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      The 2014–2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: Time-series analyses for 2010–2016

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          Abstract

          Background

          The aim of this study is to estimate the immediate and lasting effects of the 2014–2015 Ebola virus disease (EVD) outbreak on public-sector primary healthcare delivery in Liberia using 7 years of comprehensive routine health information system data.

          Methods and findings

          We analyzed 10 key primary healthcare indicators before, during, and after the EVD outbreak using 31,836 facility-month service outputs from 1 January 2010 to 31 December 2016 across a census of 379 public-sector health facilities in Liberia (excluding Montserrado County). All indicators had statistically significant decreases during the first 4 months of the EVD outbreak, with all indicators having their lowest raw mean outputs in August 2014. Decreases in outputs comparing the end of the initial EVD period (September 2014) to May 2014 (pre-EVD) ranged in magnitude from a 67.3% decrease in measles vaccinations (95% CI: −77.9%, −56.8%, p < 0.001) and a 61.4% decrease in artemisinin-based combination therapy (ACT) treatments for malaria (95% CI: −69.0%, −53.8%, p < 0.001) to a 35.2% decrease in first antenatal care (ANC) visits (95% CI: −45.8%, −24.7%, p < 0.001) and a 38.5% decrease in medroxyprogesterone acetate doses (95% CI: −47.6%, −29.5%, p < 0.001). Following the nadir of system outputs in August 2014, all indicators showed statistically significant increases from October 2014 to December 2014. All indicators had significant positive trends during the post-EVD period, with every system output exceeding pre-Ebola forecasted trends for 3 consecutive months by November 2016. Health system outputs lost during and after the EVD outbreak were large and sustained for most indicators. Prior to exceeding pre-EVD forecasted trends for 3 months, we estimate statistically significant cumulative losses of −776,110 clinic visits (95% CI: −1,480,896, −101,357, p = 0.030); −24,449 bacille Calmette–Guérin vaccinations (95% CI: −45,947, −2,020, p = 0.032); −9,129 measles vaccinations (95% CI: −12,312, −5,659, p < 0.001); −17,191 postnatal care (PNC) visits within 6 weeks of birth (95% CI: −28,344, −5,775, p = 0.002); and −101,857 ACT malaria treatments (95% CI: −205,839, −2,139, p = 0.044) due to the EVD outbreak. Other outputs showed statistically significant cumulative losses only through December 2014, including losses of −12,941 first pentavalent vaccinations (95% CI: −20,309, −5,527, p = 0.002); −5,122 institutional births (95% CI: −8,767, −1,234, p = 0.003); and −45,024 acute respiratory infections treated (95% CI: −66,185, −24,019, p < 0.001). Compared to pre-EVD forecasted trends, medroxyprogesterone acetate doses and first ANC visits did not show statistically significant net losses. ACT treatment for malaria was the only indicator with an estimated net increase in system outputs through December 2016, showing an excess of +78,583 outputs (95% CI: −309,417, +450,661, p = 0.634) compared to pre-EVD forecasted trends, although this increase was not statistically significant. However, comparing December 2013 to December 2017, ACT malaria cases have increased 49.2% (95% CI: 33.9%, 64.5%, p < 0.001). Compared to pre-EVD forecasted trends, there remains a statistically significant loss of −15,144 PNC visits within 6 weeks (95% CI: −29,453, −787, p = 0.040) through December 2016.

          Conclusions

          The Liberian public-sector primary healthcare system has made strides towards recovery from the 2014–2015 EVD outbreak. All primary healthcare indicators tracked have recovered to pre-EVD levels as of November 2016. Yet, for most indicators, it took more than 1 year to recover to pre-EVD levels. During this time, large losses of essential primary healthcare services occurred compared to what would have been expected had the EVD outbreak not occurred. The disruption of malaria case management during the EVD outbreak may have resulted in increased malaria cases. Large and sustained investments in public-sector primary care health system strengthening are urgently needed for EVD-affected countries.

