International Journal of Epidemiology
Volume 43 Issue 6 December 2014
http://ije.oxfordjournals.org/content/current

Editorials
To hasten Ebola containment, mobilize survivors
Zena A Stein1,2, Jack Ume Tocco1,*, Joanne E Mantell1 and Raymond A Smith1
Author Affiliations
1HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality and Health, New York State Psychiatric Institute and Columbia University, New York, NY, USA
2Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
Extract
The current Ebola outbreak is unique in its magnitude and its dispersion in dense, mobile populations. Physician and nurse responders face high mortality, and foreign aid in the form of medical supplies and staff continues to be unequal to the scope of the problem. Fear and loss have overwhelmed affected communities, already among the poorest in the world and still recovering from brutal civil wars. While the number of Ebola cases in Liberia appears to be on the decline, Ebola infections in Sierra Leone and Guinea continue to increase.1 That the response to the epidemic be swift and massive is a matter of life and an unknown number of deaths.

Survivors of Ebola infection are valuable resources still largely overlooked in the struggle to contain the epidemic. With a case recovery rate of around 30% at the present time for the current West African epidemic,2 survivors already number thousands. There are several reasons why Ebola survivors may be critical to controlling the epidemic.

First, and most importantly, the recovered have developed immunity to the current strain of Ebola and therefore are able to care for the sick with …

International Journal of Infectious Diseases
January 2015 Volume 30, p1
http://www.ijidonline.com/current

Guidelines for treatment of patients with Ebola Virus Diseases are urgently needed
Eskild Petersen1, Boubacar Maiga2
1ProMED Moderator, Parasitic Diseases
2ProMED Moderator for Infectious Diseases, ProMED-FRA (Francophone Africa)
Open Access
DOI: http://dx.doi.org/10.1016/j.ijid.2014.12.002
The Ebola Virus Diseases, EVD, epidemic is still unfolding in West Africa with Guinea, Sierra Leone and Liberia most severely affected. This week it was estimated that there is at least 500 new cases every week and the total number of cases has passed 16,000, but there is probably a substantial underreporting of both cases and fatalities.1 There are some doubts about the mortality rate, but one recent case series reported a mortality of 72%.2

The outbreak is unprecedented in magnitude and few would have predicted that such an outbreak was possible. However, it seems clear that it is not due to a more pathogenic version of the Ebola virus and indeed low virus genetic diversity has been observed in person-to-person virus transmission.3, 4 Therefore, the current situation is most probable due to the poor status of the health care systems especially in Liberia and Sierra Leone, which has both recently suffered long civil wars, which have left the countries drained for educated health care staff and a dilapidated health infrastructure.

There is no approved, specific treatment of EVD. Several experimental anti-virals, immune-therapy5 and use of hyperimmune plasma from survivors have been proposed, but data from controlled clinical trials are lacking.6

After a slow start the international community including many Non Governmental Organizations, NGO’s, are managing treatment facilities in West Africa
But what are these treatment facilities offering?
Very little data has emerged. One published study reported a mortality of 72% but astonishingly the study contained no information of any treatment.2 Thus the question remains if the patients included in that study received any treatment at all. These patients were all from Sierra Leone and in contrast, nationals from industrialized countries are evacuated and treated in their home country and survived.7, 8 In particular, the case evacuated to Germany7 show very clearly that the treatment with classical tools used for patients in severe chock (bacterial septicemia, severe malaria) is expected to substantially reduce mortality. The patients received 30 liters of fluid intravenously over the first three days, had paralytic ileus and thus could not take oral fluid, had an fecal output of 14 liters over three days and severe hypokalemia. The same problems were seen in the two patients evacuated to the United States and one of these also had malaria.8

Is this a proper level of inpatient care in the Ebola treatment facilities or should we aim higher?
A mortality of 43% were reported in a case series of 80 patients with EVD from Guinea where 76% of the patients received intravenous fluid even though only 1 titer over 24 hours in average.9 If the difference in mortality between the report from Sierra Leone (72%)2 and Guinea (43%)9 are due to the use of intravenous fluid and even though one liter intravenous fluid seems very modest in view the need in the three expatriated cases7, 8, it seems that intravenous fluid replacement may significantly reduce mortality in the treatment centers perhaps by as much as 50%. This can be done in the conditions prevailing in West Africa using pulse, blood pressure, body weight and urine output as guidance and using simple point-of-care tests for measuring electrolytes, but require intravenous access, abundant fluid for intravenous administration and trained staff.

It is telling that the NGO’s have not published any treatment results and it is unclear if there is any control of treatment outcomes in EVD treatment facilities. Simply notifying confirmed cases and outcomes (fatal or not) and publishing weekly updates broken down to different NGO’s would allow quality control and allow adjustment of treatment algorithms adopting procedures identifying the highest survival rates. The difference in mortality between the two published case series2, 9 indicate that this is urgently needed.

We must to ensure that treatment is not palliation and that the so-called “Ebola hospitals” are hospitals and not hospices for untreated cases with the sole purpose of isolating cases from the community.

It is estimated in a study from Liberia, that only 25% of known Ebola patients had been admitted to an Ebola treatment facility as of August 14, 2014.10 The reasons for this low number are many, but a key point is probably that the chance of survival in these units does not differ significantly from patients staying at home.

The national governments in the affected countries does not have the resources nor the manpower to ensure the quality of the care provided by NGO’s and others. Thus the World Health Organization or others with the necessary resources should establish a notification system, to ensure that facilities are providing treatment and not only palliation and publish for instance weekly updates of survival figures broken down for each NGO to ensure quality control, transparency and optimization of treatment algorithms.

The German patient7 had septicemia and one of the American patients had malaria.8 Both diagnosis can lead to disseminated intravascular coagulation and will thus easily be confused with Ebola. If diagnostics are not available perhaps every patients in this highly endemic malaria area should receive a malaria treatment course and an infusion of a broad spectrum antibiotic, for instance ceftriaxone.

It is important to know if a patient is HIV positive as a low CD4 T cell count is expected to increase the risk of a fatal outcome, and thus treatment efficacy if at all possible should be stratified according to HIV status.

It is urgently needed to develop guidelines for treatment of EVD patients and to distinguish treatment from palliation and hospitals from hospices.

