Surveillance in the field: Over-identification of Ebola suspect cases and its contributing factors in West African at-risk contexts

ABSTRACT

During an Ebola outbreak, the WHO recommends that health professionals consider people as suspect cases (SCs) when they show key signs such as the sudden onset of high fever or specific symptoms after having had contact with a suspect or confirmed Ebola case. SCs should then get care, be isolated and be reported to health authorities until the Ebola virus disease is confirmed through a lab test. This exploratory study aims to understand this identification process in the field based on a qualitative analysis of the diagnosis and therapeutic itineraries of 19 SCs in Cote d’Ivoire and Senegal (2014–2015). Results indicate that the main criteria for SC identification at the field level were fever (understood broadly) and provenance from a highly affected country (applied indiscriminately). WHO criteria were not followed in at least 9 of the 19 cases. Several medical, social and cultural factors favour over-identification of people as SCs, including relativism in defining ‘high fever’, placism, humanitarian or securitarian bias, issues in categorising SC's contact cases, and the context of fear. To avoid undue categorisation and its possible harmful social effects, the WHO definition should be implemented more carefully in various contexts and with greater consideration for ethical issues, while prioritising diagnosis strategies with higher specificity.

KEYWORDS:

• Ebola
• identification
• suspect case
• West Africa
• surveillance

Acknowledgements

We gratefully acknowledge interviewees and health teams from the Ministries of Health in Senegal and Cote d’Ivoire for their collaboration, and Sharon Calandra for her editing and translation support.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

A. Desclaux http://orcid.org/0000-0002-4268-2818

M. S. Malan http://orcid.org/0000-0003-0734-954X

M. Egrot http://orcid.org/0000-0002-3871-280X

K. Sow http://orcid.org/0000-0002-7079-8869

F. Akindès http://orcid.org/0000-0003-4457-376X

Notes

1 This quotation does not present criteria for Marburg virus disease, although both diseases are presented together in the WHO definition (WHO, 2014b).

2 Research Program EBSEN: Epidémie d’Ebola et production sociale de la confiance au Sénégal, Institut de Recherche pour le Développement (TransVIHMI), Centre Régional de Recherche et de Formation de Fann, Dakar, Senegal; Research Program Ebo-CI: Epidémie d’Ebola et Côte d’Ivoire, Institut de Recherche pour le Développement (MIVEGEC), Chaire Unesco de Bioéthique, Université Alassane Ouattara de Bouaké, Côte d’Ivoire.

3 See WHO, Ebola Situation Reports, http://www.who.int/csr/disease/ebola/situation-reports/archive/en/.

4 Approval was obtained from the Comité national d’éthique pour la recherche en santé au Sénégal (no. 337/2014) and from the Comité national d’éthique et de la recherche pour la Côte d’Ivoire.

5 Some frontline health workers and other stakeholders have long shared a perception with local populations of air-borne transmission of the Ebola virus, which is erroneous from a scientific point of view.

6 Such as the Global Health Security Agenda.

Additional information

Funding

This research was supported by Expertise France [grant number CS15SANIN304]; Institut National de la Santé et de la Recherche Médicale [grant number IMMI 2014011]; Institut de Recherche pour le Développement; and UNICEF.