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Concept: Sierra Leone

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Future infectious disease epidemics are likely to disproportionately affect countries with weak health systems, exacerbating global vulnerability. To decrease the severity of epidemics in these settings, lessons can be drawn from the Ebola outbreak in West Africa. There is a dearth of literature on public perceptions of the public health response system that required citizens to report and treat Ebola cases. Epidemiological reports suggested that there were delays in diagnosis and treatment. The purpose of our study was to explore the barriers preventing Sierra Leoneans from trusting and using the Ebola response system during the height of the outbreak.

Concepts: Epidemiology, Infectious disease, West Africa, Ghana, Liberia, Atlantic slave trade, Sierra Leone, Guinea

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Between September 2014 and February 2015, the number of Ebola virus disease (EVD) cases reported in Sierra Leone declined in many districts. During this period, a major international response was put in place, with thousands of treatment beds introduced alongside other infection control measures. However, assessing the impact of the response is challenging, as several factors could have influenced the decline in infections, including behavior changes and other community interventions. We developed a mathematical model of EVD transmission, and measured how transmission changed over time in the 12 districts of Sierra Leone with sustained transmission between June 2014 and February 2015. We used the model to estimate how many cases were averted as a result of the introduction of additional treatment beds in each area. Examining epidemic dynamics at the district level, we estimated that 56,600 (95% credible interval: 48,300-84,500) Ebola cases (both reported and unreported) were averted in Sierra Leone up to February 2, 2015 as a direct result of additional treatment beds being introduced. We also found that if beds had been introduced 1 month earlier, a further 12,500 cases could have been averted. Our results suggest the unprecedented local and international response led to a substantial decline in EVD transmission during 2014-2015. In particular, the introduction of beds had a direct impact on reducing EVD cases in Sierra Leone, although the effect varied considerably between districts.

Concepts: Infectious disease, Mathematics, Introduction, Ebola, Viral hemorrhagic fever, Malaise, Sierra Leone

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Agroforestry systems and tree cover on agricultural land make an important contribution to climate change mitigation, but are not systematically accounted for in either global carbon budgets or national carbon accounting. This paper assesses the role of trees on agricultural land and their significance for carbon sequestration at a global level, along with recent change trends. Remote sensing data show that in 2010, 43% of all agricultural land globally had at least 10% tree cover and that this has increased by 2% over the previous ten years. Combining geographically and bioclimatically stratified Intergovernmental Panel on Climate Change (IPCC) Tier 1 default estimates of carbon storage with this tree cover analysis, we estimated 45.3 PgC on agricultural land globally, with trees contributing >75%. Between 2000 and 2010 tree cover increased by 3.7%, resulting in an increase of >2 PgC (or 4.6%) of biomass carbon. On average, globally, biomass carbon increased from 20.4 to 21.4 tC ha(-1). Regional and country-level variation in stocks and trends were mapped and tabulated globally, and for all countries. Brazil, Indonesia, China and India had the largest increases in biomass carbon stored on agricultural land, while Argentina, Myanmar, and Sierra Leone had the largest decreases.

Concepts: Climate change, Forestry, Remote sensing, Globalization, Global warming, Carbon capture and storage, Sierra Leone, Agroforestry

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The current outbreak of Ebola Virus Disease in Upper West Africa is the largest ever recorded. Molecular evidence suggests spread has been almost exclusively through human-to-human contact. Social factors are thus clearly important to understand the epidemic and ways in which it might be stopped, but these factors have so far been little analyzed. The present paper focuses on Sierra Leone, and provides cross sectional data on the least understood part of the epidemic-the largely undocumented spread of Ebola in rural areas. Various forms of social networking in rural communities and their relevance for understanding pathways of transmission are described. Particular attention is paid to the relationship between marriage, funerals and land tenure. Funerals are known to be a high-risk factor for infection. It is suggested that more than a shift in awareness of risks will be needed to change local patterns of behavior, especially in regard to funerals, since these are central to the consolidation of community ties. A concluding discussion relates the information presented to plans for halting the disease. Local consultation and access are seen as major challenges to be addressed.