          Abstract

          Bradley Wagenaar and colleagues use health facility data to analyze losses to essential primary healthcare service outputs during and immediately after the EVD outbreak, and their recovery in the years after.

          Author summary

          Why was this study done?
          • Almost 2 years after the final case of Ebola virus disease (EVD) was discharged in Liberia, it is essential to understand the lingering effects of the EVD outbreak on the public-sector primary healthcare system.

          • Existing studies of the effects of the EVD outbreak on population health and health system functioning have relied on small survey samples, mathematical modeling approaches, and data collected at single points in time before, during, or immediately after the epidemic rather than using health system output data to understand long-term system trends.

          • We aimed to improve on these limitations and extend existing analyses to cover a census of health facilities in Liberia (excluding Montserrado County) from January 2010 to December 2016.

          What did the authors do and find?
          • We used health facility data across a census of facilities and over an 84-month period to analyze changes in essential primary healthcare service indicators during and after the EVD outbreak.

          • We found that it took only 4 months (June–September 2014) to lose between 35% and 67% of essential primary care health system outputs across Liberian clinics, and that, as of November 2016 (19 months post-EVD), all health system indicators had recovered to their pre-EVD levels.

          • Given that health system outputs are time-limited, the loss of an estimated 776,110 clinic visits, 24,449 bacille Calmette–Guérin vaccinations, 9,129 measles vaccinations, 12,941 first pentavalent vaccinations, 5,122 institutional births, 17,191 postnatal care visits within 6 weeks of birth, 101,857 artemisinin-based combination therapy treatments for malaria, and 45,024 treatments of acute respiratory infections due to the EVD outbreak will continue to severely affect population health.

          • We estimate that the number of malaria cases treated has increased by 49% from December 2013 to December 2016—a finding potentially due to increases in the transmission of the disease following large-scale treatment interruptions during the EVD outbreak.

          What do these findings mean?
          • These findings add to the body of literature suggesting that the 2014–2015 EVD outbreak across West Africa had devastating effects on the delivery of all types of public-sector primary healthcare services.

          • For most primary healthcare indicators, it took more than 1 year post-EVD to recover to pre-EVD levels, with net losses persisting as of December 2016.

          • Malaria cases may have increased since the EVD outbreak in Liberia, as predicted from previous modelling efforts across EVD-affected countries; the extent to which a similar trend for malaria has been recorded in Sierra Leone or Guinea is not clear.

          • Public-sector primary healthcare system strengthening is urgently needed across West Africa, with specific focus targeted to general outpatient care, childhood vaccination, maternal health, and malaria prevention/treatment.

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          Most cited references26

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          Effects of the West Africa Ebola Virus Disease on Health-Care Utilization – A Systematic Review

          Significant efforts were invested in halting the recent Ebola virus disease outbreak in West Africa. Now, studies are emerging on the magnitude of the indirect health effects of the outbreak in the affected countries, and the aim of this study is to systematically assess the results of these publications. The methodology for this review adhered to the Prisma guidelines for systematic reviews. A total of 3354 articles were identified for screening, and while 117 articles were read in full, 22 studies were included in the final review. Utilization of maternal health services decreased during the outbreak. The number of cesarean sections and facility-based deliveries declined and followed a similar pattern in Guinea, Liberia, and Sierra Leone. A change in the utilization of antenatal and postnatal care and family planning services was also seen, as well as a drop in utilization of children’s health services, especially in terms of vaccination coverage. In addition, the uptake of HIV/AIDS and malaria services, general hospital admissions, and major surgeries decreased as well. Interestingly, it was the uptake of health service provision by the population that decreased, rather than the volume of health service provision. Estimates from the various studies suggest that non-Ebola morbidity and mortality have increased after the onset of the outbreak in Sierra Leone, Guinea, and Liberia. Reproductive, maternal, and child health services were especially affected, and the decrease in facility deliveries, cesarean sections, and volume of antenatal and postnatal care visits might have significant adverse effects on maternal and newborn health. The impact of Ebola stretches far beyond Ebola cases and deaths. This review indicates that indirect health service effects are substantial and both short and long term, and highlights the importance of support to maintain routine health service delivery and the maintenance of vaccination programs as well as preventative and curative malaria programs, both in general but especially in times of a disaster.
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            An evaluation of psychological distress and social support of survivors and contacts of Ebola virus disease infection and their relatives in Lagos, Nigeria: a cross sectional study − 2014

