The counter effects of the Ebola epidemic on control and treatment of HIV/AIDS, tuberculosis, and malaria in West Africa
2016; Lippincott Williams & Wilkins; Volume: 30; Issue: 16 Linguagem: Inglês
10.1097/qad.0000000000001231
ISSN1473-5571
Autores Tópico(s)Global Maternal and Child Health
ResumoThe epidemic of Ebola in 2014–2015 in Guinea, Liberia, and Sierra Leone in West Africa caused a breakdown of healthcare systems, adversely affecting diagnosis and treatment of endemic diseases such as HIV/AIDS, tuberculosis (TB), and malaria, and of vaccination programs and maternal health [1,2]. Although the health systems of these countries had been improving in the years before the epidemic, they were generally in a poor state for quite some time as a result of the civil war in two countries and long-term neglect. They were further paralyzed because of deaths of several healthcare workers early in the epidemic in 2014. There was further disruption caused by some initial large numbers of patients compounded with a reduced staff. That resulted in the closure of many clinics/hospitals and the interruption of routine health delivery services, such as HIV counseling and testing, dispensing the antiretroviral therapy and TB medications, treatment of malaria and delivery of long-lasting insecticide treated-nets, childhood vaccinations, and maternity care. Moreover, further lack of medicines and fear of Ebola transmission at health facilities subsequently decreased outpatient attendance to as low as 10% [3,4]. In addition, the national health authorities imposed city-wide curfews, border closures, and disruption of transportation routes that caused blockade to transportation of medical services and drug supplies. Consequently, reduced availability of healthcare providers and their services in the Ebola-affected regions exacerbated the severity of common illnesses and the number of deaths caused by HIV/AIDS, TB, and malaria [5]. HIV prevalence among persons 15–49 years of age is fairly low in the region: 1.7% in Guinea, 1.1% in Liberia, and 1.6% in Sierra Leone [6,7], and TB prevalence in the three countries is 0.24, 0.44, and 0.43%, respectively [8]. However, malaria is a very serious problem among children less than 5 years of age. The annual incidence of malaria is estimated to be 44% in Guinea, 45% in Liberia, and 43% in Sierra Leone [9–11]. Considering that HIV infection and TB require long-term treatment, and malaria reinfections require repeated treatment, any disruptions of healthcare services that cause interruption of treatment will increase the number of deaths associated with these diseases [12]. The study of functional health facilities conducted in Guinea in 2014 showed that there was a marginal decline in the number of functional facilities in Ebola-affected prefectures as compared with the Ebola-unaffected prefectures. However, there was a significant decline of 33–50% of hospital attendees with each wave of Ebola outbreak in decreasing order of frequency for: fever cases, dispensed oral antimalarial, or administered injectable antimalarial (all decreased by ∼50%). All visits declined by ∼40% [12]. Death from Ebola infection among healthcare workers in Guinea, Liberia, and Sierra Leone has been extensive, with 1.4, 6.8, and 8.1%, respectively, according to the WHO [13]. Evans et al.[14] modeled how the loss of healthcare workers affected maternal, infant, and under-5 mortality in the three countries. The largest effect was on maternal mortality, with increases of 38–111%, relative to pre-Ebola rates, which were already among the highest in the world. The impact on infant and under-5 mortality was more modest, between 10 and 28% [14]. A study conducted in Sierra Leone in 2014 to document effects of Ebola on health service functions showed that in week 21 (when Ebola outbreak occurred), the median number of admissions per facility was 40 [interquartile range (IQR) 20–76]. However, in week 41 (when the study ended), the median number of admissions had dropped to 12 (IQR 4–30) (Fig. 1). This amount equals a 70% drop in the median number of admissions (P value = 0.005). Similarly, in week 21, the median number of major surgeries was six (IQR 2–14) that fell to median 3 (IQR 0–6) in week 41. This amount equals a 50% drop in the median number of major surgeries (P value = 0.014) [15]. To demonstrate the counter effects of the Ebola epidemic on several health indicators, synthesis of data from several studies are presented in Table 1.Fig. 1: Median (a) and total number (b) of admissions and median (c) and total number (d) of surgeries by week in Sierra Leone until week 41 in 40 health facilities.This is compared with occurrence of Ebola cases (WHO data in golden shade). Reproduced with permission from [15].Table 1: Synthesis of data from several studies to demonstrate the counter effects of the Ebola epidemic in three countries.Another study [16] published by the Centers for Disease Control-Atlanta (CDC) to estimate the indirect health burden of the Ebola epidemic in Guinea, Liberia, and Sierra Leone in 2014–2015 used computational simulation models for HIV, TB, and malaria. The deaths were then calibrated for interruption in treatment and health services because of the Ebola epidemic [17–27]. For HIV/AIDS estimates for 15–49 year olds, the study assumed 50% reduction in antiretroviral therapy coverage because of disruption of health services caused by the Ebola epidemic. Thus, the excess death rates in Guinea, Liberia, and Sierra Leone were estimated for HIV/AIDS to be 16.2, 13.0, and 9.1%, respectively. This number translates to absolute excess deaths of 713, 155, and 223, respectively [16]. For cases of TB, the study assumed that persons with drug-sensitive TB who received treatment will either be successfully treated, be unsuccessfully treated and remain alive with latent TB, or death will occur. Those with drug-sensitive TB who experience treatment failure may progress to multidrug-resistant TB. They will then present for treatment for multidrug-resistant TB for which adequate treatment is required for 24 months [28]. The excess death rates in Guinea, Liberia, and Sierra Leone were estimated for 50% reduced coverage of TB treatment to be 51.1, 59.0, and 61.4%, respectively. That number translates to absolute excess deaths of 