Table 1

Additional examples of changes and impact of the use of CASS studies during the 2018–2020 Eastern Democratic Republic of the Congo Ebola outbreak

StudyRationale for study, key partners, study aim and methodsResults/RecommendationsChange and impact on outbreak intervention
1Perceptions of risk among pregnant and breastfeeding women
(October 2018)18
Rationale: routinely collected surveillance data on uptake of the novel Ebola vaccine did not include information on pregnant or breastfeeding women as they were not considered eligible for vaccination at that time
Key partner: MoH, UNICEF, surveillance pillar, psychosocial pillar
Study aim: to understand views of pregnant and breastfeeding women who had been identified as contacts (self-reported) and their partners in relation to accessing the novel Ebola vaccine
Methods: rapid qualitative study
  • Women who were not eligible for the vaccine reported feeling abandoned, not receiving psychosocial support or surveillance and follow-up (compared with their neighbours or others who had been contacts). Both women and men requested that women be allowed the vaccine, regardless of the risks to the pregnancy as the vaccine was being promoted as the best way to save one’s life.

  • Female breastfeeding healthcare workers continued to work and place themselves at risk, without access to the vaccine, while others decided independently to stop breast feeding (or report stopping) to access the vaccine.

  1. Surveillance forms were adapted to include pregnant and breastfeeding status.

  2. Vaccination teams began reporting daily how many non-eligible were not vaccinated: this further highlighted the daily number of women at risk because of the eligibility criteria.

  3. Kits were provided to support breastfeeding mothers (healthcare worker, frontline responder, high-risk contact) who wished to stop breast feeding and access the vaccine.

  4. Advocacy to allow pregnant and breastfeeding women access to the novel Ebola vaccine. This was raised to SAGE and, following this, the policy was changed in June 2019.

2Perceptions of infection prevention control (IPC) and healthcare services measures
(January 2019)19
Rationale: low uptake of recommended IPC decontamination practices among local communities
Key partner: MoH, IPC pillar, WHO
Study aim: to understand local community views on IPC decontamination practices in order to inform community engagement and improve practice
Methods: qualitative interviews and focus group discussions
Community members saw the value and benefit of decontamination practices. Reluctance to engage with decontamination practices was linked to the fact that decontamination for Ebola was being undertaken by unknown external teams in a context of significant mistrust. For other infectious disease scenarios requiring decontamination, local community members were used to this being conducted at the level of the health facilities by local healthcare workers.
  1. Guidelines for community engagement in IPC (March 2019).

  2. Training of 95 local hygienists in 30 neighbourhoods in all the health areas of Beni and 50 others in the health facilities of 15 surrounding health facilities (July 2019).

  3. Recommendation implemented and inserted in the strategic response plan 4: involve communities and families in decontamination and in close collaboration with the risk communication and community engagement and psychosocial support (PSS) teams.

3Understanding delays in treatment- seeking
(July 2019)20
Rationale: epidemiological data highlighted continued long delays in treatment- seeking (5–12 days), increasing the risk of mortality of those affected by Ebola
Key partner: MoH, Epidemiology Cell, CDC-Atlanta
Study aim: to explain the potential causes in delays related to treatment-seeking among those with symptoms of Ebola
Methods: meta- analysis of existing qualitative and quantitative data form CASS studies
Barriers to treatment-seeking were largely due to misunderstanding of Ebola symptoms (posters and images focused on severe rather than more common symptoms) as well as fear that Ebola Treatment Centres would result in death.
  1. Development of new communications tools (messages and images) which include ‘dry’ symptoms and make comparisons to other known illnesses (now included in all communication tools).

  2. Messages and campaigns focused on early treatment-seeking for survival.

4Understanding nosocomial transmission 21Rationale: epidemiological analysis indicated that, when a nosocomial transmission occurred, there was a greater likelihood of further spread
Key partner: IPC-WASH pillar
Study aim: to explain potential reasons and factors related to nosocomial infection
Methods: integrated analysis including a meta-synthesis of healthcare worker surveys, household surveys and qualitative studies on healthcare-seeking behaviour integrated with epidemiological analysis of transmission chains, DHIS2 data and programmes data from IPC teams
  • IPC data highlighted that less than half of the healthcare facilities had received training.

  • CASS healthcare worker surveys conducted across all response locations smaller and harder to reach facilities were less likely to report having received support.

  • The majority of healthcare workers were not being trained on location and did not feel able to stop nosocomial transmission due to reported lack of training.

  • Many healthcare workers did not feel able to detect a possible Ebola case.

  • Healthcare workers reported increased community tensions and fear of accusations from communities for working for the response, which may influence willingness to raise an alert.

  • Traditional practitioners were reported as not sufficiently involved in the response.

  1.  New IPC-WASH training to focus on smaller healthcare facilities and to include practical demonstrations and application as a key component of the training.

  2.  Communication materials adapted to better explain and communicate on common Ebola systems (less visibly severe).

  3.  Traditional practitioners were included into the IPC-WASH pillars across multiple locations, reinforcing their engagement with the response.

5Factors of risk for children under 5 years of age
(multiple studies Octobers 2018, December 2019, March 2020)22
Rationale: children under 5 years of age continued to represent 14% of caseloads throughout the outbreak; however, limited understanding of the factors contributing to a greater exposure and infection than anticipated.
Key partner: Epidemiology Cell
Study aim: understand the factors (situation, behaviours, services use) recurrent among children under 5 years of age and drivers influencing risk and transmission among small children
Methods: integrated analysis using illness narratives and verbal autopsies, DHIS2 analysis (interrupted time series), transmission chain analysis, programmes data (IPC data), household and healthcare worker surveys, epidemiological analysis, no delays in treatment-seeking, symptoms and health outcomes for children under 5 years of age
  • CASS analysis of health services use data demonstrated increased use of healthcare facilities by up to 300%–400% for children under 5 years of age.

  • IPC data highlighted that nosocomial infections were more likely in smaller healthcare facilities; there the increased use of services was likely to cause overcrowding and limited capacity to stop nosocomial transmission.

  • Surveillance data found that children under 5 years of age were less to be listed as contacts and, when listed, less likely to be followed up.

  • CASS qualitative data found that children continued to receive injections and intravenous treatments in healthcare facilities, that parents reported bed-sharing and lack of IPC measures. Parents and surveillance teams also perceived small children as not likely to be contacts and were therefore not quick to list them.

  1. Communication materials were developed to explain the risks for children (when they may have become a contact) and the importance of listing children.

  2. Training for PSS and surveillance teams were reinforced to increase the number of children under 5 years of age listed as contacts and to reinforce follow-up of cases.

  • This list is not exhaustive. A complete list of CASS studies conducted during the outbreak can be found online.23

  • ; CASS, Cellulle d’Analyse en Sciences Sociales; CDC, Centers for Disease Control and Prevention; DHIS2, The District Health Information Software (; IPC-WASH, Infection Prevention and Control-Water Sanitation Hygiene; MoH, Ministry of Health.