            Background By September 2014, an outbreak of Ebola Viral Disease (EVD) in West African countries of Guinea, Liberia, Sierra Leone, Senegal and Nigeria, had recorded over 4500 and 2200 probable or confirmed cases and deaths respectively. EVD, an emerging infectious disease, can create fear and panic among patients, contacts and relatives, which could be a risk factor for psychological distress. Psychological distress among this subgroup could have public health implication for control of EVD, because of potential effects on patient management and contact tracing. We determined the Prevalence, pattern and factors associated with psychological distress among survivors and contacts of EVD and their relatives. Methods In a descriptive cross sectional study, we used General Health Questionnaire to assess psychological distress and Oslo Social Support Scale to assess social support among 117 participants who survived EVD, listed as EVD contacts or their relatives at Ebola Emergency Operation Center in Lagos, Nigeria. Factors associated with psychological distress were determined using chi square/odds ratio and adjusted odds ratio. Results The mean age and standard deviation of participants was 34 +/ - 9.6 years. Of 117 participants, 78 (66.7 %) were females, 77 (65.8 %) had a tertiary education and 45 (38.5 %) were health workers. Most frequently occurring psychological distress were inability to concentrate (37.6 %) and loss of sleep over worry (33.3 %). Losing a relation to EVD outbreak (OR = 6.0, 95 % CI, 1.2–32.9) was significantly associated with feeling unhappy or depressed while being a health worker was protective (OR = 0.4, 95 % CI, 0.2–0.9). Adjusted Odds Ratio (AOR) showed losing a relation (AOR = 5.7, 95 % CI, 1.2–28.0) was a predictor of “feeling unhappy or depressed”, loss of a relation (AOR = 10.1, 95 % CI, 1.7–60.7) was a predictor of inability to concentrate. Conclusions Survivors and contacts of EVD and their relations develop psychological distress. Development of psychological distress could be predicted by loss of family member. It is recommended that psychiatrists and other mental health specialists be part of case management teams. The clinical teams managing EVD patients should be trained on recognition of common psychological distress among patients. A mental health specialist should review contacts being monitored for EVD for psychological distress or disorders.
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              Effect of the Ebola-virus-disease epidemic on malaria case management in Guinea, 2014: a cross-sectional survey of health facilities

