Suspect Ebola Admissions by County, June-Nov Liberia, 2014
Location of hotspots in hard-to-reach areas, Liberia, August-December 2014
Tayla-ta
Bomota
Geleyansiesu
Kayah
John Logan Town
Gov’t Camp
Quewein
Dorley-La
JeneWonde Waleaqua
h
Parluken
Ganta
Parluken, Grand Kru District, October 28, 2014:
• Remote area w difficult access • 21 total cases since August • 19 deaths. • County seeking support to
airlift supplies for CCC • 3 cases and 2 deaths reported
on 11/3 in nearby Niaplakpo
RITE response
• Primary aim: – rapid isolation in remote
communities – complement other
outbreak response activities
• Partners – MOH, WHO, CDC,
UNICEF, MSF, DoD UNMEER, NGOs.
Timing of outbreak alerts, investigation and resolution
Summary: Impact of Ebola on epidemiology of other infectious diseases
• Ebola outbreak had major impact on health work force and health service delivery
• Lead to decrease in access and utilization of services for major infectious diseases
• Models predicted an increase in mortality – Difficult to measure – Local measures may have mitigated the impact
Summary: Lessons learned on Ebola in urban settings
• Key issues for preparedness – Rapid detection and isolation of patients – Identification in advance facilities to manage
patients with hemorrhagic fever – Infection control practices need to be embedded
into every day practice – Maintain skills of clinical staff – Community engagement is critical for effective
management of response
