Thursday, March 12, 2015

What Went Wrong: An Autopsy of the Guinea Disease Surveillance System

            On March 23, 2013 the World Health Organization announced an outbreak of Ebola Virus Disease in the country of Guinea.[1] Located in West Africa, the tiny country is home to nearly 11 million people and is ranked 179th on the Human Development Index.[2] The fact that it was the World Health Organization, and not the Guinea Ministry of Health, that made the announcement of the outbreak is telling in and of itself. Guinea had not detected the outbreak, it was only the coincidental presence of a Médecins Sans Frontieres team in the country to treat a Malaria outbreak that led to the discovery of what would become the largest Ebola outbreak in the history of the disease.[3] This paper will analyze the health surveillance system of Guinea in an effort to understand how such an outbreak could have gone unnoticed, continuing to spread among the population and to neighboring countries for nearly three months before the WHO announcement.



            The Guinea Ministry of Health and Public Hygiene did have a simple national health surveillance system in place prior to the outbreak. Each Prefectural Health Directorate reported their weekly tallies to the Directorate of Prevention and Disease Control which compiled that data into a national database of cases.[4] But that system was limited by both resource constraints and the number of physicians and healthcare workers in the country. There is one physician for every 7,143 people in the country, compared to one physician for every 500 people in the United States.[1] Physicians in Guinea have significantly less capability to follow up on idiopathic cases with a pathological investigation. And those that did would have had limited lab capabilities, mainly focused around the infectious diseases considered endemic to the region.
            The fatal flaw in the system lay in its inflexible nature. The system had been designed nearly entirely around monitoring patients with symptoms of the major infectious diseases: Yellow Fever, Cholera, Poliomyelitis, and to a much smaller extent certain Viral Hemorrhagic Fevers such as Marburg and Crimean-Congo, but never Ebola.[4] And there was simply no capacity for the system to identify new infectious disease outbreaks that hadn’t been previously identified in the region.
            The data that was available in Guinea rarely went beyond simple case counts.  And where electronic records were kept, they were often incomplete or invalid.[4] Few organizations were active in the area, meaning that the Ministry of Health numbers were generally taken at face value, with no effort expended in order to determine the actual numbers of infected persons by other means.
            As previously stated, the number of physicians meant that workload was high and resources scarce. Furthermore, almost 93% of all health expenditures occurred outside the formal health infrastructure, meaning physicians were unlikely to see even a tenth of the population with health complaints.  Previous efforts at reforming the Guinea Health System, such as the Bamako Initiative of 1987, were primarily focused around access to drugs and essential health services.  Little or no consideration was given to infectious disease surveillance.[6]
            The sensitivity of the system to detecting the endemic diseases is impossible to verify.  Retrospective case finding by the WHO indicates that by time the first Ebola case had been confirmed by the Insitiut Pasteur in Paris, there were at least 59 cases throughout Guinea, and likely more in the neighboring countries of Sierra Leone and Liberia.[3] Because no cases were reported, there was no Predictive Value Positive for the surveillance system. In fact, had staff from Médecins Sans Frontieres not brought the disease to the attention of the Ministry of Health and Public Hygiene, it is unlikely that it would have been detected at all. Rather, it would most likely have been brought to light when the disease spread to a country with a more developed surveillance system.
            The failure of the system to detect the Ebola Virus Disease outbreak in a timely fashion makes it difficult to put much faith in the system’s ability to provide an accurate picture of the overall state of health in the country of Guinea. With the tide of the Ebola outbreak now receding, it is likely that the accompanying loss in funding and resources will draw with it the ability of the country to detect, identify, and treat disease.  With the devastating effect the disease has had on healthcare workers, the surveillance system will likely operate at an even lower level than before. Without the benefit of additional capacity in diagnostic facilities and healthcare workers, the system will continue to rely on the presence of outside organizations for major components of healthcare such as infectious disease surveillance, making it impossible for it to respond to outbreaks in a timely manner.
            The failure of the Guinea infectious disease surveillance system is a story of the disparity in global burden of disease.  Ebola cannot thrive in a country with a sensitive and timely surveillance system, but such a system is reliant on effective institutions and adequate resources that were not present in Guinea prior to the outbreak. Furthermore, a surveillance system cannot detect what it isn’t looking for, and this outbreak has demonstrated the great risk posed to numerous countries for whom that same lack of effective institutions and adequate resources is the norm.  If these factors are not addressed there is no way of preventing a new outbreak of viral hemorrhagic fever, an aggressive strain of multi-drug resistant tuberculosis, or some other disease that is just as costly as the one we are just now starting to bring under control.

  1.  World Health Organization.  Ebola Virus Disease in Guinea. http://www.afro.who.int/en/clusters-a-programmes/dpc/epidemic-a-pandemic-alert-and-response/outbreak-news/4063-ebola-virus-disease-in-guinea.html.  23 March 2013\
  2. Central Intelligence Agency. (2014). Guinea. In The World Factbook. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/geos/gv.html 14 February 2014.
  3. World Health Organization.  Ground zero in Guinea: the outbreak smoulders – undetected – for more than 3 months. http://www.who.int/csr/disease/ebola/ebola-6-months/guinea/en/#.  July 2013.
  4. Rebaudet S, Mengel MA, Koivogui L, et al. Deciphering the Origin of the 2012 Cholera Epidemic in Guinea by Integrating Epidemiological and Molecular Analyses. Ryan ET, ed. PLoS Neglected Tropical Diseases 2014;8(6):e2898. doi:10.1371/journal.pntd.0002898.
  5. Sudre B, Bompangue D (2009) Epidémiologie du choléra et Evaluation du Système d'Alerte Précoce en République de Guinée. Rapport de mission. UNICEF. in French. Available:https://wca.humanitarianresponse.info/fr/system/files/documents/files/EpidemiologieCholera_Evaluation_Guinee_dec09.pdf Accessed 13 December 2013.
  6. Ridde V. Report from West Africa: Is the Bamako Initiative Still Relevant for West African Health Systems? Int J Health Serv January 2011 41: 175-184, doi:10.2190/HS.41.1.l

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