A review of the John F. Kennedy Medical Center's response to the COVID-19 pandemic in Liberia.

Objective: Over the past decades, the world has experienced a series of emerging and re-emerging infectious disease pandemics with dire consequences for economies and healthcare delivery. Hospitals are expected to have the ability to detect and respond appropriately to epidemics with minimal disruptions to routine services. We sought to review the John F. Kennedy Medical Center's readiness to respond to the COVID-19 pandemic. Methods: We used the pretest-posttest design in June 2021 and May 2023 to assess the hospital's improvements in its COVID-19 readiness capacity by collecting data on the hospital's characteristics and using the WHO COVID-19 Rapid hospital readiness checklist. We scored each readiness indicator according to the WHO criteria and the hospital's overall readiness score, performed the chi-square test for the change in readiness (change, 95% CI, p-value) between 2021 and 2023, and classified the center's readiness (poor: < 50%, fair: 50-79%, or satisfactory: ≥80%). The overall hospital readiness for COVID-19 response was poor in 2021 (mean score = 49%, 95% CI: 39-57%) and fair in 2023 (mean score = 69%, 95% CI: 56-81%). The mean change in hospital readiness was 20% (95% CI: 5.7-35%, p-value = 0.009). Between 2021 and 2023, the hospital made satisfactory improvements in leadership and incident management system [from 57% in 2021 to 86% in 2023 (change = 29%, 95% CI: 17-41%, p < 0.001)]; risk communication and community engagement [38-88% (change = 50%, 95% CI: 39-61%, p < 0.001)]; patient management [63-88% (change = 25%, 95% CI: 14-36%, p < 0.001)]; and rapid identification and diagnosis [67-83% (change = 16%, 95% CI: 4.2-28%, p = 0.009)]. The hospital made fair but significant improvements in terms of coordination and communication [42-75% (change = 33%, 95% CI: 20-46%, p < 0.001)], human resources capacity [33-75% (change = 42%, 95% CI: 29-55%, p < 0.001)], continuation of critical support services [50-75% (PD = 25%, 95% CI: 12-38%, p < 0.001)], and IPC [38-63% (change = 25%, 12-38%, p < 0.001)]. However, there was no or unsatisfactory improvement in terms of surveillance and information management; administration, finance, and business continuity; surge capacity; and occupational and mental health psychosocial support. Conclusion: Substantial gaps still remain in the hospital's readiness to respond to the COVID-19 outbreak. The study highlights the urgent need for investment in resilient strategies to boost readiness to respond to future outbreaks at the hospital.

Clinical sequelae among individuals with pauci-symptomatic or asymptomatic Ebola virus infection and unrecognised Ebola virus disease in Liberia: a longitudinal cohort study.

BACKGROUND: Whether or not individuals with pauci-symptomatic or asymptomatic Ebola virus infection and unrecognised Ebola virus disease develop clinical sequelae is unknown. We assessed current symptoms and physical examination findings among individuals with pauci-symptomatic or asymptomatic infection and unrecognised Ebola virus disease compared with Ebola virus disease survivors and uninfected contacts. METHODS: Between June 17, 2015, and June 30, 2017, we studied a cohort of Ebola virus disease survivors and their contacts in Liberia. Surveys, current symptoms and physical examination findings, and serology were used to characterise disease status of reported Ebola virus disease, unrecognised Ebola virus disease, pauci-symptomatic or asymptomatic Ebola virus infection, or no infection. We pre-specified findings known to be differentially prevalent among Ebola virus disease survivors versus their contacts (urinary frequency, headache, fatigue, muscle pain, memory loss, joint pain, neurological findings, chest findings, muscle findings, joint findings, abdominal findings, and uveitis). We estimated the prevalence and incidence of selected clinical findings by disease status. FINDINGS: Our analytical cohort included 991 reported Ebola virus disease survivors and 2688 close contacts. The median time from acute Ebola virus disease onset to baseline was 317 days (IQR 271-366). Of 222 seropositive contacts, 115 had pauci-symptomatic or asymptomatic Ebola virus infection and 107 had unrecognised Ebola virus disease. At baseline, prevalent findings of joint pain, memory loss, muscle pain, and fatigue were lowest among those with pauci-symptomatic or asymptomatic infection or no infection, higher among contacts with unrecognised Ebola virus disease, and highest in reported survivors of Ebola virus disease. Joint pain was the most prevalent finding, and was reported in 434 (18%) of 2466 individuals with no infection, 14 (12%) of 115 with pauci-symptomatic or asymptomatic infection, 31 (29%) of 107 with unrecognised Ebola virus disease, and 476 (48%) of 991 with reported Ebola virus disease. In adjusted analyses, this pattern remained for joint pain and memory loss. Survivors had an increased odds of joint pain compared with unrecognised Ebola virus disease contacts (adjusted odds ratio [OR] 2·13, 95% CI 1·34-3·39); unrecognised Ebola virus disease contacts had an increased odds of joint pain compared with those with pauci-symptomatic or asymptomatic infection and uninfected contacts (adjusted OR 1·89, 95% CI 1·21-2·97). The adjusted odds of memory loss was more than four-times higher among survivors than among unrecognised Ebola virus disease contacts (adjusted OR 4·47, 95% CI 2·41-8·30) and two-times higher among unrecognised Ebola virus disease contacts than in those with pauci-symptomatic or asymptomatic infection and uninfected contacts (adjusted OR 2·05, 95% CI 1·10-3·84). By 12 months, prevalent findings had decreased in the three infected groups. INTERPRETATION: Our findings provide evidence of post-Ebola virus disease clinical sequelae among contacts with unrecognised Ebola virus disease but not in people with pauci-symptomatic or asymptomatic Ebola virus infection. FUNDING: National Cancer Institute and National Institute of Allergy and Infectious Diseases of the National Institutes of Health.

Triangulating Evidence to Infer Pathways that Influence Ebola Virus Disease-Related Stigma and Clinical Findings among Survivors: An Observational Cohort Study.

Visible signs of disease can evoke stigma while stigma contributes to depression and mental illness, sometimes manifesting as somatic symptoms. We assessed these hypotheses among Ebola virus disease (EVD) survivors, some of whom experienced clinical sequelae. Ebola virus disease survivors in Liberia were enrolled in an observational cohort study starting in June 2015 with visits every 6 months. At baseline and 18 months later, a seven-item index of EVD-related stigma was administered. Clinical findings (self-reported symptoms and abnormal findings) were obtained at each visit. We applied the generalized estimating equation method to assess the bidirectional concurrent and lagged associations between clinical findings and stigma, adjusting for age, gender, educational level, referral to medical care, and HIV serostatus as confounders. When assessing the contribution of stigma to later clinical findings, we restricted clinical findings to five that were also considered somatic symptoms. Data were obtained from 859 EVD survivors. In concurrent longitudinal analyses, each additional clinical finding increased the adjusted odds of stigma by 18% (95% CI: 1.11, 1.25), particularly palpitations, muscle pain, joint pain, urinary frequency, and memory loss. In lagged associations, memory loss (adjusted odds ratio [AOR]: 4.6; 95% CI: 1.73, 12.36) and anorexia (AOR: 4.17; 95% CI: 1.82, 9.53) were associated with later stigma, but stigma was not significantly associated with later clinical findings. Stigma was associated with select symptoms, not abnormal objective findings. Lagged associations between symptoms and later stigma substantiate the possibility of a pathway related to visible symptoms identified by community members and leading to fear of contagion.