1281, 592, and 841, respectively [16]. Similarly, the CDC study has estimated the death rate of malaria among children less than 5 years of age. In Africa, the treatment model for uncomplicated malaria is still based on presumptive diagnosis using clinical symptoms rather than formal medical diagnosis, and malaria medication is generally purchased from a drug store [29,30]. Hence, closure of health services caused by Ebola epidemic would have affected hospitalization and treatment of cerebral/severe malaria. The excess death rates in Guinea, Liberia, and Sierra Leone were estimated for a 50% reduced coverage of treatment of severe malaria to be 48.0, 53.6, and 50.0%, respectively: net number translates to absolute excess deaths of 4 275 788 and 1755, respectively [16]. The sensitivity analysis study [31] shown in Fig. 2 had the following effects of reduced treatment coverage for the three diseases: in Guinea, at more than 15% reduced coverage of treatment, the indirect deaths from HIV/AIDS, TB, and malaria during the Ebola epidemic exceeded the 2170 death toll from Ebola through March 2015; in Liberia, at any rate of reduced treatment coverage, the reported 4162 direct deaths from Ebola was greater than its indirect repercussions on HIV/AIDS, TB, and malaria; and in Sierra Leone, a 65% reduction in treatment coverage resulted in higher numbers of indirect deaths from HIV/AIDS, TB, and malaria than those reported as 3629 direct deaths from Ebola. Overall, in the three countries studied in West Africa, a reduction in treatment coverage by say 50%, resulted in higher indirect deaths than direct deaths from Ebola.Fig. 2: Sensitivity analysis of model to estimate deaths attributed to variation in treatment coverage during Ebola epidemic.Reproduced with permission from [16]. TB, tuberculosis.It is evident that the Ebola epidemic was devastating for the people and the health systems of Guinea, Liberia, and Sierra Leone. Consequently, the indirect mortality because of interruption of health services and delayed treatment of endemic diseases may have been even greater than the deaths directly attributed to Ebola. For example, even in the assumption of a modest 15% reduction in treatment coverage for HIV/AIDS, TB, and malaria, there were higher indirect than direct deaths from Ebola in Guinea, underscoring the fragility of the local healthcare systems. Similarly, a 65% reduction in treatment coverage resulted in more deaths than those directly attributed to Ebola in Sierra Leone. Furthermore, in Liberia, for a 70% or more reduction in treatment, 4376 indirectly attributable deaths were recorded that exceeded the direct Ebola deaths [16]. The CDC study [16] cited for this review was conservative in several respects such as 50% reduction in treatment accessibility for endemic diseases and the lack of change in transmission rates of HIV/AIDS, TB, and malaria. Thus, having taken a reduction in treatment coverage of 50% for three diseases, the study estimated 6269 [95% confidence interval (CI) 2564–12407] additional deaths in Guinea, 1535 (95% CI 522–2878) in Liberia, and 2819 (95% CI 844–4844) in Sierra Leone [16]. These results are consistent with those of other studies that showed the number of deaths attributed to Ebola may have even been surpassed by other endemic diseases [32]. As evidenced during the Ebola epidemic, the burden of other illnesses grew beyond deaths related to HIV/AIDS, TB, and malaria. Fear among communities about hospital transmission of Ebola virus may have kept persons away from seeking treatment for the three diseases that have presenting symptoms similar to Ebola, for example, fever, dizziness, and skin rashes [1]. The epidemic was further compounded by the weak health systems of Guinea, Liberia, and Sierra Leon, which were not only unable to provide routine health services, including childhood immunizations, maternal care, and for sexually transmitted infections [1,33], but also failed to cope with neglected tropical diseases [34]. The social burden of Ebola is further compounded by poverty, which deters education of children and job opportunities for adults. National governments and local community-based organizations, together with international organizations were instrumental in curtailing the Ebola epidemic in West Africa, without which more deaths would have occurred; both because of Ebola, as well as indirect deaths because of endemic diseases [35]. Although control efforts were directed at the Ebola epidemic, the inadvertent weakening of healthcare systems because of the Ebola epidemic requires extensive investment directed at strengthening the shattered healthcare systems [36]. In addition, there is an urgent need to invest in local capacity for surveillance and epidemic response, as recommended by various panels on lessons from the Ebola outbreak [37,38]. In conclusion, the Ebola epidemic in West Africa overwhelmed the healthcare systems of Guinea, Liberia, and Sierra Leone during 2014–2015. The epidemic was catastrophic for these countries with over 11 000 deaths, including over 500 healthcare workers. Moreover, its indirect impact of increasing the mortality rates of other endemic diseases was substantial because of an implosion of the healthcare system. This Ebola outbreak in West Africa adversely affected control of several endemic diseases, including HIV/AIDS, TB. Then, as the Ebola epidemic waned, the postemergency control strategies involved a comprehensive approach to curtail the spread of Ebola, provide care for recovered Ebola patients, and psychosocial support for their families. Notably, at this time, the strengthening and reconstruction of the health systems in these countries is needed, in terms of service delivery, health infrastructure, health human resources and education, data management using e-health, supply chain management, health financing, and community systems strengthening. This approach will empower the healthcare systems to effectively manage the long-term consequences of the epidemic that appear long after Ebola is eliminated. Particular attention should be given, during epidemics, to sustaining regular healthcare provision and prevention programs. Acknowledgements Conflicts of interest There are no conflicts of interest.
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