Interrupting Ebola Transmission in Liberia Through Community-Based Initiatives

On 6 March 2014, Ebola virus disease spread from Guinea to Liberia, sparking an unprecedented outbreak. At the peak of the epidemic in western Africa, Liberia was the most affected country (1). Despite its extraordinary resource constraintsper capita gross domestic product is much lower than that of Guinea or Sierra Leone (2)Liberia's steep epidemic trajectory was reversed several weeks before that of those countries. This article details the community-based initiative (CBI) that was instrumental to the shift in transmission dynamics. In the design of public health strategies, organizational and cultural sensitivity, as well as an awareness of infrastructure constraints, are fundamental to promoting adherence to policy recommendations (3, 4). Inadequate consideration of these factors hindered the initial top-down Ebola response in western Africa. Slum and ethnic settlements tend to have cultures characterized by rituals of prevailing tribal groups and a strong sense of connectedness among persons who have lived together for decades. Externally led interventions, such as quarantine and body collection, that did not engage regarded community leaders led to distrust for and underuse of these interventions. In addition, the infrastructural constraints of these impoverished communities, including the lack of running water and overcrowding, made such recommendations as hand washing and isolation of the sick inapplicable (Table). Table. Community Reaction to Misalignment Between Cultural Practice and Public Health Policies In August 2014, unmitigated transmission in West Point, Monrovia's largest slum, was recognized as a potentially insurmountable threat to disease containment. Here, we focus on the outbreak in West Point as a case study that can inform the future control of Ebola in the world's most challenging settings. A Case Study: West Point The first suspected case in West Point was reported to the National Ebola Incident Management System on 6 August 2014. The slum was particularly vulnerable to intense transmission given the cramped conditions of more than 80000 persons living in less than a half square kilometer without municipal water or a sewage system and only 1 physician for the entire community (5). Poverty compounded the distrust of external authorities, including skepticism about whether the Ebola outbreak was real (6). Initially, no Ebola treatment unit facilities were available in West Point to isolate infected patients. A holding center was opened for interim isolation. When it began to receive patients from outside of West Point, unrest erupted over concern that disease was being imported into the community. On 18 August, the center was ransacked and contaminated materials were looted. To prevent the spread of Ebola, the government quarantined the entire slum on 20 August using police and military forces, leading to clashes with the community and the death of a boy shot in his legs. Members of the Ebola Incident Management System with ties to the local community recognized that a less-invasive approach would be needed to achieve acceptance of the interventions. Although West Point residents typically resist government policies, trust for community leaders is unwavering. Harnessing the cooperation of local leaders to build trust between the community and public health authorities was paramount to the successful control of Ebola. On 17 September, a district-wide program was piloted to enhance awareness of and participation in response efforts, with an external team of public health advisors providing guidance (Figure). Coordinators from the Ministry of Health identified districts with active Ebola transmission to engage with the CBI. Community, tribal, and religious leaders, as well as other stakeholders, were invited to an open meeting where they were encouraged to express their thoughts about the Ebola response and propose ways to facilitate public health efforts. The community then organized a team to comprehensively map the area to assess human resource requirements. Figure. Components of the CBI. CBI = community-based initiative. The community leaders who attended the initial meeting recruited community members for a 1-day training session on active surveillance. Each CBI-employed community member was assigned approximately 25 households for daily surveillance. At the training session, county-level CBI coordinators reviewed data collection forms with community members. Supervisors received and were trained to use a mobile telephone preloaded with a user-friendly application for submitting data in real time to inform rapid-response action by case investigation, contact tracing, burial, and ambulance teams. Trained community members collected forms each day that reported on the sick, dead, visitors, and other factors that influenced Ebola transmission in their communities. A hierarchical reporting and coordinating structure was executed, with the community members submitting these forms to their immediate supervisors, who sent aggregate data to the district-level supervisors. The United Nations Development Programme funded CBI training and employed community members and coordinators. Altogether, 6500 persons were employed and equipped for 6 months at a cost of approximately $65000 (U.S. dollars). Within 24 hours of launching the CBI in West Point, 42 persons with Ebola-like symptoms were identified and transported to Ebola treatment units. Furthermore, the CBI uncovered 34 deaths from suspected Ebola and several secret burials that had not been reported as a result of mistrust of authorities or concern about stigma. The CBI team and local leaders developed a procedure to deliver food and offer social support to make household-based quarantine of contacts feasible. Ultimately, the door-to-door assessments in West Point were accomplished by 152 active case finders, 15 psychosocial support workers, 8 supervisors, and 2 district leaders. After the success in West Point, the Liberian Ministry of Health commissioned a scale-up of the CBI to Ebola hotspots throughout Montserrado County. By 21 September, the CBI was deployed in 6 districts. The implementation of these initiatives substantially improved contact-tracing cooperation and adherence to case isolation. For cases in the districts where the CBI was being implemented, the average number of contacts reported increased from 7.6 to 9.9 and mean time from symptom onset to isolation decreased from 6.5 to 4.7 days. This decrease in duration until isolation is crucial to reduce transmission, because viral load and thus infectiousness of patients with Ebola increase substantially over the course of infection (7). Latest Outbreak In July 2015, a new outbreak emerged in Margibi County, Liberia, where a teenage boy with Ebola was misdiagnosed with malaria. Contact-tracing efforts and the CBI were deployed in parallel to follow known contacts and conduct community-driven surveillance, respectively. A CBI team of 75 community members visited 397 households in the vicinity, identifying 126 contacts who were followed for 21 days. This community mobilization curtailed transmission before any tertiary cases emerged. The success of this effort starkly contrasts with the spiraling epidemic observed a year before, fueled by a similar number of secondary cases before the CBI was initiated. Conclusion By engaging and empowering local communities, the CBI was instrumental to cooperation with contact tracing and accelerating case isolation. This strategy is both feasible and effective in the resource-constrained settings of many western African countries. Leaders of the Liberian CBI are currently advising the Sierra Leone Ministry of Health on the implementation of community-driven efforts to control its outbreak that has yet to be extinguished. More broadly, the momentum of community involvement spurred by the Ebola response provides an opportunity for sustained improvement in the public health infrastructure in Liberia and other western African countries.