Abstract
The 2014–2016 West Africa Ebola Virus Disease (EVD) Epidemic devastated Guinea’s health system and constituted a public health emergency of international concern. Following the crisis, Guinea invested in the establishment of basic health system reforms and crucial legal instruments for strengthening national health security in line with the WHO’s recommendations for ensuring better preparedness for (and, therefore, a response to) health emergencies. The investments included the scaling up of Integrated Disease Surveillance and Response; Joint External Evaluation of International Health Regulation capacities; National Action Plan for Health Security; Simulation Exercises; One Health platforms; creation of decentralised structures such as regional and prefectural Emergency Operation Centres; Risk assessment and hazard identification; Expanding human resources capacity; Early Warning Alert System and community preparedness. These investments were tested in the subsequent 2021 EVD outbreak and other epidemics. In this case, there was a timely declaration and response to the 2021 EVD epidemic, a lower-case burden and mortality rate, a shorter duration of the epidemic and a significant reduction in the cost of the response. Similarly, there was timely detection, response and containment of other epidemics including Lassa fever and Marburg virus disease. Findings suggest the utility of the preparedness activities for the early detection and efficient containment of outbreaks, which, therefore, underlines the need for all countries at risk of infectious disease epidemics to invest in similar reforms. Doing so promises to be not only cost-effective but also lifesaving.
Keywords: Public Health, Health policy, Control strategies
SUMMARY BOX.
Infectious diseases with epidemic potential, in particular Ebola virus disease (EVD), have demonstrated in Guinea (2014–2016), that a single unidentified transmission chain in a susceptible area (ie, an area with a weak health system and absence of an Early Warning Alert System) can quickly escalate beyond straightforward containment.
The 2014–2016 West African EVD epidemic was a compelling reminder of the need to strengthen preparations in all countries worldwide for improved global health security.
After this 2014–2016 EVD epidemic, the Guinean government and partners invested in strengthening epidemic preparedness and response capacity, which contributed to rapidly detect and respond to several subsequent epidemics.
Health reforms and investment in outbreak preparedness implemented in Guinea after 2014–2016 EVD outbreak collectively served to the early detection of the 2021 EVD outbreak and its rapid control (shorten duration of response and prevent international spread).
Governance and technical autonomy of epidemic response structures are needed as well as building trust with the community for rapid control of epidemics.
Introduction
In recent decades, emerging infectious disease outbreaks have occurred at an increasing scale and frequency.1 Along with the recent and ongoing COVID-19 pandemic, these outbreaks should be a wake-up call for all countries to invest in preparedness to avoid their health systems being overwhelmed during health crises.2
Such preparedness activities may seem out of reach especially where health systems generally perform poorly like most African countries,3 which are also prone to epidemics. During the COVID-19 pandemic, low-income groups were more affected in terms of morbidity and mortality. Furthermore, gender inequalities and family violence also increased during lockdowns further impacting on women.4 Epidemics can also create or incur indirect economic losses such as workforce absenteeism, wages not earned, lower tax revenue, informal health costs (eg, for patient transport), negative impacts on human resources for health, losses in the agriculture sector, reduced tourism and travel, reduced trade and retail activity, environmental impacts and/or educational losses, all of which can serve to exacerbate existing inequalities, especially for marginalised populations.5 6
One profound example of these consequences of global health inequalities is the 2014–2016 EVD epidemic in West Africa. The epidemic exposed major health system weaknesses including severe shortages of skilled health workers and a general lack of preparedness within the health system for the prevention, detection and containment of the outbreak at its source.7 8 Subsequently, the largest, longest and deadliest outbreak of EVD in human history occurred, causing 28 652 infections and resulting in 11 325 deaths across 10 countries with 99% of fatalities occurring in three neighbouring countries: Guinea, Sierra Leone and Liberia.9 The direct fiscal costs of the 2014 EVD epidemic were estimated to be around 6 billion USD, while the estimated economic burden ranged from 2.8 to 32.6 billion USD in lost gross domestic product.10
Investment in epidemic preparedness is crucial, because its cost is small compared with the unmitigated impact of a health emergency.1 Adequate investment in epidemic preparedness capacities can help communities and countries avoid or at least minimise the impacts of outbreaks. However, as the results of this investment in preparedness are not immediate and visible (especially when successful),7 many governments inadequately invest in building preventative capacities and implementing preventive interventions during the ‘preoutbreak’ period.11
Nevertheless, building on lessons learnt from the West African EVD disaster, and in line with the Joint external evaluation (JEE) report of International Health Regulations, 2005 (IHR, 2005) core capacities,12 Guinea invested in preparedness and health emergency management capacity after the 2014–2016 EVD epidemic.13 The country then was able to rapidly detect and respond to several epidemics from 2017 to 2020, including yellow fever, measles, anthrax, Lassa fever, food-borne illness, circulating vaccine-derived poliovirus type 2 (cVDPV2) and COVID-19.14 The country has also been stress testing its capacity to respond to several concurrent epidemics (yellow fever, COVID-19, EVD, Lassa fever and Marburg virus disease) from 2020 to 2021. This latest EVD outbreak declared on 14 February 2021 was reported in Nzerekore, near the epicentre of the previous outbreak15 and lasted only 5 months.
