About an Outbreak

Written by Harriet on 2nd May 2020

What is an outbreak?

Outbreaks are considered to be rare events but, there is a level of regularity(1). Outbreaks occur when there is a sudden increase of people with a particular disease (let’s call it ‘Disease A’) more than what is expected in a particular population. In any given community or time, there is always an amount of ‘Disease A’ present. The amount (without any interventions) is referred to as the baseline in public health circles(2). When ‘Disease A’ goes above its baseline, we have an outbreak. It can evolve into an epidemic or pandemic depending on the geographical reach(1,2). Each time an outbreak happens (seemingly 20–30 years), the way we do life at a micro and macro-level shifts. This article will briefly look at the impact an outbreak can have on an economy, society and a health system.

General Impacts of outbreaks

One macro-level impact of any outbreak is the economy. Generally, economic growth is reduced, in some cases stunted (1). During the 2003 SARS outbreak, the East Asian region collectively saw a substantial decrease in: tourism- related exports, service exports, consumer and investor confidence, and domestic spending (3). Hong Kong, the centre of the SARS ’03 outbreak saw a 63% drop on average in the total number of visitors to Hong Kong (which is considered one of the pillars of Hong Kong’s economy) and the value of domestic exports decrease by 10.4% between January to March 2003(4). In total, Hong Kong suffered US$3.7 billion loss to its gross domestic product (GDP).

The economic cost goes beyond the direct health effects i.e. mortality and morbidity because of how various sectors interact with each other.

One of the biggest contributors to this economic cost is the behavioural change which is usually driven by fear(1).

In the previously mentioned 2003 SARS outbreak, across the countries in the European (5) and Asian regions(3) found a similar pattern of behaviour. People were more likely to limit their use of public transport, entertainment and shopping for non- essentials(5). It is not just the physical behaviours that change, attitudes too. For example, the 2014 Ebola crisis saw distrust for healthcare workers increase, culminating in riots, shootings and death. The wider social impact of outbreaks must also be considered. Using the previously mentioned outbreak, school closures caused an estimated 5 million children to lose a year of education with many becoming wage earners instead. Children who had lost their parents to the disease were particularly vulnerable to stigma and discrimination(6). The Ebola outbreak began to erode some of the long held community behaviours and practices e.g. funerals and caring for family and community members. It also weakened familial, within community and between different community relationships (7). Most of these changes were influenced by medical need e.g. changing the high risks funeral and burial practices in order to reduce spread.

The rapidly changing medical need during an outbreak puts health systems under immense amounts of pressure. Yes, there is the overall increased mortality and morbidity but, as seen in the 2003 SARS and the 2014 Ebola crisis there were other negative and surprisingly positive health system outcomes too.

Examples of positive Health outcomes

Amidst the 2014 Ebola outbreak, community event surveillance systems were established to widen the surveillance and response systems in Liberia and Sierra Leone. It involved training and selecting a “monitor” who would be the first to respond within 24hrs and be responsible for escalating it to the appropriate medical staff (8).

Though a delayed response, there was an increase in funding from international donors and governments. The support led to an increase in treatment beds and laboratory testing capacity. Additionally, there was more funding for health system strengthening which is traditionally overlooked especially in Low Middle Income Countries(LMIC)(9–11).

To ensure access to health services and accurate information , across Sierra Leone , Guinea and Liberia a SMS system was established to map patients to their nearest health facility if they reported Ebola like symptoms (12). Similarly, to ensure the public had access to accurate information, Sierra Leone created a national toll-free call centre. It offered education messages, flag alerts and referred people to appropriate health officials (9).

Examples of negative Health outcomes.

In Sierra Leone, Guinea and Liberia, their health systems were already understaffed, and the outbreak further exacerbated that. There was increased stigmatisation and distrust of healthcare workers. Some were rejected by the community and as a consequence there is thought to be a huge negative psychological effect on the workers (9).

Photo by Ashkan Forouzani on Unsplash

The stigma and the distrust of health services led to an underutilisation of local health services’ Sierra Leone, there was a reduction in the number of deliveries at health facilities and women attending antenatal appointments (13).

There were also major disruptions to vertical health programmes, for example, a childhood vaccination programme in Koinadugu, Sierra Leone. The number of children under 1 who has been fully vaccinated fell by more than half between June and July 2014 (13).

How it pertains to now — this is new but yet not?

Our current pandemic bears a lot of similarities to the SARS outbreak in 2003. The saying goes, history doesn’t repeat itself, it rhymes. Right now, we are living in one of the rhyming couplets. The trends of the outbreaks, transmissions, symptoms and even treatments are looking similar through the use of antivirals that are used to treat HIV(14). Looking at the response West African countries have to the current pandemic; it is clear that they have taken lessons from the Ebola outbreak. For example, Tanzania is using existing Ebola isolation units for COVID-19(15).

