An epidemic illness characterized by head nodding associated with onchocerciasis has been described in eastern Africa since the early 1960s; we summarize published reports and recent studies. Onset ...of nodding occurs in previously healthy 5-15-year-old children and is often triggered by eating or cold temperatures and accompanied by cognitive impairment. Its incidence has increased in Uganda and South Sudan over the past 10 years. Four case-control studies identified modest and inconsistent associations. There were nonspecific lesions seen by magnetic resonance imaging, no cerebrospinal fluid inflammation, and markedly abnormal electroencephalography results. Nodding episodes are atonic seizures. Testing has failed to demonstrate associations with trypanosomiasis, cysticercosis, loiasis, lymphatic filariasis, cerebral malaria, measles, prion disease, or novel pathogens; or deficiencies of folate, cobalamin, pyridoxine, retinol, or zinc; or toxicity from mercury, copper, or homocysteine. There is a consistent enigmatic association with onchocerciasis detected by skin snip or serologic analysis. Nodding syndrome is an unexplained epidemic epilepsy.
Ebola virus (EBOV) can persist in immunologically protected body sites in survivors of Ebola virus disease, creating the potential to initiate new chains of transmission. From the outbreak in West ...Africa during 2014-2016, we identified 13 possible events of viral persistence-derived transmission of EBOV (VPDTe) and applied predefined criteria to classify transmission events based on the strength of evidence for VPDTe and source and route of transmission. For 8 events, a recipient case was identified; possible source cases were identified for 5 of these 8. For 5 events, a recipient case or chain of transmission could not be confidently determined. Five events met our criteria for sexual transmission (male-to-female). One VPDTe event led to at least 4 generations of cases; transmission was limited after the other events. VPDTe has increased the importance of Ebola survivor services and sustained surveillance and response capacity in regions with previously widespread transmission.
Response to the 2014-2015 Ebola virus disease (EVD) outbreak in Sierra Leone overwhelmed the national capacity to contain it and necessitated a massive international response and strong coordination ...platform. Consequently, the Sierra Leone Government, with support of the international humanitarian community, established and implemented various models for national coordination of the outbreak. In this article, we review the strengths and limitations of the EVD outbreak response coordination systems in Sierra Leone and propose recommendations for improving coordination of similar outbreaks in the future.
There were two main frameworks used for the coordination of the outbreak; the Emergency Operation Center (EOC) and the National Ebola Response Center (NERC). We observed an improvement in outbreak coordination as the management mechanism evolved from the EOC to the NERC. Both coordination systems had their advantages and disadvantages; however, the NERC coordination mechanism appeared to be more robust. We identified challenges, such as competition and duplication of efforts between the numerous coordination groups, slow resource mobilization, inadequate capacity of NERC/EOC staff for health coordination, and an overtly centralized coordination and decision-making system as the main coordination challenges during the outbreak.
We recommend the establishment of EOCs with simple incident management system-based coordination prior to outbreaks, strong government leadership, decentralization of coordination systems, and functions to the epicenter of outbreaks, with clear demarcation of roles and responsibilities between different levels, regular training of key coordination leaders, and better community participation as methods to improve coordination of future disease outbreaks.
Fortunately, the Ebola outbreak has been controlled. In this final report, data on the duration of the persistence of Ebola virus in semen are provided.
The initiative is part of the WHO Secretariat's commitment to strengthening the IHR framework, which is a legally binding instrument to protect global public health and prevent unnecessary disruption ...to international traffic and trade; this framework has been adopted by 196 States Parties, including all 194 Member States of WHO. For decades, countries affected by disease outbreaks have often been subjected to trade and travel sanctions imposed by other governments.1–3 These sanctions harm national economies, discourage countries from openly reporting outbreaks, and create barriers between vital aid and the affected countries while they are dealing with a public health crisis. For the new monitoring instrument, although technical and financial support might be required for full operationalisation, WHO aims to be more proactive in helping countries address not only the immediate health needs of affected populations during public health emergencies but also the wider socioeconomic consequences of such events.
O'nyong-nyong (ONN) fever, caused by infection with a mosquito-borne central African alphavirus, is an acute, nonfatal illness characterized by polyarthralgia. During 1996-1997, south-central Uganda ...experienced the second ONN fever epidemic ever recognized. Among 391 persons interviewed and sampled, 40 cases of confirmed and 21 of presumptive, well-characterized acute, recent, or previous ONN fever were identified through active case-finding efforts or during a household serosurvey and by the application of clinical and laboratory criteria. Among confirmed cases, the knees and ankles were the joints most commonly affected. The median duration of arthralgia was 6 days (range, 2-21 days) and of immobilization was 4 days (range, 1-14 days). In the majority, generalized skin rash was reported, and nearly half had lymphadenopathy, mainly of the cervical region. Viremia was documented in 16 cases, primarily during the first 3 days of illness, and in some of these, body temperature was normal. During this epidemic, the combination of fever, arthralgia, and lymphadenopathy had a specificity of 83% and a sensitivity of 61% in the identification of cases of ONN fever and thus could be useful for surveillance purposes.
