摘要：Objectives. To examine the acceptability, use, effects on early isolation, and contribution to Ebola virus disease (EVD) transmission of Community Care Centers (CCCs), which were rapidly deployed in Sierra Leone during an accelerated phase of the 2014–2015 EVD epidemic. Methods. Focus group discussions, triads, and key informant interviews assessed acceptability of the CCCs. Facility registers, structured questionnaires, and laboratory records documented use, admission, and case identification. We estimated transmission effects by comparing time between symptom onset and isolation at CCCs relative to other facilities with the national Viral Hemorrhagic Fever data set. Results. Between November 2014 and January 2015, 46 CCCs were operational. Over 13 epidemic weeks, 6129 patients were triaged identifying 719 (12%) EVD suspects. Community acceptance was high despite initial mistrust. Nearly all patients presented to CCCs outside the national alert system. Isolation of EVD suspects within 4 days of symptoms was higher in CCCs compared with other facilities (85% vs 49%; odds ratio = 6.0; 95% confidence interval = 4.0, 9.1), contributing to a 13% to 32% reduction in the EVD reproduction number ( R o ). Conclusions. Community-based approaches to prevention and care can reduce Ebola transmission. West Africa’s Ebola virus disease (EVD) epidemic is unprecedented in scale and intensity and larger than all previous EVD epidemics combined. 1 Sierra Leone is the worst-affected country. Cases were first observed in May 2014 in the remote eastern part of the country intersecting Guinea and Liberia. 2 The outbreak quickly progressed from a localized to a generalized epidemic. By May 2015, there were more than 8500 confirmed cases and 3800 reported deaths, 3 though actual caseloads were presumed to be substantially higher. 4 Limiting Ebola transmission requires reducing the basic reproduction number ( R o ), which is the number of secondary infections resulting from each infected case. 5 The common underlying exposure is contact with infected body fluids of the sick or deceased. 6 From a public health perspective, reducing R o requires strong community systems to support early case detection and isolation as well as conducting safe and dignified burials. In addition, social mobilization can improve awareness and shift norms around key risk behaviors. 7 Sierra Leone underwent a phase of accelerated EVD transmission during the last quarter of 2014. 8 At the time, high levels of fear and stigma prevailed, with widespread mistrust in Ebola response systems. 9,10 The mainstay of case identification was a national alert system, where toll-free calls triggered the investigation of potential EVD suspects. In September, a 3-day national campaign was launched to disseminate information on Ebola to every household in the country and refer potential cases, which resulted in a spike in EVD suspects. 11 (Ebola suspects are persons fitting the World Health Organization case definition for mobile teams or health stations of fever with recent contact, or fever plus 3 or more cardinal symptoms, or inexplicable bleeding, or sudden unexplained death. 12 ) The demand for safe isolation and treatment beds rapidly outpaced supply. By the end of October, there were just 287 high-quality Ebola Treatment Center beds in 4 urban centers despite widespread transmission across all 14 districts. 13 The World Health Organization and partners advocated the establishment of Ebola Community Care Centers (CCCs) as a strategy to increase access to care and decentralize the EVD response. 14 Key components of the model are outlined in Figure A, available as a supplement to the online version of this article at http://www.ajph.org . The CCCs in Sierra Leone were purpose-built, infection-prevention– and infection-control–compliant, 8- to 24-bed temporary facilities. Their primary aims were to support early case detection and isolation, provide basic supportive care for EVD suspects, and facilitate diagnostic testing and referral within a community context. The CCCs were also intended to act as hubs for a range of prevention services including safe burials, contact tracing, case finding, and social mobilization. Although recent models suggest that CCCs could limit transmission by shortening the time between symptom onset and admission, this has yet to be operationally assessed. 15 As influencing community dynamics and behaviors was central to the CCC strategy, a number of measures were adopted to enhance community engagement in the Ebola response. (The term community engagement refers to the process of working collaboratively with and through groups of people to address priority concerns. 16 Social mobilization refers to a process that engages and motivates a wide range of partners and allies at national and local levels to raise awareness of and demand for a particular development objective through dialogue. 17 ) An initial consultation took place with traditional leaders and community members who selected site locations and participated in CCC construction. Communities toured facilities before opening and in some places conducted traditional rituals to prepare facilities for use. Care, support, and nutritional services were provided by community members themselves. Social mobilization activities were conducted by trained facilitators from local nongovernmental organizations (approximately 10 per CCC) and aimed to enhance Ebola awareness and foster appropriate facility use. These included household visits, meetings with village leaders and community groups including youth and women’s groups, and mass media campaigns through radio and megaphone-based messaging. We report on the implementation of CCCs in Sierra Leone across 5 districts, with a focus on activities undertaken by the United Nations International Children’s Emergency Fund (UNICEF) in partnership with the Ministry of Health and Sanitation that established three quarters of facilities in the country. The objectives were to examine (1) acceptability of CCCs to local communities, (2) patterns of use, (3) their contribution to early suspect isolation, and (4) effects on EVD transmission in districts where they were deployed. Finally, emerging lessons are discussed to inform Ebola elimination efforts and the wider health systems–strengthening agenda.