Concepts: Understanding, West Africa, Ghana, Viral hemorrhagic fever, Malaise, Incubation period, Liberia, Sierra Leone

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Background On March 23, 2014, the World Health Organization (WHO) was notified of an outbreak of Ebola virus disease (EVD) in Guinea. On August 8, the WHO declared the epidemic to be a “public health emergency of international concern.” Methods By September 14, 2014, a total of 4507 probable and confirmed cases, including 2296 deaths from EVD (Zaire species) had been reported from five countries in West Africa - Guinea, Liberia, Nigeria, Senegal, and Sierra Leone. We analyzed a detailed subset of data on 3343 confirmed and 667 probable Ebola cases collected in Guinea, Liberia, Nigeria, and Sierra Leone as of September 14. Results The majority of patients are 15 to 44 years of age (49.9% male), and we estimate that the case fatality rate is 70.8% (95% confidence interval [CI], 69 to 73) among persons with known clinical outcome of infection. The course of infection, including signs and symptoms, incubation period (11.4 days), and serial interval (15.3 days), is similar to that reported in previous outbreaks of EVD. On the basis of the initial periods of exponential growth, the estimated basic reproduction numbers (R0 ) are 1.71 (95% CI, 1.44 to 2.01) for Guinea, 1.83 (95% CI, 1.72 to 1.94) for Liberia, and 2.02 (95% CI, 1.79 to 2.26) for Sierra Leone. The estimated current reproduction numbers ® are 1.81 (95% CI, 1.60 to 2.03) for Guinea, 1.51 (95% CI, 1.41 to 1.60) for Liberia, and 1.38 (95% CI, 1.27 to 1.51) for Sierra Leone; the corresponding doubling times are 15.7 days (95% CI, 12.9 to 20.3) for Guinea, 23.6 days (95% CI, 20.2 to 28.2) for Liberia, and 30.2 days (95% CI, 23.6 to 42.3) for Sierra Leone. Assuming no change in the control measures for this epidemic, by November 2, 2014, the cumulative reported numbers of confirmed and probable cases are predicted to be 5740 in Guinea, 9890 in Liberia, and 5000 in Sierra Leone, exceeding 20,000 in total. Conclusions These data indicate that without drastic improvements in control measures, the numbers of cases of and deaths from EVD are expected to continue increasing from hundreds to thousands per week in the coming months.

Concepts: Nigeria, West Africa, Ebola, Incubation period, Liberia, Sierra Leone, Economic Community of West African States, Guinea

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We conducted a case-control study in Freetown, Sierra Leone, to investigate ocular signs in Ebola virus disease (EVD) survivors. A total of 82 EVD survivors with ocular symptoms and 105 controls from asymptomatic civilian and military personnel and symptomatic eye clinic attendees underwent ophthalmic examination, including widefield retinal imaging. Snellen visual acuity was <6/7.5 in 75.6% (97.5% CI 63%-85.7%) of EVD survivors and 75.5% (97.5% CI 59.1%-87.9%) of controls. Unilateral white cataracts were present in 7.4% (97.5% CI 2.4%-16.7%) of EVD survivors and no controls. Aqueous humor from 2 EVD survivors with cataract but no anterior chamber inflammation were PCR-negative for Zaire Ebola virus, permitting cataract surgery. A novel retinal lesion following the anatomic distribution of the optic nerve axons occurred in 14.6% (97.5% CI 7.1%-25.6%) of EVD survivors and no controls, suggesting neuronal transmission as a route of ocular entry.

Concepts: Visual acuity, Ophthalmology, Ebola, Viral hemorrhagic fever, Sierra Leone, Freetown, Western Area, Ahmad Tejan Kabbah

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Sierra Leone in West Africa is in a Lassa fever-hyperendemic region that also includes Guinea and Liberia. Each year, suspected Lassa fever cases result in submission of ≈500-700 samples to the Kenema Government Hospital Lassa Diagnostic Laboratory in eastern Sierra Leone. Generally only 30%-40% of samples tested are positive for Lassa virus (LASV) antigen and/or LASV-specific IgM; thus, 60%-70% of these patients have acute diseases of unknown origin. To investigate what other arthropod-borne and hemorrhagic fever viral diseases might cause serious illness in this region and mimic Lassa fever, we tested patient serum samples that were negative for malaria parasites and LASV. Using IgM-capture ELISAs, we evaluated samples for antibodies to arthropod-borne and other hemorrhagic fever viruses. Approximately 25% of LASV-negative patients had IgM to dengue, West Nile, yellow fever, Rift Valley fever, chikungunya, Ebola, and Marburg viruses but not to Crimean-Congo hemorrhagic fever virus.

