Ebola interventions: listen to communities
Authors: Ruth Kutalek, Shiyong Wang, Mosoka Fallah, Chea Sanford Wesseh, Jeffrey Gilbert
Journal: The Lancet Global Health (2015)

Active case finding (which includes contact tracing) ensures early identification and prompt isolation of potential cases of Ebola virus disease (EVD), leading to successful interruption of transmission in a community. Failure to identify and follow up all contacts could be enough to keep the outbreak going. In late November, 2014, Liberia's Ministry of Health and WHO Liberia did a rapid qualitative assessment (supported by the World Bank) of the perceptions of selected communities in Monrovia on an incentive scheme that intends to increase the reporting of EVD cases. This scheme proposed that, for each suspect case reported, US$5 would be provided. Participants from various groups living in Monrovia were invited to participate in focus-group discussions: contact tracers, active case finders, community leaders, young people, and women. 66 people responded to our call. The following questions were asked: How is it possible to reduce Ebola cases in your community? What do you think can be done to encourage case reporting? What do you think about a monetary incentive when a suspected case is reported? The incentive scheme was rejected by most participants. Contact tracers and active case finders are already facing resistance from communities, and families hide their sick at home. The groups feared that an incentive payment would create social disruptions in families and communities. Furthermore they concurred that suspected cases are facing stigma and are often not accepted by health facilities, even when they are negative. Participants argued that the following pressing problems have to be solved in order to curb the disease: (1)Provide food for families in quarantine. Although there are steps in place to provide all contacts with food while under follow-up, a substantial number of families who are quarantined do not receive food or they receive it late. It forces families to break the quarantine to buy food.(2)Enable reliable communication between Ebola treatment units and the families of the sick. Families are often not informed to which unit their loved ones are taken or what the condition of their relative is. People see the treatment units as "black holes" where loved ones disappear.(3)Restore and improve basic health services. Very few clinics and hospitals are operational; pregnant women especially are often rejected when they attend for delivery.(4)Provide psychosocial support to families of EVD patients. Supporting families who have lost loved ones should be an essential part of care in any Ebola response.(5)Include Ebola survivors in the teams of active case finders and contact tracers. The investigation revealed some important information from the demand side on how to make sure active case finding and community based EVD interventions work. These challenges are substantial, especially since Liberia's existing public health services were already quite limited before the outbreak. One strategy is to build resilient health systems that are grounded in primary health care. An assessment of the health system that will provide evidence is planned. The government of Liberia has formulated standard operating procedures for contact tracing and food distribution for quarantined populations, and has instituted measures to improve patients' feedback (purchase of phones for patients in the Ebola treatment units, wrist bands with contact information of patients, and circulation of laboratory results to relevant people). Accountability of governments and partners has to lead all efforts. Furthermore, enhancing community participation and engagement is key since contact tracing has been impeded by communities' lack of trust, information, and ownership. Engaging social scientists will contribute to a great extent to the success of the EVD response. This work has been approved by the Incident Management System, Liberia. We acknowledge discussions and suggestions from colleagues in UNICEF, UNDP, International Rescue Committee, Action Contre le Faim, and the Tony Blair Africa Governance Initiative. We thank Licé González-Angulo for organising the assessment, and Konah Lavelah Kennedy, Josephine Monger, and Kodjo Tehoungue for their help in conducting the focus group discussions. We declare no competing interests.