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Poverty has been implicated as a challenge in the control of the current Ebola outbreak in West Africa. Although disparities between affected countries have been appreciated, disparities within West African countries have not been investigated as drivers of Ebola transmission. To quantify the role that poverty plays in the transmission of Ebola, we analyzed heterogeneity of Ebola incidence and transmission factors among over 300 communities, categorized by socioeconomic status (SES), within Montserrado County, Liberia. We evaluated 4,437 Ebola cases reported between February 28, 2014 and December 1, 2014 for Montserrado County to determine SES-stratified temporal trends and drivers of Ebola transmission. A dataset including dates of symptom onset, hospitalization, and death, and specified community of residence was used to stratify cases into high, middle and low SES. Additionally, information about 9,129 contacts was provided for a subset of 1,585 traced individuals. To evaluate transmission within and across socioeconomic subpopulations, as well as over the trajectory of the outbreak, we analyzed these data with a time-dependent stochastic model. Cases in the most impoverished communities reported three more contacts on average than cases in high SES communities (p<0.001). Our transmission model shows that infected individuals from middle and low SES communities were associated with 1.5 (95% CI: 1.4-1.6) and 3.5 (95% CI: 3.1-3.9) times as many secondary cases as those from high SES communities, respectively. Furthermore, most of the spread of Ebola across Montserrado County originated from areas of lower SES. Individuals from areas of poverty were associated with high rates of transmission and spread of Ebola to other regions. Thus, Ebola could most effectively be prevented or contained if disease interventions were targeted to areas of extreme poverty and funding was dedicated to development projects that meet basic needs.

Background Data about the effectiveness of digital contact tracing are based on studies conducted in countries with predominantly high- or middle-income settings. Up to now, little research is done to identify specific problems for the implementation of such technique in low-income countries. Methods A Bluetooth-assisted GPS location-based digital contact tracing (DCT) app was tested by 141 participants during 14 days in a hospital in Monrovia, Liberia in February 2020. The DCT app was compared to a paper-based reference system. Hits between participants and 10 designated infected participants were recorded simultaneously by both methods. Additional data about GPS and Bluetooth adherence were gathered and surveys to estimate battery consumption and app adherence were conducted. DCT apps accuracy was evaluated in different settings. Results GPS coordinates from 101/141 (71.6%) participants were received. The number of hours recorded by the participants during the study period, true Hours Recorded ( tHR ), was 496.3 h (1.1% of maximum Hours recordable) during the study period. With the paper-based method 1075 hits and with the DCT app five hits of designated infected participants with other participants have been listed. Differences between true and maximum recording times were due to failed permission settings (45%), data transmission issues (11.3%), of the participants 10.1% switched off GPS and 32.5% experienced other technical or compliance problems. In buildings, use of Bluetooth increased the accuracy of the DCT app (GPS + BT 22.9 m ± 21.6 SD vs. GPS 60.9 m ± 34.7 SD; p  = 0.004). GPS accuracy in public transportation was 10.3 m ± 10.05 SD with a significant ( p  = 0.007) correlation between precision and phone brand. GPS resolution outdoors was 10.4 m ± 4.2 SD. Conclusion In our study several limitations of the DCT together with the impairment of GPS accuracy in urban settings impede the solely use of a DCT app. It could be feasible as a supplement to traditional manual contact tracing. DKRS, DRKS00029327 . Registered 20 June 2020 - Retrospectively registered.

While qualitative assessments of Ebola virus disease (EVD)-related stigma have been undertaken among survivors and the general public, quantitative tools and assessment targeting survivors have been lacking. Beginning in June 2015, EVD survivors from seven Liberian counties, where most of the country's EVD cases occurred, were eligible to enroll in a longitudinal cohort. Seven stigma questions were adapted from the People Living with HIV Stigma Index and asked to EVD survivors over the age of 12 at initial visit (median 358 days post-EVD) and 18 months later. Primary outcome was a 7-item EVD-related stigma index. Explanatory variables included age, gender, educational level, pregnancy status, post-EVD hospitalization, referred to medical care and EVD source. Proportional odds logistic regression models and generalized linear mixed-effects models were used to assess stigma at initial visit and over time. The stigma questions were administered to 859 EVD survivors at initial visit and 741 (86%) survivors at follow-up. While 63% of survivors reported any stigma at initial visit, only 5% reported any stigma at follow-up. Over the 18-month period, there was a significant decrease in stigma among EVD survivors (Adjusted Odds Ratio [AOR], 0.02; 95% Confidence Interval [CI], 0.01-0.04). At initial visit, having primary, junior high or vocational education, and being referred to medical care was associated with higher odds of stigma (educational level: AOR, 1.82; 95%CI, 1.27-2.62; referred: AOR, 1.50; 95%CI, 1.16-1.94). Compared to ages of 20-29, those who had ages of 12-19 or 50+ experienced lower odds of stigma (12-19: AOR, 0.32; 95%CI, 0.21-0.48; 50+: AOR, 0.58 95%CI, 0.37-0.91). Our data suggest that EVD-related stigma was much lower more than a year after active Ebola transmission ended in Liberia. Among survivors who screened negative for stigma, additional probing may be considered based on age, education, and referral to care.