Concepts: Malaria, Yellow fever, Ribavirin, Fever, Viral diseases, Viral hemorrhagic fever, Lassa fever, Sierra Leone

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Thousands of persons have survived Ebola virus disease. Almost all survivors describe symptoms that persist or develop after hospital discharge. A cross-sectional survey of the symptoms of all survivors from the Ebola treatment unit (ETU) at 34th Regimental Military Hospital, Freetown, Sierra Leone (MH34), was conducted after discharge at their initial follow-up appointment within 3 weeks after their second negative PCR result. From its opening on December 1, 2014, through March 31, 2015, the MH34 ETU treated 84 persons (8-70 years of age) with PCR-confirmed Ebola virus disease, of whom 44 survived. Survivors reported musculoskeletal pain (70%), headache (48%), and ocular problems (14%). Those who reported headache had had lower admission cycle threshold Ebola PCR than did those who did not (p<0.03). This complete survivor cohort from 1 ETU enables analysis of the proportion of symptoms of post-Ebola syndrome. The Ebola epidemic is waning, but the effects of the disease will remain.

Concepts: Epidemiology, Biological warfare, Viral hemorrhagic fever, Incubation period, Sierra Leone, Freetown, Western Area, Ahmad Tejan Kabbah

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The West African cocoa belt, reaching from Sierra Leone to southern Cameroon, is the origin of about 70% of the world’s cocoa (Theobroma cacao), which in turn is the basis of the livelihoods of about two million farmers. We analyze cocoa’s vulnerability to climate change in the West African cocoa belt, based on climate projections for the 2050s of 19 Global Circulation Models under the Intergovernmental Panel on Climate Change intermediate emissions scenario RCP 6.0. We use a combination of a statistical model of climatic suitability (Maxent) and the analysis of individual, potentially limiting climate variables. We find that: 1) contrary to expectation, maximum dry season temperatures are projected to become as or more limiting for cocoa as dry season water availability; 2) to reduce the vulnerability of cocoa to excessive dry season temperatures, the systematic use of adaptation strategies like shade trees in cocoa farms will be necessary, in reversal of the current trend of shade reduction; 3) there is a strong differentiation of climate vulnerability within the cocoa belt, with the most vulnerable areas near the forest-savanna transition in Nigeria and eastern Côte d'Ivoire, and the least vulnerable areas in the southern parts of Cameroon, Ghana, Côte d'Ivoire and Liberia; 4) this spatial differentiation of climate vulnerability may lead to future shifts in cocoa production within the region, with the opportunity of partially compensating losses and gains, but also the risk of local production expansion leading to new deforestation. We conclude that adaptation strategies for cocoa in West Africa need to focus at several levels, from the consideration of tolerance to high temperatures in cocoa breeding programs, the promotion of shade trees in cocoa farms, to policies incentivizing the intensification of cocoa production on existing farms where future climate conditions permit and the establishment of new farms in already deforested areas.

Concepts: Africa, Nigeria, Climate, West Africa, Ghana, Liberia, Sierra Leone, Economic Community of West African States

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Near the end of 2013, an outbreak of Zaire ebolavirus (EBOV) began in Guinea, subsequently spreading to neighboring Liberia and Sierra Leone. As this epidemic grew, important public health questions emerged about how and why this outbreak was so different from previous episodes. This review provides a synthetic synopsis of the 2014-15 outbreak, with the aim of understanding its unprecedented spread. We present a summary of the history of previous epidemics, describe the structure and genetics of the ebolavirus, and review our current understanding of viral vectors and the latest treatment practices. We conclude with an analysis of the public health challenges epidemic responders faced and some of the lessons that could be applied to future outbreaks of Ebola or other viruses.

Concepts: Epidemiology, Nigeria, West Africa, Liberia, Sierra Leone, Economic Community of West African States, Guinea