Ebola Virus Disease Surveillance in Two High-Transmission Districts of Sierra Leone During the 2013–2015 Outbreak: Surveillance Methods, Implications for Maternal and Child Health, and Recommendations

Abstract

Effective surveillance for Ebola virus disease (EVD) was critical to control the 2013–2015 epidemic in West Africa. At the community level, this work was done by surveillance officers, who were responsible for conducting investigations to identify and refer suspected cases for testing and isolation. Surveillance was also conducted in health care facilities to identify potential cases of EVD and prevent spread of the disease within the facility.

Surveillance for EVD infection in pregnant, postpartum, and breastfeeding mothers and their children presented more challenges than in the general population. This was especially due to the nonspecific nature of the symptoms used to identify suspected cases of EVD, which overlapped with pregnancy, labor, and its complications, and diseases common in West Africa, notably, malaria. These challenges meant that conducting EVD surveillance itself had ramifications on maternal child health. These impacts were magnified by the breakdown in primary health care and restrictions on movement, which increased the number of ill persons detected through the surveillance system. At the same time, some people took measures to avoid the surveillance system by not reporting or seeking care for their sicknesses due to fear of referral to Ebola health care facilities.

Surveillance officers, mothers, and their families faced difficult choices, particularly regarding the separation of a mother from her baby when the mother met the criteria for suspected EVD and was referred for isolation and laboratory testing. If the baby was not also a suspected EVD case, the risk of nosocomial infection in Ebola holding facilities had to be weighed against the lack of infant formula in communities, making the decision on how to care for the baby difficult. Breakdowns in surveillance in communities and in health care facilities, along with lack of food and health services for those in quarantine, negatively impacted the health of mothers, their children, and the overall population. Additonally, it adversely affected outbreak control and the community’s trust and engagement on which it depended. Surveillance officers had to skillfully navigate these complex and dynamic circumstances in order to be effective.