Enlist community members to find and support cases — trust is crucial to containment. Enlist community members to find and support cases — trust is crucial to containment. Mosoka P. Fallah

Due to the high unemployment rate in Liberia, many individuals engage in waste scavenging as a means of survival. These scavengers are exposed to various hazards, including infections, respiratory illnesses, and accidents, often operating in unsafe environments without protective equipment. This study applied the Job Demands-Resources (JD-R) Theory to examine how the work environment mediates the relationship between occupational hygiene practices and health and safety among waste scavengers. The sample size was determined using Cochran’s formula for an unknown population, and data were collected from 384 waste scavengers in Liberia through snowball sampling. Partial Least Squares Structural Equation Modeling (PLS-SEM), specifically the bootstrapping method, was employed to analyze the data and evaluate both measurement and structural models. The results showed that occupational hygiene practices have a significant positive effect on both health and safety and the work environment. Additionally, the work environment was found to partially mediate the relationship between occupational hygiene practices and health and safety. The study recommends that the government implement regulations to ensure safe working conditions for waste scavengers. These policies should require waste management companies to adopt appropriate hygiene standards, safeguard the environment, and follow proper waste disposal protocols.

Liana Woskie and Mosoka Fallah use the Ebola outbreak in Liberia to better understand the role and consequences of distrust in health systems and how it affects universal health coverage

Antibody titers against a viral pathogen are typically measured using an antigen binding assay, such as an enzyme-linked immunosorbent assay (ELISA), which only measures the ability of antibodies to identify a viral antigen of interest. Neutralization assays measure the presence of virus-neutralizing antibodies in a sample. Traditional neutralization assays, such as the plaque reduction neutralization test (PRNT), are often difficult to use on a large scale due to being both labor and resource intensive. Here we describe an Ebola virus fluorescence reduction neutralization assay (FRNA), which tests for neutralizing antibodies, that requires only a small volume of sample in a 96-well format and is easy to automate. The readout of the FRNA is the percentage of Ebola virus-infected cells measured with an optical reader or overall chemiluminescence that can be generated by multiple reading platforms. Using blinded human clinical samples (EVD survivors or contacts) obtained in Liberia during the 2013-2016 Ebola virus disease outbreak, we demonstrate there was a high degree of agreement between the FRNA-measured antibody titers and the Filovirus Animal Non-clinical Group (FANG) ELISA titers with the FRNA providing information on the neutralizing capabilities of the antibodies.

Filoviruses such as Ebola virus (EBOV) cause outbreaks of viral hemorrhagic fevers for which no FDA-approved vaccines or drugs are available. The 2014-2016 EBOV outbreak in West Africa infected approximately 30,000 people, killing more than 11,000 and affecting thousands more in areas still suffering from the effects of civil wars. Sierra Leone and Liberia reported EBOV cases in every county demonstrating the efficient spread of this highly contagious virus in the well-connected societies of West Africa. In communities, canines are often in contact with people while scavenging for food, which may include sickly bush animals or, as reported from the outbreak, EBOV infected human bodies and excrement. Therefore, dogs may serve as sentinel animals for seroprevalence studies of emerging infectious viruses. Further, due to their proximity to humans, they may have important One Health implications while offering specimens, which may be easier to obtain than human serum samples. Previous reports on detecting EBOV exposure in canines have been limited. Herein we describe a pilot project to detect IgG-responses directed against multiple filovirus and Lassa virus (LASV) antigens in dogs from EBOV affected communities in Liberia. We used a multiplex Luminex-based microsphere immunoassay (MIA) to detect dog IgG binding to recombinant filovirus antigens or LASV glycoprotein (GP) in serum from dogs that were old enough to be present during the EBOV outbreak. We identified 47 (73%) of 64 dog serum samples as potentially exposed to filoviruses and up to 100% of the dogs from some communities were found to have elevated levels of EBOV antigen-binding IgG titers. The multiplex MIA described in this study provides evidence for EBOV IgG antibodies present in dogs potentially exposed to the virus during the 2014-16 outbreak in Liberia. These data support the feasibility of canines as EBOV sentinels and provides evidence that seroprevalence studies in dogs can be conducted using suitable assays even under challenging field conditions. Further studies are warranted to collect data and to define the role canines may play in transmission or detection of emerging infectious diseases.

Despite casting themselves as the protectors of universal human rights, many Euro-American leaders continued to enforce a global order in which the value of life was determined by geography and economic status. Behind visions of jet-setting “disease hunters”, travel bans, and rapid response teams of hazmat-clad scientists and military operatives, there is an assumption that security in HICs could be achieved through systems of surveillance, quarantine, and isolation that aim to confine biological threats posed by “foreign” bodies such that disease burns where it arises without ever reaching “our” shores. [...]these frameworks cannot be substitutes for the urgent task of building wider systems for care and disease prevention, including access to clean air and water, basic income, housing, and environmental regulations alongside medicines and health care. In light of this reality, HIC leaders––in coordination with their LIMC counterparts––must mobilise now to create strong public health systems for both immediate and long-term benefit.