Another round-up of new publications on Ebola, primarily items first put out in public in the month of October 2015. This is largely a list, with a little light curation and commentary. Comments, missed items and disagreements welcome.
A. Clinical epidemiology
Papers this month highlight how Ebola differentially affects healthcare workers, children, mothers and infants and survivors and their sexual partners.
Epidemiology of Ebola virus disease transmission among health care workers in Sierra Leone, May to December 2014: a retrospective descriptive study. Olushayo Olu and MoH/WHO colleagues interviewed 293 infected healthcare workers and found the main (presumed) locations of infection to be the workers’ homes and non-Ebola healthcare settings. Over one-third of infected HCWs reported not having been trained in infection prevention/control pre-infection.
Did Ebola relatively spare children? Stephane Helleringer and colleagues cast some doubt on previous estimates that children had lower Ebola incidence rates than children, noting age-specific differences in: (i) historic health-seeking behaviour; (ii) speed of disease progression; and (iii) identification as contacts of infected individuals, each of which may have led to selective underreporting.
Ebola viral disease and pregnancy. Benjamin Black and colleagues review the many complications of pregnancy and birth for women infected with Ebola, including the absence of any recorded neonatal survival, potential for transmission perinatally to healthcare workers and ongoing risk from breast milk which may be infected. The authors suggest a focus on maternal support, given the very low probability of child survival.
Ebola RNA Persistence in Semen of Ebola Virus Disease Survivors — Preliminary Report. Gibrilla Deen and colleagues analysed one-off semen from 93 Ebola survivors, finding RT-PCR positive results as late as 9 months post-infection: although there was a notable fall-off in detection probability after 5 months. Crucially, the authors note we do not know how RT-PCR positivity is associated with virus infectivity.
Molecular Evidence of Sexual Transmission of Ebola Virus. Suzanne Mate and colleagues present genomic evidence to support the claim that the last known Ebola infection in Liberia (in March 2015) was infected via sexual transmission from an Ebola survivor six months post-disease onset.
Not a published paper yet, but Miles Carroll and colleagues presented ongoing work that suggested a woman had acquired Ebola antibodies without apparently ever contracting the virus. This could be very important for understanding both individual immunity, and evidence that a minority of those living in West Africa had Ebola antibodies prior to 2014. This was part of a larger body of work studying Ebola infected survivors and close contacts of infected individuals.
B. Non-Ebola impact of the epidemic
Papers this month include the past and continuing impact of Ebola on those giving birth, TB, measles, the healthcare system as a whole and GDP.
A case series study on the effect of Ebola on facility-based deliveries in rural Liberia. Jody Lori and colleagues show the rapid fall-off in use of maternal waiting homes as Ebola advanced in the middle of 2014 in Bong county. Impact on MCH.
Ebola, fragile health systems and tuberculosis care: a call for pre-emptive action and operational research. Rony Zachariah and colleagues highlight the potential spillover of the Ebola epidemic in affecting tuberculosis control efforts in affected countries, due to repurposing or mothballing of TB resources, fear of healthcare generally and loss of healthcare staff to Ebola. The authors highlight the lack of research into the impact of Ebola on TB to date.
Mitigating measles outbreaks in West Africa post-Ebola. Shaun Truelove and colleagues are not the first to point out the risk of re-emerging infectious diseases in the countries most affected by Ebola (see also, TB, malaria, maternal and infant health, nutrition, etc). Their editorial, however, does point to the need to fill gaps left by the Ebola epidemic, and to leverage systems set up for Ebola to fight the potential wave of post-Ebola health issues.
Impact of the Ebola outbreak on health systems and population health in Sierra Leone. James Elston and colleagues highlight (using both quantitative and qualitative methods) the multiple ways in which the Ebola epidemic has led to a loss of trust in the healthcare system in Sierra Leone, even as the epidemic has waned, and the need for investment in rebuilding the system and engagement between community and healthcare providers.
Indirect costs associated with deaths from the Ebola virus disease in West Africa. Joses Muthuri Kirigia (at WHO AFRO) and colleagues calculated the future loss of GDP due to productive years of life lost from Ebola morbidity and mortality. They estimate that the three most-affected nations will lose approximately I$ 150m from this epidemic due to non-health GDP losses.
C. Operational research
A range of topics here: three evaluations of epidemic responses – contact tracing, healthcare workers as infection vectors, treatment beds as prevention – as well as estimates of epidemic underreporting and variation in numbers of secondary cases created by those infected.
Contact Tracing Activities during the Ebola Virus Disease Epidemic in Kindia and Faranah, Guinea, 2014. Meredith Dixon and colleagues highlight the limited capacity of contact tracing to find cases before they became symptomatic in Guinea in late 2014.
Role of healthcare workers in early epidemic spread of Ebola: policy implications of prophylactic compared to reactive vaccination policy in outbreak prevention and control. Cordelia Coltart and colleagues highlight the potential benefits of inoculating healthcare workers in at-risk settings with any Ebola vaccine that proved to provide long-lived immunity: not just in terms of maintaining a motivated and healthy workforce during any future outbreak, but also as a means of dramatically reducing take-off of infection chains – based on evidence from past outbreaks.
Measuring the impact of Ebola control measures in Sierra Leone. Adam Kucharski and colleagues highlight (via a mathematical model) that the exact timing of effective control measures (specifically the expansion of treatment beds) in late 2014 had a huge impact on the total number cases and deaths seen – since it altered the whole trajectory of the epidemic.
Use of Capture–Recapture to Estimate Underreporting of Ebola Virus Disease, Montserrado County, Liberia. Etienne Gignoux and colleagues at MSF triangulated data from Ministry of Health case investigation records and ETU records from June to August 2014, to estimate that three-quarters of all cases in this period were unreported.
MERS, SARS and Ebola: The role of super-spreaders in infectious disease. Gary Wong and colleagues highlight the importance of heterogeneity in numbers of cases caused by each infectious person in Ebola, as in key emerging respiratory infections over the past few years.
Each of the issues raised below is important, I just could not easily find a theme under which to categorize them.
Effectively Communicating the Uncertainties Surrounding Ebola Virus Transmission. Andy Kilianski and Nicholas Evans draw on academic literature debating the possibility of airborne Ebola at the peak of the epidemic to highlight the importance of making claims with clear markers of uncertainty of evidence and relative likelihood of competing hypotheses, for the good of both the research community’s reputation and the public’s future health.
Beyond Ebola Ethics: Do Nurses have a Duty to Treat? Miriam Walter explores the duty of care that nurses and other healthcare workers may have to patients of highly virulent or infectious diseases, such as Ebola, and whether society has the legal or moral right to require such service. No easy answers, but a thought-provoking read.
The Ebola response in West Africa Exposing the politics and culture of international aid. Marc DuBois and colleageus at the ODI have compiled a report looking at the humanitarian aid system in light of the Ebola outbreak. The authors are damning, but not in a blanket manner, and highlight the importance of political rather than technical changes in achieving better results in the future.