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Ahead of Print -Evaluation of the Benefits and Risks of Introducing Ebola Community Care Centers, Sierra Leone - Volume 21, Number 3—March 2015 - Emerging Infectious Disease journal - CDC

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Ahead of Print -Evaluation of the Benefits and Risks of Introducing Ebola Community Care Centers, Sierra Leone - Volume 21, Number 3—March 2015 - Emerging Infectious Disease journal - CDC

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Thumbnail of Structure of transmission model used to evaluate the benefits and risks of introducing CCCs into Western Area, Sierra Leone. Persons start off being susceptible to infection (S). Upon infection with Ebola virus, they enter an incubation period (E), and at symptom onset, they become infectious in the community (I+). After this point, infected persons seek health care in CCCs or ETCs; if centers are full, the infectious persons remain in the community until the infection is resolved (

Figure 1. Structure of transmission model used to evaluate the benefits and risks of introducing CCCs into Western Area, Sierra Leone. Persons start off being susceptible to infection (S). Upon infection with Ebola...

Volume 21, Number 3—March 2015


Evaluation of the Benefits and Risks of Introducing Ebola Community Care Centers, Sierra Leone

Adam J. KucharskiComments to Author , Anton Camacho, Francesco Checchi, Ron Waldman, Rebecca F. Grais, Jean-Clement Cabrol, Sylvie Briand, Marc Baguelin, Stefan Flasche, Sebastian Funk, and W. John Edmunds
Author affiliations: London School of Hygiene and Tropical Medicine, London, UK (A.J. Kucharski, A. Camacho, M. Baguelin, S. Flasche, S. Funk, W.J. Edmunds)Save the Children, London (F. Checchi)Milken Institute School of Public Health, George Washington University, Washington, DC, USA (R. Waldman)Epicentre, Paris, France (R.F. Grais)Médecins sans Frontières, Geneva, Switzerland (J.-C. Cabrol)World Health Organization, Geneva (S. Briand)


In some parts of western Africa, Ebola treatment centers (ETCs) have reached capacity. Unless capacity is rapidly scaled up, the chance to avoid a generalized Ebola epidemic will soon diminish. The World Health Organization and partners are considering additional Ebola patient care options, including community care centers (CCCs), small, lightly staffed units that could be used to isolate patients outside the home and get them into care sooner than otherwise possible. Using a transmission model, we evaluated the benefits and risks of introducing CCCs into Sierra Leone’s Western Area, where most ETCs are at capacity. We found that use of CCCs could lead to a decline in cases, even if virus transmission occurs between CCC patients and the community. However, to prevent CCC amplification of the epidemic, the risk of Ebola virus–negative persons being exposed to virus within CCCs would have to be offset by a reduction in community transmission resulting from CCC use.
The current epidemic of Ebola virus disease in western Africa has resulted in thousands of cases during 2014 (1). To date, Ebola treatment centers (ETCs) have been used to isolate patients and provide clinical care. These facilities typically have large capacity (some have >100 beds) and function under high levels of infection control. However, in Sierra Leone, ETCs have reached capacity, and patients are being turned away (1). The reproduction number (defined as the average number of secondary cases generated by a typical infectious person) has been >1 in Sierra Leone, leading to growth in the number of cases reported each week (24). As a result, there is an urgent need to rapidly scale up treatment and isolation facilities. Delays in implementation will result in falling further behind the epidemic curve and in an even greater need for patient care facilities.
ETCs are complex facilities that require a substantial number of staff and time to set up; thus, the World Health Organization and other partners are looking at additional care options to supplement existing ETCs. One approach is the use of Ebola community care centers (CCCs), which would represent a possible change in operational approach (57). As envisioned in the World Health Organization approach, CCCs would be small units with 3–5 beds and would be staffed by a small group of health care workers. The main objective would be to isolate patients outside the home and, hence, reduce the movement and contacts of infectious persons within the community. CCCs are designed to engage the community and to increase the acceptance of isolation. Care for patients in CCCs would be provided primarily by a caregiver who would be given personal protective equipment (PPE) and basic patient care training. Patients would be free to leave the unit while awaiting test results. The specific utilization of CCCs would vary, depending on local context, and units would form part of a package of interventions, including monitoring of community contacts and burials within the community.
CCCs would be easier to set up than ETCs because they would be lightly staffed and could be made from local materials or even tents. Thus, CCCs have the potential to more rapidly begin treating patients. At present in Sierra Leone, the average time from symptom onset to hospitalization for Ebola virus disease patients is 4.6 days, which means patients remain in the community until the late stage of the disease (4). However, the use of CCCs has potential risks: the number of cases could be amplified if Ebola virus–negative patients in CCC assessment areas are exposed to infectious persons before admission, and virus could be transmitted between patients and caregivers or others in the community if virus containment within the CCC is not perfect. Given the urgent need for new operational solutions for Ebola patient care, it is critical to assess the conditions under which CCCs might exacerbate or mitigate the epidemic and to compare the scale-up of CCCs with the expansion of ETCs or home care.
We used an Ebola virus transmission model to evaluate the relative benefits and risks of introducing CCCs in a situation similar to that in Western Area, an administrative division of Sierra Leone. Western Area has exhibited consistent exponential growth in reported cases, and ETCs in the area are at capacity (1). Expert elicitation was used to estimate plausible values for key model parameters; these values were compared with simulation results to establish whether CCCs could be beneficial. We also estimated how many CCC beds, either alone or in combination with additional ETC beds, would be required to potentially turn over the epidemic (i.e., reduce the reproduction number below the critical threshold of 1).

Dr. Kucharski is a research fellow in infectious disease epidemiology at London School of Hygiene and Tropical Medicine. His research focuses on the dynamics of emerging infections and how population structure and social behavior shape disease transmission.


Funding was provided by the Medical Research Council (fellowships: MR/J01432X/1 to A.C., MR/K021524/1 to A.J.K., and MR/K021680/1 to S.F.) and the Research for Health in Humanitarian Crises (R2HC) Programme, managed by the Research for Humanitarian Assistance (grant no. 13165).


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Suggested citation for this article: Kucharski AJ, Camacho A, Checchi F, Waldman R, Grais RF, Cabrol JC, et al. Evaluation of the benefits and risks of introducing Ebola community care centers, Sierra Leone. Emerg Infect Dis. 2015 Mar [date cited]. http://dx.doi.org/10.3201/eid2103.141892
DOI: 10.3201/eid2103.141892

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