To end the largest known outbreak of Ebola virus disease (EVD) in West Africa and to prevent new transmissions, rapid epidemiological tracing of cases and contacts was required. The ability to ...quickly identify unknown sources and chains of transmission is key to ending the EVD epidemic and of even greater importance in the context of recent reports of Ebola virus (EBOV) persistence in survivors. Phylogenetic analysis of complete EBOV genomes can provide important information on the source of any new infection. A local deep sequencing facility was established at the Mateneh Ebola Treatment Centre in central Sierra Leone. The facility included all wetlab and computational resources to rapidly process EBOV diagnostic samples into full genome sequences. We produced 554 EBOV genomes from EVD cases across Sierra Leone. These genomes provided a detailed description of EBOV evolution and facilitated phylogenetic tracking of new EVD cases. Importantly, we show that linked genomic and epidemiological data can not only support contact tracing but also identify unconventional transmission chains involving body fluids, including semen. Rapid EBOV genome sequencing, when linked to epidemiological information and a comprehensive database of virus sequences across the outbreak, provided a powerful tool for public health epidemic control efforts.
Contact tracing is a critical strategy required for timely prevention and control of Ebola virus disease (EVD) outbreaks. Available evidence suggests that poor contact tracing was a driver of the EVD ...outbreak in West Africa, including Sierra Leone. In this article, we answered the question as to whether EVD contact tracing, as practiced in Western Area (WA) districts of Sierra Leone from 2014 to 2015, was effective. The goal is to describe contact tracing and identify obstacles to its effective implementation.
Mixed methods comprising secondary data analysis of the EVD case and contact tracing data sets collected from WA during the period from 2014 to 2015, key informant interviews of contact tracers and their supervisors, and a review of available reports on contact tracing were implemented to obtain data for this study.
During the study period, 3,838 confirmed cases and 32,706 contacts were listed in the viral hemorrhagic fever and contact databases for the district (mean 8.5 contacts per case). Only 22.1% (852) of the confirmed cases in the study area were listed as contacts at the onset of their illness, which indicates incomplete identification and tracing of contacts. Challenges associated with effective contact tracing included lack of community trust, concealing of exposure information, political interference with recruitment of tracers, inadequate training of contact tracers, and incomplete EVD case and contact database. While the tracers noted the usefulness of community quarantine in facilitating their work, they also reported delayed or irregular supply of basic needs, such as food and water, which created resistance from the communities.
Multiple gaps in contact tracing attributed to a variety of factors associated with implementers, and communities were identified as obstacles that impeded timely control of the EVD outbreak in the WA of Sierra Leone. In future outbreaks, early community engagement and participation in contact tracing, establishment of appropriate mechanisms for selection, adequate training and supervision of qualified contact tracers, establishment of a well-managed and complete contact tracing database, and provision of basic needs to quarantined contacts are recommended as measures to enhance effective contact tracing.
Process mapping is a systems thinking approach used to understand, analyse and optimise processes within complex systems. We aim to demonstrate how this methodology can be applied during disease ...outbreaks to strengthen response and health systems. Process mapping exercises were conducted during three unique emerging disease outbreak contexts with different: mode of transmission, size, and health system infrastructure. System functioning improved considerably in each country. In Sierra Leone, laboratory testing was accelerated from 6 days to within 24 hours. In the Democratic Republic of Congo, time to suspected case notification reduced from 7 to 3 days. In Nigeria, key data reached the national level in 48 hours instead of 5 days. Our research shows that despite the chaos and complexities associated with emerging pathogen outbreaks, the implementation of a process mapping exercise can address immediate response priorities while simultaneously strengthening components of a health system.
To share lessons learned with experience in concept development of electronic disease early warning system (eDEWS) as a standardized informatic tool for optimal disease surveillance for early warning ...and response Network (EWARN) during humanitarian crisis.
We did literature search, review and analysis to document system attributes of existing electronic tools being used for disease surveillance, early warning and health management information system (HMIS). We generated baseline information and conducted multiple planning sessions with stakeholders for EWARN system requirement elicitation and validation to inform concept development of standardized electronic tool.
We identified 98 electronic health projects, classified 22 projects under 'Disease and epidemic outbreak surveillance' theme, whereas only four electronic tools met our selection criteria and were reported to be implemented in humanitarian settings complimentary to EWARN. Baseline information was obtained to guide work on requirement gathering and analysis process, and development of concept for a standardized electronic tool for EWARN.
The eDEWS was enhanced with an objective to develop standardize electronic tools and data collection procedures to monitor diseases and health events for alert detection in global humanitarian settings. The enhanced system could be harnessed as a powerful tool by outbreak response teams in getting vital epidemiological information for appropriate and timely response during emergencies.
eDEWS experiences in Yemen, Somalia, Liberia and Pakistan offers an opportunity to learn and apply lessons to improve future health informatics initiatives or adapt eDEWS as a feasible standardized approach to enhance EWARN implementation during humanitarian crisis, and potential integration into routine surveillance systems.
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