Based on field experience, as a result of participating in both EVD outbreaks as well as other outbreaks and preparedness capacity building activities, we described in this paper, health system reforms conducted in Guinea before, during and after the 2021 EVD outbreak that may have contributed to a more effective response and its rapid containment.
The ‘preoutbreak’ period (from the end of 2014–2016 EVD outbreak leading up to the 2021 EVD outbreak)
The 2014–2016 EVD epidemic evidenced the need for the affected countries, and other low-income countries with similarly weak health systems, to build stronger health systems and surveillance mechanisms in order to prevent future outbreaks from escalating in a similar fashion.16 Accordingly, Guinea implemented WHO recommendations by maintaining 90 days of postepidemic enhanced surveillance, during which several capacity-building activities, such as Integrated Disease Surveillance and Response (IDSR) cascade trainings from national to community level and data management training for Health District Management Team, were carried out to strengthen the country’s capacities.17 Subsequently, the government achieved key preparedness activities related to IHR core capacities (discussed hereafter).
Scaling up IDSR capacity
Challenges in the transmission and management of surveillance data contributed to the delay in detecting and confirming the EVD outbreak.18 There was a shortage of IDSR-trained public health workers, leading to under-reporting of cases and problems with data completeness, accuracy and reliability.19 In 2015, the Guinean Ministry of Health (MoH) begun IDSR strengthening19 20 to have surveillance and early warning systems that transmitted information from the community level to the health centre level, which was then sequentially relayed to the district level, the regional level and, finally, to the central or national level.
Joint External Evaluation
Guinea conducted its first JEE21 in April 2017 using the third version of the JEE that has 19 technical areas and 48 indicators.12 The JEE helped determine the country’s baseline capacities as required under the IHR (2005). The country was found to have no capacity on 18 indicators, limited capacity on 20 indicators, developed capacity on nine indicators and demonstrated capacity on one indicator. The JEE informed the development of the National Action Plan for Health Security
National Action Plan for Health Security
Guinea’s national health security action plan22 was developed and validated in April 2019 due to extensive work that brought together 19 focal points of the IHR technical areas and partners. This 4-year plan (2019–2023) involved the sectors of health, livestock, environment and the Ministry of Agriculture.23
Simulation exercises (SIMEX)
During the 2014–2016 EVD outbreak in West Africa, WHO and others within the public health community emphasised the need for simulation exercises to ensure that public health emergency response systems were in place to manage the importation of EVD into high-priority, non-affected countries.24
In October 2018, the National Health Security Agency (ANSS) of Guinea, with the support of partners including WHO, organised tabletop exercises and drilled simulation exercises for the response to a possible cholera outbreak. These simulation exercises revealed that the preparedness and response mechanisms including Regional Epidemic Alert and Response Teams (ERARE), Prefectural Epidemic Alert and Response Teams (EPARE), Epidemic-prone diseases Treatment Centers (CT-Epi), Public Health Emergency Operations Centers (PHEOCs) are in place and capable of being operational at any time. Additionally, the strong involvement of the administrative and political authorities and the commitment of the communities in the localities visited revealed their interest in the emergency response teams.25
One health
In the wake of the 2014–2016 EVD outbreak, Guinea was targeted for substantial support and capacity building from the USA and other nations to facilitate the recovery and renewal of its health system incorporating a One Health approach.26 27 In November 2016, an interministerial meeting held in Dakar, Senegal, resulted in formalised commitments from the three nations (Guinea, Liberia and Sierra Leone) to strengthen resilience to health threats by establishing a Regional Strategic Roadmap to institutionalise the One Health approach. Since then, Guinea has made significant progress towards establishing National One Health platforms to coordinate health security interventions in collaboration with international partners.28