We suggest that the World Health Organization take the leadership and develop guidelines for treatment including:
1. Diagnosis of EVD
2. Principles for intravenous fluid replacement
3. Principles for measurement of electrolyte imbalance
4. Principles for correction of electrolyte imbalance
5. Diagnosis and treatment of concomitant malaria
6. When to administer antibiotics based on suspicion of septicemia
7. HIV testing.
8. Implement a reporting system for all EVD treatment facilities

These measures can all be implemented under the field conditions in West Africa, provided the staff are trained in high volume fluid replacement. Participating should be a prerequisite for receiving financial support from governments and receiving permission to manage EVD treatment facilities.
The staffing of the treatment facilities is a crucial issue and it can be speculated that the NGO’s does not have access to physicians and nurses with knowledge and experience in high volume fluid replacement and correction of electrolyte imbalance.
One solution could be twinning with hospitals in industrialized countries where these hospitals adopt an EVD treatment facility and ensure staffing and training. This of course would need support from the national health authorities. Such a program would ensure effective intravenous fluid replacement therapy were provided, most probably significantly reduce mortality, ensure confidence in the treatment facilities from the local population and thus increase the use of these facilities (earlier admission and higher proportion of cases treated, isolated and recovered).
[References]

International Journal of Mass Emergencies & Disasters
November 2014 (VOL. 32, NO. 3)
http://www.ijmed.org/issues/32/3/

:: Determining Causal Factors of Community Recovery, 405 -427

:: “Everything Always Works”: Continuity as a Source of Disaster Preparedness Problems, 428 -458

:: The Private and Social Benefits of Preparing For Natural Disasters, 459 -483

:: Modeling Psychosocial Decision Making in Emergency Operations Centres, 484 -507

:: Vietnamese Refugees’ Perspectives on their Community’s Resilience in the Event of a Natural Disaster, 508 -531

JAMA
December 24/31, 2014, Vol 312, No. 24
http://jama.jamanetwork.com/issue.aspx

The 2014 Ebola Outbreak and Mental Health: Current Status and Recommended Response
James M. Shultz, MS, PhD, Florence Baingana, MB, ChB, MMed (Psychiatry), MSc (HPPF), Yuval Neria, PhD.
JAMA. Published online December 22, 2014. doi:10.1001/jama.2014.17934

Editorial | December 24/31, 2014
2015 Theme Issue on Trauma Associated With Violence and Human Rights Abuses
Call for Papers FREE
Annette Flanagin, RN, MA1; Thomas B. Cole, MD, MPH2,3
Author Affiliations
JAMA. 2014;312(24):2627-2628. doi:10.1001/jama.2014.16413.
Excerpt
In August 2015, JAMA will publish a theme issue on violence and human rights with an emphasis on the causes, consequences, and management of trauma. Violence is an important cause of physical and emotional trauma, and the scope of trauma care is broad, including care for survivors of unintentional injuries as well as injuries resulting from many forms of violence. Injuries and violence cause 5.8 million deaths each year worldwide, accounting for about 10% of the world’s deaths, more than the number of deaths that result from malaria, tuberculosis, and AIDS combined.1,2 The primary causes of these 5.8 million deaths are road traffic crashes, suicide, and homicide, followed by falls, drowning, poisoning, burns, and war.2 In the United States, data from the Global Burden of Disease 2010 Study indicate the following among the leading diseases and injuries contributing to premature mortality: road injury (fifth leading cause), self-harm (sixth), and interpersonal violence (12th).3 For the 2015 JAMA theme issue, we are soliciting papers on trauma resulting from unintentional and intentional injury, from interpersonal and community-levels of violence, and from mass conflict, war, displacement, and natural disasters…

Effect of Maternal Multiple Micronutrient vs Iron–Folic Acid Supplementation on Infant Mortality and Adverse Birth Outcomes in Rural Bangladesh: The JiVitA-3 Randomized Trial
Keith P. West Jr, DrPH; Abu Ahmed Shamim, MSc; Sucheta Mehra, MS; Alain B. Labrique, PhD; Hasmot Ali, MBBS, MPH; Saijuddin Shaikh, PhD, MPH; Rolf D. W. Klemm, DrPH; Lee S-F. Wu, MHS; Maithilee Mitra, MS; Rezwanul Haque, MA; Abu A. M. Hanif, MBBS; Allan B. Massie, PhD; Rebecca Day Merrill, PhD; Kerry J. Schulze, PhD; Parul Christian, DrPH, MSc
Importance
Maternal micronutrient deficiencies may adversely affect fetal and infant health, yet there is insufficient evidence of effects on these outcomes to guide antenatal micronutrient supplementation in South Asia.
Objective
To assess effects of antenatal multiple micronutrient vs iron–folic acid supplementation on 6-month infant mortality and adverse birth outcomes.
Design, Setting, and Participants
Cluster randomized, double-masked trial in Bangladesh, with pregnancy surveillance starting December 4, 2007, and recruitment on January 11, 2008. Six-month infant follow-up ended August 30, 2012. Surveillance included 127 282 women; 44 567 became pregnant and were included in the analysis and delivered 28 516 live-born infants. Median gestation at enrollment was 9 weeks (interquartile range, 7-12).
Interventions
Women were provided supplements containing 15 micronutrients or iron–folic acid alone, taken daily from early pregnancy to 12 weeks postpartum.
Main Outcomes and Measures
The primary outcome was all-cause infant mortality through 6 months (180 days). Prespecified secondary outcomes in this analysis included stillbirth, preterm birth (<37 weeks), and low birth weight (<2500 g). To maintain overall significance of α = .05, a Bonferroni-corrected α = .01 was calculated to evaluate statistical significance of primary and 4 secondary risk outcomes (.05/5).
Results
Among the 22 405 pregnancies in the multiple micronutrient group and the 22 162 pregnancies in the iron–folic acid group, there were 14 374 and 14 142 live-born infants, respectively, included in the analysis. At 6 months, multiple micronutrients did not significantly reduce infant mortality; there were 764 deaths (54.0 per 1000 live births) in the iron–folic acid group and 741 deaths (51.6 per 1000 live births) in the multiple micronutrient group (relative risk [RR], 0.95; 95% CI, 0.86-1.06). Multiple micronutrient supplementation resulted in a non–statistically significant reduction in stillbirths (43.1 vs 48.2 per 1000 births; RR, 0.89; 95% CI, 0.81-0.99; P = .02) and significant reductions in preterm births (18.6 vs 21.8 per 100 live births; RR, 0.85; 95% CI, 0.80-0.91; P < .001) and low birth weight (40.2 vs 45.7 per 100 live births; RR, 0.88; 95% CI, 0.85-0.91; P < .001).
Conclusions and Relevance
In Bangladesh, antenatal multiple micronutrient compared with iron–folic acid supplementation did not reduce all-cause infant mortality to age 6 months but resulted in a non–statistically significant reduction in stillbirths and significant reductions in preterm births and low birth weight.

