Enhancing Ebola Virus Disease Surveillance And Prevention In Counties Without Confirmed Cases In Rural Liberia: Experiences From Sinoe County During The Flare-Up In Monrovia, April To June, 2016

Introduction During the flare-ups of Ebola virus disease (EVD) in Liberia, Sinoe County reactivated the multi-sectorial EVD control strategy in order to be ready to respond to the eventual reintroduction of cases. This paper describes the impacts of the interventions implemented in Sinoe County during the last flare-up in Monrovia, from April 1 to June 9, 2016, using the resources provided during the original outbreak that ended one year back. Methods We conducted a descriptive study to describe the key interventions implemented in Sinoe County, the capacity available, the implications for the reactivation of the multi-sectoral EVD control strategy, and the results of the same. We also conducted a cross-sectional study to analyze the impact of the interventions on the surveillance and on infection prevention and control (IPC). Results The attrition of the staff trained during the original outbreak was low, and most of the supplies, equipment, and infrastructure from the original outbreak remained available. With an additional US$1755, improvements were observed in the IPC indicators of triage, which increased from a mean of 60% during the first assessment to 77% (P=0.002). Additionally, personal/staff training improved from 78% to 89% (P=0.04). The percentage of EVD death alerts per expected deaths investigated increased from 26% to 63% (P<0.0001). Discussion The small attrition of the trained staff and the availability of most of the supplies, equipment, and infrastructure made the reactivation of the multi-sectoral EVD control strategy fast and affordable. The improvement of the EVD surveillance was possibly affected by the community engagement activities, awareness and mentoring of the health workers, and improved availability of clinicians in the facilities during the flare-up. The community engagement may contribute to the report of community-based events, specifically community deaths. The mentoring of the staff during the supportive supervisions also contributed to improve the IPC indicators.


Introduction
During the flare-ups of Ebola virus disease (EVD) in Liberia, Sinoe County reactivated the multisectorial EVD control strategy in order to be ready to respond to the eventual reintroduction of cases. This paper describes the impacts of the interventions implemented in Sinoe County during the last flare-up in Monrovia, from April 1 to June 9, 2016, using the resources provided during the original outbreak that ended one year back.

Methods
We conducted a descriptive study to describe the key interventions implemented in Sinoe County, the capacity available, the implications for the reactivation of the multi-sectoral EVD control strategy, and the results of the same. We also conducted a cross-sectional study to analyze the impact of the interventions on the surveillance and on infection prevention and control (IPC).

Results
The attrition of the staff trained during the original outbreak was low, and most of the supplies, equipment, and infrastructure from the original outbreak remained available.
With an additional US$1755, improvements were observed in the IPC indicators of triage, which increased from a mean of 60% during the first assessment to 77% (P=0.002). Additionally, personal/staff training improved from 78% to 89% (P=0.04).
The percentage of EVD death alerts per expected deaths investigated increased from 26% to 63% (P<0.0001).

Discussion
The small attrition of the trained staff and the availability of most of the supplies, equipment, and infrastructure made the reactivation of the multisectoral EVD control strategy fast and affordable.

Introduction
The Ebola virus disease (EVD) outbreak started in The flare-ups may occur due to importation, reintroduction of the virus from animal reservoir, missed chain of transmission, and reemergence of virus from a survivor (4,(6)(7)(8)(9)(10), and can be easily detected when EVD surveillance, including the community-based surveillance and laboratory capacity, is established (11). EVD flare-up can also be controlled on time when a multi-sectorial EVD control strategy is implemented effectively. This strategy involves different committees, including clinical case management, surveillance, laboratory, logistic, behavioral and social interventions, psychosocial support, coordination, and others (11).
Liberia reported three flare-ups after the initial declaration of "disease free" status on May 9, 2015 (2,12,13), the first one being from June 29 to September 3, 2015 in Margibi County (14), which occurred after the re-emergence of the virus from a survivor through sexual contact (12,14), and the second one being in Duport road, Monrovia, from November 24, 2015 (15,16)

Setting
Sinoe County, one of the southeastern counties in rural Liberia, is divided into 10 health districts, four of which have a history of EVD positive cases reported during the original outbreak (Fig 1)

Study design
We conducted a descriptive study to describe the key interventions implemented in the county from April 1 to June 9, 2016, the capacity available, the implications for the reactivation of the multi-sectoral EVD control strategy, and the results of the same. We also conducted a cross-sectional study to analyze the impact of the interventions on surveillance and infection, prevention and control (IPC).

Data analysis
We

Key interventions
We reactivated the different committees involved in the EVD control activities, as recommended by the WHO (Fig 2)   The coordination committee conducted meetings with county, district, and community stakeholders, partners, and other line 8 ministries for coordination, awareness, and advocacy, in order to mobilize resources.

Logistics and human resources
We analyzed the human resources database to assess how many Rapid Response Team

SUSPECTED CASE:
Any person, alive or dead, suffering or having suffered from a sudden onset of high fever and having had contact with • a suspected, probable or confirmed Ebola or Marburg case • a dead or sick animal (for Ebola)

OR:
Any person with sudden onset of high fever and at least three of the following symptoms:

OR:
Any person with inexplicable bleeding

Behavioral and social interventions
We disseminated EVD prevention messages through radio talk shows with county authorities and traditional leaders at a local radio station. We also conducted community meetings in high risk communities, churches, mosques, and funeral and healing homes to increase awareness and to encourage the reporting of community deaths to the health facilities.

Ethical considerations
Ethical approval was not required to implement the activities since they were part of the activities of the Ministry of Health to respond to outbreaks in Liberia. We did not use any confidential data and did not disclose any unauthorized names in our report.

Coordination
The county's task force for EVD was

Funding Statement
The author(s) received no specific funding for this work.