Creation of decentralised structures
Based on experiences in the 2014–2016 EVD epidemic in Guinea, the ANSS acquired decentralised structures for its operationalisation. They include 8 ERARE; 33 EPARE; 33 CT-Epi and 33 PHEOCs. Normative documents were developed to guide and assist the staff of these facilities.25
Risk assessment and hazard identification
Guinea conducted a risk assessment in October 2017 to develop a multihazard plan as recommended by the JEE report.12 The exercise involved a risk assessment and vulnerability mapping in the country, using the Strategic Tools for Assessing Risk and Vulnerability Risk Assessment and Mapping approach. Six hazards with a high risk of occurrence and impact on communities in Guinea, including EVD, were identified29 and a multihazards plan developed.
Expanding human resource capacity
The state of the Guinean health workforce is one of the country’s bottlenecks in advancing health outcomes. The 2014–2015 EVD outbreak provided a policy window to invest in the workforce and reform the health system.13 The Government of Guinea launched its Field Epidemiology Training Programme (FETP) in 2016. Since then, it has graduated 179 staff from the frontline (ie, district-level) programme and 16 from the intermediate programme and 10 advanced FETP graduates who participated in the Burkina Faso (Formerly West Africa) Field Epidemiology and Laboratory Training Programme.30
Strengthening community preparedness
In the 2014–2016 post—Ebola agenda—setting for health system strengthening, the MoH Guinea recruited 5000 Healthcare Workers (HCW) and deployed in rural areas. A number of health centres were rehabilitated and logistics support provided to health districts for field activities, such as vaccination campaigns and training, and local contracting of 10–15 community health workers per subdistrict for epidemic-prone diseases surveillance.31
The outbreak period (14 February 2021 to 19 June 2021)
On the 14 February 2021, a case of EVD was identified in N’zerekore. Thereafter, reactive interventions—including establishing an Emergency Operations Centre (EOC); the reinforcement of an Early Warning Alert System (EWAR); and the reinforcement of active readiness capabilities in districts adjacent to N’zerekore were set up to contain the 2021 EVD outbreak.
Emergency operation centres
Once EVD was detected, it was crucial to have a well-prepared workforce (sufficient in both skills and numbers); updated response plan; standard operating procedures (SOPs) and protocols for field epidemiology and laboratory investigations, case identification, management, and contact tracing protocols. These SOPs and protocols were implemented through functional EOC that provided leadership with clear lines of command and with daily review of the outbreak.7 EOC activation procedures and outbreak management were coordinated mainly at district and regional (Nzerekore) in 2021.
Early Warning Alert System
EWAR32 help in: detecting the first case of the disease in a population previously free of disease; detecting new cases in an area already affected by disease; detecting of an abnormal increase in the level of a disease normally present from a baseline level in a timely fashion; screening for individual cases of a non-communicable disease; and first detecting an invasive species in an area previously free of that species.33
In Guinea, the WHO supported the strengthening of the alert system.34 A green number (a toll-free telephone line) was set up over the outbreak period that community members could call to alert the health system of any health event in the community, including but not limited to EVD-related concerns.
Active readiness in non-affected health districts
Based on the conclusion of the WHO rapid risk assessment (a very high risk at the national level, an increased risk at the regional level, and a low risk at the global level); and considering lessons learnt from prior EVD experiences (including the need to move fast and use national expertise much as possible), dedicated full response capacity was rapidly established in N’zerekore—the areas of active transmission. Additionally, an active response mode in the six health districts bordering N’zerekore was also developed and implemented, due to their proximity to known cases. Scaling up active readiness in other health districts and regions also occurred through reinforcing the existing IDSR mechanism with daily alerts and reporting.