The Lancet
Jan 03, 2015 Volume 385 Number 9962 p1-88 e1-e3
http://www.thelancet.com/journals/lancet/issue/current

Comment
Ebola: worldwide dissemination risk and response priorities
Benjamin J Cowling, Hongjie Yu
Open Access
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61895-X
References
The scale of the current outbreak of Ebola virus disease in west Africa is staggering. Thousands of infections and deaths have been reported in recent months, and unless major changes occur in the situation, incidence of Ebola virus disease has been projected to continue to grow and cumulative incidence to exceed 20 000 by November.1 A humanitarian crisis that stretches far beyond the impact of Ebola virus infections is unfolding in Africa, devastating the health systems and economies in affected countries.2 In the present outbreak, most infections remain confined to west Africa, although four cases have been detected outside this region: three cases diagnosed in Dallas, USA (of which one infection was contracted in Liberia and two were associated with nosocomial transmission from the first case), and one case in Madrid, Spain, associated with nosocomial transmission (figuravergaee).

Among all reported cases in the 2014 outbreak to date, most infections have been contracted in three countries in west Africa: Guinea, Liberia, and Sierra Leone.

In The Lancet, Isaac Bogoch and colleagues3 report on the potential for international dissemination of Ebola virus disease. Their assessment of risk for different countries is an advance over previous work,4 which analysed flight networks and connectivity, but did not account for passenger flows and final destinations. Because of the assumptions of uniform risk across the population and constant prevalence of infection (whereas, in fact, risk within the population is not likely to be uniform and incidence is doubling every 15–30 days),1 the relative risks comparing different countries can be more valuable than the estimated absolute risks. Bogoch and colleagues report that the two countries at highest risk of receiving cases are Ghana and Senegal and, outside Africa, the risk for export to the UK or France combined was estimated to be about eight times higher than the risk for export to the USA (15•8 vs 2•0).3 In other words, for every case of Ebola virus disease exported to the USA, the authors predict that there will be roughly eight cases exported to the UK or France combined.

Bogoch and colleagues3 then studied the potential for exit and entry screening to reduce export of unidentified infections, concluding that exit screening would be a much more efficient approach than entry screening. We would like to add several points to this discussion. First, international support would be essential for implementation of exit screening in the three highly-affected resource-poor countries in west Africa. However, implementation of more stringent checks beyond what is already being done could be very challenging. The affected countries have many urgent priorities—resources including money, personnel, medical equipment, and supplies are urgently needed to expand capacity for detection, diagnosis, and treatment of patients with Ebola virus disease, and to implement isolation and contact tracing, which are currently the best available interventions to control the outbreak. Meanwhile, the outbreak is having a catastrophic effect on the local health-care systems, which were already fragile.2, 5 No announcements have been made yet about earmarked contributions from the international community to support exit screening.

Second, exit and entry screening might not have a substantial effect on export rates, because of the long incubation period of the disease (average 8–10 days, range 2–21 days),1 combined with rapid disease progression after onset, so that most exportations would be incubating infections missed at border screening points. Finally, a choice is posed between entry and exit screening in Bogoch and colleagues’ study,3 with exit screening shown to be more efficient than entry screening and the combination of entry and exit screening shown to have little incremental usefulness. However, some countries have implemented and will continue entry screening6, 7 for various reasons. Subject to entry screening already being implemented, exit screening from the affected countries might not have incremental utility, especially considering the other urgent priorities in the region. In addition to any entry or exit screening, vigilance within countries is essential for early detection of imported cases of Ebola virus disease.3

There are several important near-future research needs. Perhaps most urgent is a better understanding of the effectiveness of existing treatment options, including convalescent serum. In the medium term, it is hoped that new vaccines and drugs will be available quickly for human clinical trials and in exposed populations.8 The WHO Ebola Response team has neatly summarised the transmission dynamics and epidemiological characteristics including the reproductive number, incubation period, and case fatality risk in the current Ebola virus outbreak,1 but one important unknown is the proportion of infections that are asymptomatic or mildly symptomatic. If mild infections do occur and are infectious, disease control outside west Africa might be increasingly challenging. However, this scenario is thought to be unlikely.9 One particularly pressing need is for the reassessment of appropriate procedures for infection control, and the potential for the virus to spread via small particle aerosols10 in addition to via contact with infected patients or their bodily fluids. Infection of health-care personnel in west Africa is often attributed to the scarcity of appropriate protective equipment and supplies, or inadequate administrative controls.11, 12 However, the nosocomial cases in Dallas and Madrid have raised the concern that present protocols might not be sufficient to protect health-care personnel fully against infection, particularly if cases are managed in health-care facilities that are not fully prepared.

BJC has received research funding from MedImmune and Sanofi Pasteur, and consults for Crucell. HY declares no competing interests. We thank Ren Xiang, Michael Ni, and Charles Yiu for technical assistance with the figure.

