Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Feb 13;18(1):248.
doi: 10.1186/s12889-018-5158-6.

The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone

Grazia Caleo  1   2 , Jennifer Duncombe  3 , Freya Jephcott  4 , Kamalini Lokuge  5   6 , Clair Mills  3 , Evita Looijen  3 , Fivi Theoharaki  5 , Ronald Kremer  3 , Karline Kleijer  3 , James Squire  7 , Manjo Lamin  7 , Beverley Stringer  8 , Helen A Weiss  9 , Daniel Culli  5 , Gian Luca Di Tanna  10 , Jane Greig  5
Affiliations

The factors affecting household transmission dynamics and community compliance with Ebola control measures: a mixed-methods study in a rural village in Sierra Leone

Grazia Caleo et al. BMC Public Health. .

Abstract

Background: Little is understood of Ebola virus disease (EVD) transmission dynamics and community compliance with control measures over time. Understanding these interactions is essential if interventions are to be effective in future outbreaks. We conducted a mixed-methods study to explore these factors in a rural village that experienced sustained EVD transmission in Kailahun District, Sierra Leone.

Methods: We reconstructed transmission dynamics using a cross-sectional survey conducted in April 2015, and cross-referenced our results with surveillance, burial, and Ebola Management Centre (EMC) data. Factors associated with EVD transmission were assessed with Cox proportional hazards regression. Following the survey, qualitative semi-structured interviews explored views of community informants and households.

Results: All households (n = 240; 1161 individuals) participated in the survey. 29 of 31 EVD probable/confirmed cases died (93·5% case fatality rate); six deaths (20·6%) had been missed by other surveillance systems. Transmission over five generations lasted 16 weeks. Although most households had ≤5 members there was a significant increase in risk of Ebola in households with > 5 members. Risk of EVD was also associated with older age. Cases were spatially clustered; all occurred in 15 households. EVD transmission was better understood when the community experience started to concord with public health messages being given. Perceptions of contact tracing changed from invading privacy and selling people to ensuring community safety. Burials in plastic bags, without female attendants or prayer, were perceived as dishonourable. Further reasons for low compliance were low EMC survival rates, family perceptions of a moral duty to provide care to relatives, poor communication with the EMC, and loss of livelihoods due to quarantine. Compliance with response measures increased only after the second generation, coinciding with the implementation of restrictive by-laws, return of the first survivor, reduced contact with dead bodies, and admission of patients to the EMC.

Conclusions: Transmission occurred primarily in a few large households, with prolonged transmission and a high death toll. Return of a survivor to the village and more effective implementation of control strategies coincided with increased compliance to control measures, with few subsequent cases. We propose key recommendations for management of EVD outbreaks based on this experience.

Keywords: Community perception; Ebola virus disease; Transmission dynamics.

PubMed Disclaimer

Conflict of interest statement

Authors’ information

GC, JG, FT, DC, KL are associated with the Manson Unit, Médecins Sans Frontières (MSF).

KL is associated with the National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University.

JD, CM, EL, RK, KK are associated with Médecins Sans Frontières (MSF) Amsterdam.

FJ is associated with the Department of Veterinary Medicine, University of Cambridge.

JS, ML are associated with the District Health Management Team, Ministry of Health and Sanitation, Kailahun, Sierra Leone.

BS is associated with Médecins Sans Frontières (MSF) London.

HW is associated with MRC Tropical Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine.

GDT is associated with the Centre for Primary Care and Public Health, Queen Mary University of London.

Ethics approval and consent to participate

The study protocol was approved by the Ethics Review Board of MSF, the Internal Review Board of the Sierra Leone MoHS, and The London School of Hygiene & Tropical Medicine (LSHTM). Verbal consent for participation was obtained from the head of each household after a briefing about the aim of the survey, the questions and duration of the questionnaire, and the option to end the interview at any time if wished.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
EVD transmission generation, according to week of onset
Fig. 2
Fig. 2
Geographical distribution of cases over time, weeks 29 –week 45
See this image and copyright information in PMC

References

    1. Sierra Leone: How Kailahun district kicked Ebola out [Internet]. 2014 [cited 10 Apr 2017]. Available from: http://www.who.int/features/2014/kailahun-beats-ebola/en/
    1. Sierra Leone: Kailahun District Profile (3 December 2015) [Internet]. 2015 [cited 10 Apr 2017]. Available from: http://reliefweb.int/sites/reliefweb.int/files/resources/district_profil....
    1. Ebola in Sierra Leone: A slow start to an outbreak that eventually outpaced all others [Internet]. 2015 [cited 10 Jan 2017]. Available from: http://www.who.int/csr/disease/ebola/one-year-report/sierra-leone/en/.
    1. Dallatomasina S, Crestani R, Squire JS, Declerk H, Caleo GM, Wolz A, et al. Ebola outbreak in rural West Africa: epidemiology, clinical features and outcomes. Tropical Med Int Health. 2015;20(4):448–454. doi: 10.1111/tmi.12454. - DOI - PMC - PubMed
    1. Lokuge K, Caleo G, Greig J, Duncombe J, McWilliam N, Squire J, et al. Successful control of Ebola virus disease: analysis of service based data from rural Sierra Leone. PLoS Negl Trop Dis. 2016;10(3):e0004498. doi: 10.1371/journal.pntd.0004498. - DOI - PMC - PubMed

Publication types