The 2021 EVD post-outbreak 90 day’s surveillance period
The ANSS and the WHO maintained enhanced vigilance in the region until the end of the 90 days following the declaration of the end of the EVD epidemic in Guinea. Additionally, as part of the monitoring and evaluation of ’HR’s capacities, the Guinean MoH with technical support of WHO conducted the After-Action Review of three outbreaks (EVD in Nzerekore, Marburg virus disease in Gueckedou and Yellow Fever in Koundara) in December 2021.35 Lessons learnt and best practices identified during this exercise will help to improve the country preparedness for better response to future outbreaks.
Was Guinea better prepared for the 2021 EVD outbreak?
Timely outbreak response
The 2014–2016 West Africa EVD outbreak went on unobserved for over 3 months36; the outbreak that began in December 2013 was not officially declared until 23 March 2014 despite the first alert being issued on 24 January 2014. Further, the declaration of a Public Health Issue of International Concern (PHEIC), which would motivate financial and logistic support to the countries most affected and elevated the emergency to one demanding global attention, was not declared until 8 August 2014.37 On 7 March 2015, the WHO (in collaboration with MERCK) availed the only advanced experimental vaccine, a full year after the epidemic’s onset, as part of a clinical trial.38 The Report of the EVD Interim Assessment Panel commissioned by the WHO stated that there were “significant and unjustifiable delays occurred in the declaration” in relation to the delay between the WHO being informed of the 2014–2016 EVD epidemic in West Africa and declaring it a PHEIC.39
During the 2021 EVD outbreak, the national health authorities and the WHO rapidly reacted on notification of the suspected epidemic.40 The outbreak that commenced on 15 January 2021 (the date of symptoms onset of the first case) was reported as an alert on 28 January 2021, after a cluster of deaths in the sub-prefecture of Gouécké, N’zerekore Region. The official outbreak declaration was made on 14 February 2021, that is, within 2 weeks after alert reporting and at the same day the WHO activated its emergency procedures to support the response41 (figure 1).
Figure 1.
Timelines of the major events during the 2014–2016 (blue) and 2021 (green) EVD outbreaks in Guinea. EVD, Ebola Virus Disease; PHEIC, Public Health Issue of International Concern.
Following the declaration, a swift outbreak response was enacted with the deployment of a national support team from ANSS rapidly to thoroughly conduct an investigation of the confirmed cases and roll out specific tools for rapid epidemic control.40 With the support of WHO, the government availed vaccines that were already in existence on 23 February 2021, that is, within 1 week of the outbreak declaration. The two new Food and Drug Administration-approved therapeutic drugs (Mab-114 and Regeneron) for EVD were availed to treat eight of the confirmed EVD cases, all of whom survived.
The country opened an isolation centre within 48 hours of the declaration of the outbreak, compared with the 3 weeks it took following declaration of the 2014–2016 West Africa EVD epidemic.42
Efficient contact tracing and case investigations
The newly trained FETP graduates played leading roles in response to the 2021 EVD outbreak in the south-eastern part of the country, including alert validation, case investigations, active case finding, contact tracing, and data management. Their contributions as well as those of the community workers in local one-health platforms, led to the successful follow-up of>95% of EVD contacts, an essential component of successful EVD response.30 The one-health platforms contributed to the investigation of the source of the outbreak that is reportedly to be a persistent virus linked to the 2014–2016 EVD outbreak but not a new spillover from animal to humans.15
A reduction in the case fatality rate
The disease incidence and lethality was reduced.40 The overall lethality decreased from 2544/3814 (67%) in the 2014–2016 epidemic, to 12/23 (52%) in the 2021 outbreak, while the lethality of confirmed cases was reduced from 62% in 2014–2016 to just 31% in 2021. While this may be due to more readily accessible vaccination and therapeutic interventions, the rapid availability of these interventions nevertheless rested on the preparedness activities undertaken in Guinea before the 2021 outbreak (table 1).
Table 1.