Articles
Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak
Isaac I Bogoch, MD, Maria I Creatore, PhD, Martin S Cetron, MD, John S Brownstein, PhD, Nicki Pesik, MD, Jennifer Miniota, MSc, Theresa Tam, MD, Wei Hu, MSA, Adriano Nicolucci, MSA, Saad Ahmed, BSc, James W Yoon, MISt, Isha Berry, Prof Simon I Hay, DSc, Aranka Anema, PhD, Andrew J Tatem, PhD, Derek MacFadden, MD, Matthew German, MSc, Dr Kamran Khan, Open Access
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61828-6
Open access funded by Wellcome Trust
Summary
Background
The WHO declared the 2014 west African Ebola epidemic a public health emergency of international concern in view of its potential for further international spread. Decision makers worldwide are in need of empirical data to inform and implement emergency response measures. Our aim was to assess the potential for Ebola virus to spread across international borders via commercial air travel and assess the relative efficiency of exit versus entry screening of travellers at commercial airports.
Methods
We analysed International Air Transport Association data for worldwide flight schedules between Sept 1, 2014, and Dec 31, 2014, and historic traveller flight itinerary data from 2013 to describe expected global population movements via commercial air travel out of Guinea, Liberia, and Sierra Leone. Coupled with Ebola virus surveillance data, we modelled the expected number of internationally exported Ebola virus infections, the potential effect of air travel restrictions, and the efficiency of airport-based traveller screening at international ports of entry and exit. We deemed individuals initiating travel from any domestic or international airport within these three countries to have possible exposure to Ebola virus. We deemed all other travellers to have no significant risk of exposure to Ebola virus.
Findings
Based on epidemic conditions and international flight restrictions to and from Guinea, Liberia, and Sierra Leone as of Sept 1, 2014 (reductions in passenger seats by 51% for Liberia, 66% for Guinea, and 85% for Sierra Leone), our model projects 2•8 travellers infected with Ebola virus departing the above three countries via commercial flights, on average, every month. 91 547 (64%) of all air travellers departing Guinea, Liberia, and Sierra Leone had expected destinations in low-income and lower-middle-income countries. Screening international travellers departing three airports would enable health assessments of all travellers at highest risk of exposure to Ebola virus infection.
Interpretation
Decision makers must carefully balance the potential harms from travel restrictions imposed on countries that have Ebola virus activity against any potential reductions in risk from Ebola virus importations. Exit screening of travellers at airports in Guinea, Liberia, and Sierra Leone would be the most efficient frontier at which to assess the health status of travellers at risk of Ebola virus exposure, however, this intervention might require international support to implement effectively.
Funding
Canadian Institutes of Health Research.

Series
HIV and sex workers
Global epidemiology of HIV among female sex workers: influence of structural determinants
Kate Shannon, Steffanie A Strathdee, Shira M Goldenberg, Putu Duff, Peninah Mwangi, Maia Rusakova, Sushena Reza-Paul, Joseph Lau, Kathleen Deering, Michael R Pickles, Marie-Claude Boily
HIV and sex workers
Combination HIV prevention for female sex workers: what is the evidence?
Linda-Gail Bekker, Leigh Johnson, Frances Cowan, Cheryl Overs, Donela Besada, Sharon Hillier, Willard Cates

The Lancet Global Health
Jan 2015 Volume 3 Number 1 e1-e61
http://www.thelancet.com/journals/langlo/issue/current

Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort
Jennifer A Wagman, Ronald H Gray, Jacquelyn C Campbell, Marie Thoma, Anthony Ndyanabo, Joseph Ssekasanvu, Fred Nalugoda, Joseph Kagaayi, Gertrude Nakigozi, David Serwadda, Heena Brahmbhatt
e23

Intimate partner violence and HIV in ten sub-Saharan African countries: what do the Demographic and Health Surveys tell us?
Dick Durevall, Annika Lindskog

Funding AIDS programmes in the era of shared responsibility: an analysis of domestic spending in 12 low-income and middle-income countries
Stephen Resch, Theresa Ryckman, Robert Hecht

The Lancet Infectious Diseases
Jan 2015 Volume 15 Number 1 p1-130
http://www.thelancet.com/journals/laninf/issue/current

Articles
Spatial and temporal distribution of soil-transmitted helminth infection in sub-Saharan Africa: a systematic review and geostatistical meta-analysis
Dimitrios-Alexios Karagiannis-Voules, MSc, Patricia Biedermann, MSc, Uwem F Ekpo, PhD, Amadou Garba, MD, Erika Langer, MSc, Els Mathieu, MD, Prof Nicholas Midzi, PhD, Pauline Mwinzi, PhD, Anton M Polderman, PhD, Giovanna Raso, PhD, Moussa Sacko, PhD, Idrissa Talla, MD, Prof Louis-Albert Tchuem Tchuenté, PhD, Seydou Touré, MD, Mirko S Winkler, PhD, Prof Jürg Utzinger, PhD, Dr Penelope Vounatsou, PhD
Published Online: 02 December 2014
Summary
Background
Interest is growing in predictive risk mapping for neglected tropical diseases (NTDs), particularly to scale up preventive chemotherapy, surveillance, and elimination efforts. Soil-transmitted helminths (hookworm, Ascaris lumbricoides, and Trichuris trichiura) are the most widespread NTDs, but broad geographical analyses are scarce. We aimed to predict the spatial and temporal distribution of soil-transmitted helminth infections, including the number of infected people and treatment needs, across sub-Saharan Africa.
Methods
We systematically searched PubMed, Web of Knowledge, and African Journal Online from inception to Dec 31, 2013, without language restrictions, to identify georeferenced surveys. We extracted data from household surveys on sources of drinking water, sanitation, and women’s level of education. Bayesian geostatistical models were used to align the data in space and estimate risk of with hookworm, A lumbricoides, and T trichiura over a grid of roughly 1 million pixels at a spatial resolution of 5 × 5 km. We calculated anthelmintic treatment needs on the basis of WHO guidelines (treatment of all school-aged children once per year where prevalence in this population is 20–50% or twice per year if prevalence is greater than 50%).
Findings
We identified 459 relevant survey reports that referenced 6040 unique locations. We estimate that the prevalence of hookworm, A lumbricoides, and T trichiura among school-aged children from 2000 onwards was 16•5%, 6•6%, and 4•4%. These estimates are between 52% and 74% lower than those in surveys done before 2000, and have become similar to values for the entire communities. We estimated that 126 million doses of anthelmintic treatments are required per year.
Interpretation
Patterns of soil-transmitted helminth infection in sub-Saharan Africa have changed and the prevalence of infection has declined substantially in this millennium, probably due to socioeconomic development and large-scale deworming programmes. The global control strategy should be reassessed, with emphasis given also to adults to progress towards local elimination.
Funding
Swiss National Science Foundation and European Research Council.

New England Journal of Medicine
January 1, 2015 Vol. 372 No. 1
http://www.nejm.org/toc/nejm/medical-journal

Perspective
Communicating Uncertainty — Ebola, Public Health, and the Scientific Process
L. Rosenbaum

Interactive Perspective
International Health Care Systems — Selected Measures
N Engl J Med 2015; 372:e1January 1, 2015DOI: 10.1056/NEJMp1413937
An interactive graphic presents characteristics of selected health care systems from around the world, as well as health outcomes achieved in each country covered in the Perspective series on International Health Care Systems.