              Summary Background The ongoing west Africa Ebola-virus-disease epidemic has disrupted the entire health-care system in affected countries. Because of the overlap of symptoms of Ebola virus disease and malaria, the care delivery of malaria is particularly sensitive to the indirect effects of the current Ebola-virus-disease epidemic. We therefore characterise malaria case management in the context of the Ebola-virus-disease epidemic and document the effect of the Ebola-virus-disease epidemic on malaria case management. Methods We did a cross-sectional survey of public health facilities in Guinea in December, 2014. We selected the four prefectures most affected by Ebola virus disease and selected four randomly from prefectures without any reported cases of the disease. 60 health facilities were sampled in Ebola-affected and 60 in Ebola-unaffected prefectures. Study teams abstracted malaria case management indicators from registers for January to November for 2013 and 2014 and interviewed health-care workers. Nationwide weekly surveillance data for suspect malaria cases reported between 2011 and 2014 were analysed independently. Data for malaria indicators in 2014 were compared with previous years. Findings We noted substantial reductions in all-cause outpatient visits (by 23 103 [11%] of 214 899), cases of fever (by 20249 [15%] of 131 330), and patients treated with oral (by 22 655 [24%] of 94 785) and injectable (by 5219 [30%] of 17 684) antimalarial drugs in surveyed health facilities. In Ebola-affected prefectures, 73 of 98 interviewed community health workers were operational (74%, 95% CI 65–83) and 35 of 73 were actively treating malaria cases (48%, 36–60) compared with 106 of 112 (95%, 89–98) and 102 of 106 (96%, 91–99), respectively, in Ebola-unaffected prefectures. Nationwide, the Ebola-virus-disease epidemic was estimated to have resulted in 74 000 (71 000–77 000) fewer malaria cases seen at health facilities in 2014. Interpretation The reduction in the delivery of malaria care because of the Ebola-virus-disease epidemic threatens malaria control in Guinea. Untreated and inappropriately treated malaria cases lead to excess malaria mortality and more fever cases in the community, impeding the Ebola-virus-disease response. Funding Global Fund to Fight AIDS, Tuberculosis and Malaria, and President's Malaria Initiative.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: Writing – review & editing
                Role: InvestigationRole: MethodologyRole: ResourcesRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: MethodologyRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: MethodologyRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: MethodologyRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                20 February 2018
                February 2018
                : 15
                : 2
                : e1002508
                Affiliations
                [1 ] Department of Global Health, University of Washington, Seattle, Washington, United States of America
                [2 ] Partners in Health, Monrovia, Liberia
                [3 ] Health Alliance International, Seattle, Washington, United States of America
                [4 ] Universidade Eduardo Mondlane, Maputo, Mozambique
                [5 ] Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
                [6 ] Harvard Medical School, Boston, Massachusetts, United States of America
                [7 ] Ministry of Health, Monrovia, Liberia
                Harvard University, UNITED STATES
                Author notes

                The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0002-3351-7175
                http://orcid.org/0000-0002-0005-3968
                http://orcid.org/0000-0002-9223-532X
                Article
                PMEDICINE-D-17-02699
                10.1371/journal.pmed.1002508
                5819774
                29462138
                4d11d930-aad5-4cd2-9f2b-aa6dbf32edae
                © 2018 Wagenaar et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 3 August 2017
                : 16 January 2018
                Page count
                Figures: 10, Tables: 6, Pages: 26
                Funding
                Funded by: Partners in Health
                Funded by: Ministry of Health, Liberia
                This study was supported by Partners in Health, Liberia and the Liberian Ministry of Health. No specific funding was received for this study. No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                People and Places
                Geographical Locations
                Africa
                Liberia
                Biology and Life Sciences
                Immunology
                Vaccination and Immunization
                Medicine and Health Sciences
                Immunology
                Vaccination and Immunization
                Medicine and Health Sciences
                Public and Occupational Health
                Preventive Medicine
                Vaccination and Immunization
                Medicine and Health Sciences
                Parasitic Diseases
                Malaria
                Medicine and Health Sciences
                Tropical Diseases
                Malaria
                Medicine and Health Sciences
                Epidemiology
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Antenatal Care
                Medicine and Health Sciences
                Tropical Diseases
                Neglected Tropical Diseases
                Viral Hemorrhagic Fevers
                Ebola Hemorrhagic Fever
                Medicine and Health Sciences
                Infectious Diseases
                Viral Diseases
                Viral Hemorrhagic Fevers
                Ebola Hemorrhagic Fever
                Research and Analysis Methods
                Research Design
                Survey Research
                Census
                Medicine and Health Sciences
                Infectious Diseases
                Viral Diseases
                Measles
                Custom metadata
                Data used are property of the Liberian Ministry of Health, sourced from the online DHIS-2 system. We encourage anyone seeking access to these data to contact the Liberian Ministry of Health at: Stephen Gbanyan, HIS Director at: mambu9@ 123456gmail.com ; or J. Mike Mulbah, Deputy M&E Director at: j.mike.mulbah@ 123456gmail.com .

                Medicine
                Medicine

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