Summary of the Case Fatality Rate (CFR) for the first and second EVD outbreaks in Guinea
| EVD cases | Year of outbreak | |||||
| 2014–2016 | 2021 | |||||
| Number of cases | Number of deaths | Case fatality rate (CFR) | Number of cases | Number of deaths | Case fatality rate (CFR) | |
| Confirmed cases | 3358 | 2088 | 62%* | 16 | 5 | 31%* |
| Probable cases | 456 | 456 | – | 7 | 7 | – |
| Total number | 3814 | 2544 | 67%† | 23 | 12 | 52%† |
*CFR among confirmed EVD cases.
†Global CFR.
CFR, Case Fatality Rate; EVD, Ebola Virus Disease.
Shorter duration of the outbreak
The 2014–2016 West Africa EVD epidemic was controlled after more than 2 years, while the 2021 epidemic only lasted 5 months (figure 2). While the first one cost billions of dollars,10 the second one cost around 45 million.43
Figure 2.
Comparison of the epidemiological curves of the two EVD outbreaks 2014–2016 and 2021 in Guinea. EVD, Ebola Virus Disease.
Rapid control of the spread of the outbreak
While the initial outbreak spread over to 30 out of 38 Health Districts in the country, the subsequent outbreak was contained within one health district (figure 3).
Figure 3.
Comparison of the spread of the two EVD outbreaks 2014–2016 and 2021 in Guinea. EVD, Ebola Virus Disease; MoH, Ministry of Health.
Early detection of other epidemics
The extension of EVD surveillance into neighbouring districts identified a unique case of Lassa Fever and SARS-CoV-2 coinfection in a patient from Yomou prefecture in southeast Guinea on 6 May 2021. An alert was raised regarding the individual whose signs and symptoms of illness were commensurate with EVD infection followed prompt declaration of a Lassa fever epidemic and the rapid implementation of control measures to limit the virus’ spread in Guinea.44
In addition, a Marburg virus disease (MVD) outbreak was confirmed in Gueckedou on 9 August 2021. This is the first time it has been detected in Guinea and West Africa. An improved preparedness confined this case to a single confirmed case.45
What was the overall effect of health reforms on epidemics detection and response?
Admittedly, Guinea seemed better prepared for the 2021 epidemic than in 2014–216. While the impact of enhanced preparedness and response activities contributed to the early detection of and response to other epidemics such as yellow fever, measles, anthrax, Lassa fever, food-borne illness, cVDPV2,14 the institutional reforms undertaken had mixed effects on the COVID-19 response.46 47 Guinea delayed in declaring and taking strong action for political reasons, as 2020 was an election year. The president of the independent national electoral commission was one of the early and most visible victims.48
Furthermore, trust between political authorities and communities is never guaranteed. For instance, the community deaths reported in the village of Kpaghalaye during the 2021 epidemic,49 which resulted in the latest confirmed case preferring to remain hidden in the community until he recovered as opposed to accepting admission to the treatment centre.
Thus, governance and technical autonomy of epidemic response structures as well as building trust with the community are needed in addition to health sector reforms to improve emergency preparedness.
Conclusion
While specifically appraising the epidemiological consequences of any one intervention is not possible, the overall effect may indicate such activities represent important preparedness and early warning investments that all countries at risk of epidemics should consider. The WHO Regional Office for Africa’s (AFRO’s) three flagship projects which incorporate lessons learned from COVID-19, EVD, and other health emergencies is a viable model for Member States to develop their capacities to prepare for, detect and respond to public health emergencies.50
Footnotes
Handling editor: Seye Abimbola
Twitter: @morykeita1980, @jonny_polonsky, @godjedoprimous
Contributors: MK conceptualised the manuscript and wrote the first draft. All authors contributed to the conceptualisation of the manuscript, and revised and critically reviewed drafts. MK and BB edited the final draft. All authors approved the final draft for submission.
Funding: O.Keiser was supported by the Swiss National Science Foundation (Grant number PP00P3_202660)
Map disclaimer: The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Data availability statement
Data are available upon request.
Ethics statements
Patient consent for publication
Not applicable.
Ethics approval
Not applicable.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are available upon request.