Clinical Presentation of Patients with Ebola Virus Disease in Conakry, Guinea
E.I. Bah and Others

Editorials
International Health Care Systems
S. Morrissey, D. Blumenthal, R. Osborn, G.D. Curfman, and D. Malina

PLOS Currents: Disasters
[Accessed 3 January 2014]
http://currents.plos.org/disasters/

Snow Tweets: Emergency Information Dissemination in a US County During 2014 Winter Storms
December 22, 2014 • Research article
Abstract
Introduction: This paper describes how American federal, state, and local organizations created, sourced, and disseminated emergency information via social media in preparation for several winter storms in one county in the state of New Jersey (USA).
Methods: Postings submitted to Twitter for three winter storm periods were collected from selected organizations, along with a purposeful sample of select private local users. Storm-related posts were analyzed for stylistic features (hashtags, retweet mentions, embedded URLs). Sharing and re-tweeting patterns were also mapped using NodeXL.
Results: Results indicate emergency management entities were active in providing preparedness and response information during the selected winter weather events. A large number of posts, however, did not include unique Twitter features that maximize dissemination and discovery by users. Visual representations of interactions illustrate opportunities for developing stronger relationships among agencies.
Discussion: Whereas previous research predominantly focuses on large-scale national or international disaster contexts, the current study instead provides needed analysis in a small-scale context. With practice during localized events like extreme weather, effective information dissemination in large events can be enhanced.

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 3 January 2014)

Sequential Outbreaks Due to a New Strain of Neisseria Meningitidis Serogroup C in Northern Nigeria, 2013-14
December 29, 2014 • Research
Abstract
Background
Neisseria meningitidis serogroup C (NmC) outbreaks occur infrequently in the African meningitis belt; the most recent report of an outbreak of this serogroup was in Burkina Faso, 1979. Médecins sans Frontières (MSF) has been responding to outbreaks of meningitis in northwest Nigeria since 2007 with no reported cases of serogroup C from 2007-2012. MenAfrivac®, a serogroup A conjugate vaccine, was first used for mass vaccination in northwest Nigeria in late 2012. Reactive vaccination using polysaccharide ACYW135 vaccine was done by MSF in parts of the region in 2008 and 2009; no other vaccination campaigns are known to have occurred in the area during this period. We describe the general characteristics of an outbreak due to a novel strain of NmC in Sokoto State, Nigeria, in 2013, and a smaller outbreak in 2014 in the adjacent state, Kebbi.
Methods
Information on cases and deaths was collected using a standard line-list during each week of each meningitis outbreak in 2013 and 2014 in northwest Nigeria. Initial serogroup confirmation was by rapid Pastorex agglutination tests. Cerebrospinal fluid (CSF) samples from suspected meningitis patients were sent to the WHO Reference Laboratory in Oslo, where bacterial isolates, serogrouping, antimicrobial sensitivity testing, genotype characterisation and real-time PCR analysis were performed.
Results
In the most highly affected outbreak areas, all of the 856 and 333 clinically suspected meningitis cases were treated in 2013 and 2014, respectively. Overall attack (AR) and case fatality (CFR) rates were 673/100,000 population and 6.8% in 2013, and 165/100,000 and 10.5% in 2014. Both outbreaks affected small geographical areas of less than 150km2 and populations of less than 210,000, and occurred in neighbouring regions in two adjacent states in the successive years. Initial rapid testing identified NmC as the causative agent. Of the 21 and 17 CSF samples analysed in Oslo, NmC alone was confirmed in 11 and 10 samples in 2013 and 2014, respectively. Samples confirmed as NmC through bacterial culture had sequence type (ST)-10217.
Conclusions
These are the first recorded outbreaks of NmC in the region since 1979, and the sequence (ST)-10217 has not been identified anywhere else in the world. The outbreaks had similar characteristics to previously recorded NmC outbreaks. Outbreaks of NmC in 2 consecutive years in northern Nigeria indicate a possible emergence of this serogroup. Increased surveillance for multiple serogroups in the region is needed, along with consideration of vaccination with conjugate vaccines rather than for NmA alone.

PLoS One
[Accessed 3 January 2014]
http://www.plosone.org/

Research Article
Costs of Eliminating Malaria and the Impact of the Global Fund in 34 Countries
Brittany Zelman mail, Anthony Kiszewski, Chris Cotter, Jenny Liu
Published: December 31, 2014
DOI: 10.1371/journal.pone.0115714
Abstract
Background
International financing for malaria increased more than 18-fold between 2000 and 2011; the largest source came from The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). Countries have made substantial progress, but achieving elimination requires sustained finances to interrupt transmission and prevent reintroduction. Since 2011, global financing for malaria has declined, fueling concerns that further progress will be impeded, especially for current malaria-eliminating countries that may face resurgent malaria if programs are disrupted.
Objectives
This study aims to 1) assess past total and Global Fund funding to the 34 current malaria-eliminating countries, and 2) estimate their future funding needs to achieve malaria elimination and prevent reintroduction through 2030.
Methods
Historical funding is assessed against trends in country-level malaria annual parasite incidences (APIs) and income per capita. Following Kizewski et al. (2007), program costs to eliminate malaria and prevent reintroduction through 2030 are estimated using a deterministic model. The cost parameters are tailored to a package of interventions aimed at malaria elimination and prevention of reintroduction.
Results
The majority of Global Fund-supported countries experiencing increases in total funding from 2005 to 2010 coincided with reductions in malaria APIs and also overall GNI per capita average annual growth. The total amount of projected funding needed for the current malaria-eliminating countries to achieve elimination and prevent reintroduction through 2030 is approximately US$8.5 billion, or about $1.84 per person at risk per year (PPY) (ranging from $2.51 PPY in 2014 to $1.43 PPY in 2030).
Conclusions
Although external donor funding, particularly from the Global Fund, has been key for many malaria-eliminating countries, sustained and sufficient financing is critical for furthering global malaria elimination. Projected cost estimates for elimination provide policymakers with an indication of the level of financial resources that should be mobilized to achieve malaria elimination goals.