With this in mind, AHI intends to write a blog series reflecting on previous outbreaks on the African continent. We want to take the opportunity to look at various countries’ responses, outcomes and learning in more detail. We hope that you follow us on this journey and discover something new.

References:

1. Keogh-Brown MR. Macroeconomic Effect of Infectious Disease Outbreaks. In: Culyer AJ, editor. Encyclopedia of Health Economics [Internet]. San Diego: Elsevier; 2014 [cited 2020 Apr 22]. p. 177–80. Available from: http://www.sciencedirect.com/science/article/pii/B9780123756787006088

2. Dicker RC, Coronado F, Koo D, Parrish RG. Principles of epidemiology in public health practice; an introduction to applied epidemiology and biostatistics. 2006.

3. Fan EX. SARS Economic Impacts [Internet]. Available from: https://www.adb.org/sites/default/files/publication/28073/pb015.pdf

4. (PDF) Economic impact of SARS: the case of Hong Kong [Internet]. ResearchGate. [cited 2020 Apr 24]. Available from: https://www.researchgate.net/publication/24089623_Economic_impact_of_SARS_the_case_of_Hong_Kong

5. Sadique MZ, Edmunds WJ, Smith RD, Meerding WJ, de Zwart O, Brug J, et al. Precautionary Behavior in Response to Perceived Threat of Pandemic Influenza. Emerg Infect Dis [Internet]. 2007 Sep [cited 2020 Apr 24];13(9):1307–13. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2857294/

6. Elston JWT, Cartwright C, Ndumbi P, Wright J. The health impact of the 2014–15 Ebola outbreak. Public Health [Internet]. 2017 Feb 1 [cited 2020 Apr 24];143:60–70. Available from: http://www.sciencedirect.com/science/article/pii/S0033350616303225

7. United Nations Development Group:West and Central Africa. Socio-Economic Impact of Ebola Virus Diease in West African Countries [Internet]. 2015 Feb. Available from: https://www.undp.org/content/dam/rba/docs/Reports/ebola-west-africa.pdf

8. Crowe S, Hertz D, Maenner M, Ratnayake R, Baker P, Lash RR, et al. A Plan for Community Event-Based Surveillance to Reduce Ebola Transmission — Sierra Leone, 2014–2015. MMWR Morb Mortal Wkly Rep [Internet]. 2015 Jan 30 [cited 2020 May 2];64(3):70–3. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4584562/

9. Shoman H, Karafillakis E, Rawaf S. The link between the West African Ebola outbreak and health systems in Guinea, Liberia and Sierra Leone: a systematic review. Global Health [Internet]. 2017 Jan 4 [cited 2020 Apr 26];13. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5210305/

10. How Liberia reached zero cases of Ebola virus disease. Wkly Epidemiol Rec. 2015 May 22;90(21):259–60.

11. Adam T, Ahmad S, Bigdeli M, Ghaffar A, Røttingen J-A. Trends in Health Policy and Systems Research over the Past Decade: Still Too Little Capacity in Low-Income Countries. PLOS ONE [Internet]. 2011 Nov 22 [cited 2020 May 2];6(11):e27263. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0027263

12. Trad M-A, Jurdak R, Rana R. Guiding Ebola patients to suitable health facilities: an SMS-based approach. F1000Res [Internet]. 2015 Feb 12 [cited 2020 May 2];4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4358411/

13. Elston JWT, Moosa AJ, Moses F, Walker G, Dotta N, Waldman RJ, et al. Impact of the Ebola outbreak on health systems and population health in Sierra Leone. J Public Health (Oxf) [Internet]. 2016 Dec 2 [cited 2020 May 2];38(4):673–8. Available from: https://academic.oup.com/jpubhealth/article/38/4/673/2966926

14. Law S, Leung AW, Xu C. Severe acute respiratory syndrome (SARS) and coronavirus disease-2019 (COVID-19): From causes to preventions in Hong Kong. International Journal of Infectious Diseases [Internet]. 2020 May 1 [cited 2020 Apr 27];94:156–63. Available from: http://www.sciencedirect.com/science/article/pii/S1201971220301922

15. Drawing on Ebola readiness to tackle COVID-19 [Internet]. WHO | Regional Office for Africa. [cited 2020 May 2]. Available from: https://www.afro.who.int/news/drawing-ebola-readiness-tackle-covid-19

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Afrocentric brain gain​ platform engaging Africa’s diaspora for healthcare development