Sustainability
Volume 7, Issue 1 (January 2015)
http://www.mdpi.com/2071-1050/6/11

Article:
The Informal Economy as a Catalyst for Sustainability
by William Ruzek
Sustainability 2015, 7(1), 23-34; doi:10.3390/su7010023
Received: 13 September 2014; Accepted: 17 December 2014 / Published: 23 December 2014
Abstract: Sustainability typically involves the balancing of three major factors: the economy, the environment, and some notion of equity. Though the economy is already a key aspect, the recognition of the informal economy, seems to be absent from the many possible permutations of these three. This paper will explore the various aspects of the informal economy and how it can make a considerable impact on achieving a more sustainable future. Specifically, this paper focuses on how the informal economy can encourage the sustainable use of goods, while offering an alternative to the regulated market economy. By supporting the informal sectors such as farmers markets, street vendors and non-market activities, a shift away from a car-dominated society and singular economic trajectory can begin. The informal sector can provide, social capital, promote local economies, create jobs and provide the need economic shift toward a sustainable future.

Article:
Fit for the Future? A New Approach in the Debate about What Makes Healthcare Systems Really Sustainable
by Matthias Fischer
Sustainability 2015, 7(1), 294-312; doi:10.3390/su7010294
Received: 26 May 2014; Accepted: 24 December 2014 / Published: 30 December 2014
Abstract: As healthcare systems face enormous challenges, sustainability is seen as a crucial requirement for making them fit for the future. However, there is no consensus with regard to either the definition of the term or the factors that characterize a “sustainable healthcare system”. Therefore, the aim of this article is twofold. First, it gives examples of the existing literature about sustainable healthcare systems and analyzes this literature with regard to its understanding of sustainability and the strengths and weaknesses of the different approaches. The article then identifies crucial factors for sustainable healthcare systems, and the result, a conceptual framework consisting of five distinct and interacting factors, can be seen as a starting point for further research.

Ebola/EVD: Additional Coverage

UNMEER [UN Mission for Ebola Emergency Response] @UNMEER #EbolaResponse
UNMEER’s website is aggregating and presenting content from various sources including its own External Situation Reports, press releases, statements and what it titles “developments.” We present a composite below from the week ending 3 January 2014.

UNMEER External Situation Reports
UNMEER External Situation Reports are issued daily (excepting Saturday) with content organized under these headings:
– Highlights
– Key Political and Economic Developments
– Human Rights
– Response Efforts and Health
– Logistics
– Outreach and Education
– Resource Mobilisation
– Essential Services
– Upcoming Events
The “Week in Review” will present highly-selected elements of interest from these reports. The full daily report is available as a pdf using the link provided by the report date.

:: 02 Jan 2015 UNMEER External Situation Report
Key Political and Economic Developments
1. SRSG Banbury concluded his farewell visit to the three most affected countries in Sierra Leone from 30 to 31 December. He travelled to Bombali District, where he met with members of the District Ebola Response Center and visited three Ebola Treatment Units as well asa Community Care Center. He also met with President Ernest Bai Koroma in Freetown to commend him for his leadership and engagement on the Ebola crisis. . The President thanked UNMEER for the support provided to date, noting its positive impact on the ground. He expressed his hope that Sierra Leone, with the support of the international community, will be able to fully contain the Ebola outbreak by mid-2015 and pursue the economic agenda that had been set.
2. In his New Year’s Day Address, President Ernest Bai Koroma called on the country to begin a week of fasting and prayers to end the Ebola outbreak. The President urged people not to touch the sick or corpses and not to disobey quarantine orders. The President also indicated that schools, which have been closed since July due to the outbreak, would reopen soon.
Resource Mobilisation
11. The OCHA Ebola Virus Outbreak Overview of Needs and Requirements, now totaling USD 1.5 billion, has been funded for USD 1.1 billion, which is around 74% of the total ask.
12. The Ebola Response Multi-Partner Trust

:: 31 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. On 29 December, the Prime Minister of Guinea visited the construction site of the new centre for epidemiological research and microbiology funded by the Russian aluminum company Rusal in Kindia. The centre will become part of the Institut Pasteur de Guinée which has secured funding from the Institut Pasteur in France and the French Government to enhance its capacity for surveillance, detection and prevention of infectious diseases in Guinea and the sub-region.
2. On 30 December, three national trade unions in Guinea issued a statement requesting that the government decrease the retail price of gasoline and fuel to reflect the drop in the price of oil in the global market. They have also urged the government to honour its pledges concerning the revised pay scale of civil servants and retirees. This request comes at a time when six other trade unions have threatened to launch
Response Efforts and Health
5. To support the Government of Sierra Leone’s response to the EVD outbreak, the World Bank and UNFPA have designed a joint project to reinforce and scale-up contact tracing, so as to strengthen the existing surveillance system.
7. In Liberia, WHO has identified the growing need for more disaggregated epidemiological data on children affected by the Ebola crisis for cross-cluster planning. Other vulnerable groups (patients, affected families, the elderly and the disabled) should also be considered.
Outreach and Education
16. In Guinea, the prefect of Lola prefecture conducted a sensitization mission in the village of Thuo on 30 December to address community resistance. Thuo has seen a flare-up of EVD cases in the past ten days and 2 new suspected cases were transferred today to the ETC in Nzérékoré. Members of the local community have reportedly threatened EVD response partners who have mostly left the area due to the tensions. The return of response partners is pending the outcome of the prefect’s mission. Save the Children has begun identifying 40 children in Thuo who have lost one or both parents to EVD with the aim of providing protection, but they will only deploy after a lifting of community resistance in Thuo.
17. Similarly, on 29 December, the prefectural coordination in Nzérékoré prefecture, Guinea, deployed a sensitization mission to the resistant communities of Banzou North and Zeremouda. The mission faced difficulties in engaging in dialogue with the members of the local community in both areas. UNMEER’s FCM covering Nzérékoré is following up to ascertain the reasons for resistance in these specific communities.
Essential Services
19. In Sierra Leone, the World Bank and UNFPA have developed a joint project to support the Government of Sierra Leone to establish appropriate arrangements to revitalize Reproductive, Maternal, Adolescent and Newborn Health (RMANH) services in the context of Ebola.
20. In Liberia, the Ministry of Health with support from UNFPA is conducting fistula prevention awareness in two counties (Margibi and Grand Bassa). UNFPA also hired a local NGO (Liberia Prevention Maternal Mortality) to conduct Maternal and Newborn Health (MNH) needs assessments in 20 health facilities in four Counties (Montserrado, Cape Mount, Margibi and Grand Bassa).

:: 30 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
2. The Minister of Health of Guinea is continuing his sensitization and oversight mission in EVD affected prefectures. On 27 December, the minister took part in the prefectural coordination meeting in Nzérékoré, attended by the main response partners. The prefectural coordinator gave a briefing on the current situation, highlighting challenges including persistent resistance in communities in Sadou, Banzou North, Baya and Zenemouda; insufficient supply of thermo flash thermometers; lack of equipment and electricity; lack of an office for the prefectural coordination; and weak coordination among response partners. Concerning local resistance, the minister advised that partners must enable community members to take ownership of the sensitization process to engage their respective communities. Concerning the Community Watch Committees (CWCs), response partners briefed the minister that a number have been established but their members have not yet received training and are not operational. The minister stressed that partners involved with the CWCs had to work faster and he warned that alternative measures would be taken in case partners could not deliver on the operationalization of CWCs. He also encouraged response partners to better integrate their activities under the umbrella of the prefectural coordination and to increase their actions in the field where flare-ups and resistance are persistent.
Response Efforts and Health
4. UNDP has made additional incentive payments to 758 health personnel working in four ETUs in Guinea, ensuring their continued engagement in saving patients. The agency was requested by Guinea’s National Coordination Unit against Ebola to complete existing salaries with incentive pays for the French Red Cross, Doctors without Borders and Alima, three Non-Governmental Organizations (NGOs) operating ETUs in Donka, Macenta, Kissidougou and Nzérékoré. Together with UNMEER and the World Bank, UNDP assisted the Ministry of Health in harmonizing incentives, and ensured that US$ 220,000 were deposited in local banks.

:: 29 Dec 2014 UNMEER External Situation Report
KEY POINTS
– A field hospital donated by Israel will be established as an Ebola Treatment Unit (ETU) in Dubreka, Guinea.
– UNICEF joined partners in engaging the population of the quarantined and neighboring villages of Lonfaye town and Yekepa town, Liberia, following two separate outbreaks there.
– In response to measles cases in Lofa county, Liberia, the UNICEF-supported periodic intensification of routine immunization, or PIRI, is ongoing across all of the 15 counties.
Response Efforts and Health
3. On 26 December, the National Ebola Response Coordinator informed UNMEER that a field hospital donated by Israel would be established as an ETU in Dubreka, Guinea. He added that the target opening date was 15 January. This ETU and the one in Coyah will help relieve the caseload on the ETU in Conakry (Donka) coming from prefectures adjacent to the capital.
4. According to recent data from the Liberian health ministry, there have been at least 1,042 confirmed cases of children with EVD in the country. The number of children identified by name and location as orphaned by EVD is 4,115. All of the children identified are currently receiving follow-up and psychosocial support. Over 250 volunteer contact tracers, trained and engaged by UNICEF, are now reporting cases of children orphaned or otherwise affected by EVD. UNICEF is working to ensure that children who have lost their parents due to EVD continue to receive care through a kinship arrangement. That way children may be from becoming institutionalized, for example in an orphanage.
Essential Services
15. West Africa’s fight to contain EVD has hampered the campaign against malaria, which is a fully preventable and treatable disease. In Guéckédou, Guinea, doctors have had to stop pricking fingers to do blood tests for malaria. Bernard Nahlen, deputy director of the US President’s Malaria Initiative, said Guinea’s 40% drop in reported malaria cases this year is likely because people are too scared to go to health facilities and are not getting treated for malaria. Nets for Life Africa, a New York-based charity that provides insecticide-treated mosquito nets, said some 15,000 Guineans died from malaria last year.
16. In response to measles cases in Lofa county, Liberia, the UNICEF-supported periodic intensification of routine immunization, or PIRI, is ongoing across all 15 counties. The goal is to rapidly reduce the number of unimmunized children against measles. This intensification comes in lieu of an immunization campaign, which is not recommended in the EVD context. Vaccinators are being trained simultaneously across the country on infection prevention and control measures, supervision during PIRI and on how to conduct outreach sessions in remote areas. In addition, UNICEF provided basic infection control kits, including infrared thermometers, to 500 health facilities providing immunization services in Liberia.

:: 26 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. Sierra Leone has declared a lockdown of at least three days in the north of the country to try to contain an EVD flare-up there. Response workers will go door to door to look for suspected cases of EVD. Shops, markets and travel services will be shut down. Sierra Leone had already banned many public Christmas celebrations. Alie Kamara, resident minister for the Northern Region, indicated that “muslims and christians are not allowed to hold services in mosques and churches throughout the lockdown, except for christians on Christmas day”. No unauthorized vehicles will be allowed to operate, except those officially assigned to EVD-related assignments. The lockdown is scheduled to last for at least three days, but this could be extended if deemed necessary.
10. The Liberian health ministry has received permission from the World Bank to release funds for the payment of workers’ salaries to the counties. Unfortunately the pre-Christmas deadline was missed, but the plan to pay all workers in the counties through banks and off-site payments is being completed by the government. UNDP will support the teams financially and logistically to execute the payments, which are planned over several days and are expected to begin through the holiday period. Separately, funds that had been provided to banks in time were not paid to contact tracers and active case finders by the 23rd, due to banks’ liquidity issues. There were demonstrations at the health ministry as a result.
11. UNDP has received a request to pay more than 400 workers in Montserrado, Liberia, including staff of the newly established IMS for the county. UNDP, as a provider of last resort, will seek to ensure that all other avenues for payment have been exhausted before committing to these payments.
Essential Services
21. From 10-16 December, as part of the Integrated Management of Acute Malnutrition (IMAM), a total of 18,885 children under 5 were screened at the community level in 64 out of 149 chiefdoms (389 communities) in Sierra Leone. 506 were referred for treatment at the Peripheral Health Units that provide nutrition treatment services.

:: 24 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. The director of the US Centers for Disease Control and Prevention (CDC), Dr. Tom Frieden, said on Monday that even though the number of cases in West Africa has not reached worst-case scenario predictions, the world remains at risk until it drops to zero. “I’m hopeful about stopping the epidemic, but I remain realistic that this is going to be a long, hard fight”, he said. On his recent visit to Liberia, Guinea and Sierra Leone, Dr. Frieden said he had seen “real momentum and real progress” in combating the virus. “I am hopeful that we are going to see continued progress. The challenge is not to let up, not to be complacent and to really double down”. Asked about the CDC’s report in September that in certain scenarios, EVD cases could reach 550,000 by January, Frieden replied: “The projections we released a few months ago showed what could happen if nothing more were done – in fact an enormous amount has been done.”
2. Peter Piot, a leading researcher who helped to discover EVD, has also said that the EVD crisis is likely to last until the end of 2015, warning that vaccines would take time to develop. Professor Piot was one of the scientists who discovered EVD in 1976 and is now director of the London School of Hygiene and Tropical Medicine. He said that even though the outbreak has peaked in Liberia and was likely to peak in Sierra Leone in the next few weeks, the epidemic could have a “very long tail and a bumpy tail”. Piot stated: “We need to be ready for a long effort, a sustained effort for probably the rest of 2015.” But he added that he was impressed by the progress that he had seen on a recent visit to Sierra Leone: “Treatment units have now been established across the country. You don’t see any longer the scenes where people are dying in the streets”.
Response Efforts and Health
5. A Nigerian peacekeeper diagnosed with EVD, who had been evacuated to the Netherlands for treatment, has recovered and has returned to the UN mission in Liberia. The peacekeeper will resume duties while undergoing monitoring and psychological counseling. The man arrived in the Netherlands earlier this month. The Netherlands has followed Germany, France and Switzerland in taking on EVD patients at the request of the World Health Organization.

:: 23 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. The United Nations must learn lessons from the EVD crisis and begin preparing now for the next outbreak of a deadly disease, Secretary-General Ban Ki-moon said in New York after returning from a visit to West Africa. “We must learn the lessons of Ebola, which go well beyond strengthening public health systems”, Ban stated. “The international community needs better early warning and rapid response.” The UN chief said he will launch a serious effort to “explore what more we can do to stay ahead of the next outbreak of disease — a test that is sure to come.” Ban also called for recovery efforts to be stepped up in West Africa in order to rebuild shattered economies, get children back in school and begin caring for EVD orphans.
2. Sierra Leone is withdrawing its troops from Somalia after the African Union blocked the West African country from rotating its soldiers over fears for EVD. Sierra Leone sent 850 troops to Somalia in 2013 for a 12-month deployment to fight jihadist terrorist group al-Shabab. Their rotation was delayed after a group of 800 soldiers, who were waiting to replace their comrades in Somalia, were quarantined after one of the soldiers was tested positive for EVD. In August, Somalia’s President Hassan Sheikh Mohamud said no new troops from Sierra Leone will be deployed to his country after calls by activists and a campaign on social media by Somalis calling for a halt to the deployment.

:: 22 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. United Nations Secretary-General Ban Ki-moon made a three-day tour of the region on Friday and Saturday, visiting Liberia, Sierra Leone, Guinea, Mali and Ghana. He met with the leaders of those countries as well as with survivors of Ebola Virus Disease (EVD), healthcare workers and UN staff. In Liberia, the SG participated in an Incident Management System (IMS) meeting with EVD response partners, where he discussed current trends and the next steps in the response. He warned against complacency at what remains a critical time. The Secretary-General also visited several treatment facilities. On his visits he was accompanied by the Director General of WHO, Dr. Margaret Chan, the UN Special Envoy on Ebola, Dr. David Nabarro, and the Head of UNMEER, Anthony Banbury.
2. In Guinea, Secretary-General Ban Ki-moon warned about rising EVD infection rates in the south-east of the country. While infection rates in Liberia, one of the nations hardest hit by the outbreak, have been slowing, other areas have registered an uptick in the rate of the disease’s progress. Infection rates in south-eastern Guinea, the region where the deadliest outbreak in history began a year ago, have also failed to decline substantially. Solid cross border collaboration is necessary to prevent a resurgence of the epidemic, Ban said in Conakry. The Secretary-General also warned of the serious socio-economic consequences the outbreak is likely to have in the affected countries. “While our immediate priority is to stop the spread of the disease, it is not too early to start thinking about recovery,” Ban said. “We must scale up our efforts to restore basic social services, strengthen health services, support economic activity and build up the countries’ resilience.”
3. In Sierra Leone, Ban Ki-moon met Rebecca Johnson, a Sierra Leonean nurse who caught the virus but survived. She recounted how she fell gravely ill, recovered and is now back treating EVD patients. Ban said he was moved by Johnson’s story, especially that she still faced a stigma as a survivor. “There should be no discrimination for those who have been working or helping with Ebola. Those people are giving all of themselves,” Ban said. He also made it clear that UNMEER is intended to be a short term mission: “My intention is not to keep UNMEER longer than one year. If that isn’t the case, people will regard it as a failure”.
Response Efforts and Health
6. Last week, in support of quarantined households in the Western Area of Sierra Leone, UNICEF has distributed 2,580 jerry cans, together with a 21-day supply of aqua tabs. To date, UNICEF has provided around 6,648 quarantined households with 23,720 jerry cans and 254,643 aqua tabs, benefiting 40,164 people in quarantined households and communities. Supplies have been distributed through WFP packages. UNICEF also delivered a total of 184,000 litres of safe water to two 100-bed EVD treatment centers, while setup work is ongoing in two new 24-bed Community Care Centers (CCCs) in the Western area. UNICEF, with its partners, has also ensured that 12 newly constructed CCCs were fully stocked with Water, Sanitation and Hygiene (WASH) packages.
7. In Sierra Leone, UNDP has supported the payment of hazard pay entitlements for 16,000 EVD workers in five days, through a mobile cash transfer system. With concurrent support to the government of Sierra Leone by UNDP, the World Bank and the African Development Bank, policy and guidelines are being drafted to streamline the system.
Outreach and Education
15. Last week, 8,220 households in Liberia were reached through door-to-door campaigns with EVD prevention messages as well as through 167 meetings and group discussions, reaching 13,787 women, 11,142 men and 8,912 children across all counties. 675 community leaders and elders were engaged.
16. In the first week of December, 1,414 social mobilizers were trained by UNICEF in Sierra Leone. 48% were women and 44% were less than 25 years old. Participants were trained on topics including infection prevention and control, home protection, safe burial practices, and quarantined households. 370 religious leaders and 65 paramount chiefs were sensitized to support social mobilization activities in 8 districts. Social mobilizers engaged by partners reached 5,867 households to disseminate key messages and sensitize the community.