Mortality, Morbidity and Health-Seeking Behaviour during the Ebola Epidemic 2014–2015 in Monrovia Results from a Mobile Phone Survey

Between March 2014 and July 2015 at least 10,500 Ebola cases including more than 4,800 deaths occurred in Liberia, the majority in Monrovia. However, official numbers may have underestimated the size of the outbreak. Closure of health facilities and mistrust in existing structures may have additionally impacted on all-cause morbidity and mortality. To quantify mortality and morbidity and describe health-seeking behaviour in Monrovia, Médecins sans Frontières (MSF) conducted a mobile phone survey from December 2014 to March 2015. We drew a random sample of households in Monrovia and conducted structured mobile phone interviews, covering morbidity, mortality and health-seeking behaviour from 14 May 2014 until the day of the survey. We defined an Ebola-related death as any death meeting the Liberian Ebola case definition. We calculated all-cause and Ebola-specific mortality rates. The sample consisted of 6,813 household members in 905 households. We estimated a crude mortality rate (CMR) of 0.33/10,000 persons/day (95%CI:0.25–0.43) and an Ebola-specific mortality rate of 0.06/10,000 persons/day (95%-CI:0.03–0.11). During the recall period, 17 Ebola cases were reported including those who died. In the 30 days prior to the survey 277 household members were reported sick; malaria accounted for 54% (150/277). Of the sick household members, 43% (122/276) did not visit any health care facility. The mobile phone-based survey was found to be a feasible and acceptable alternative method when data collection in the community is impossible. CMR was estimated well below the emergency threshold of 1/10,000 persons/day. Non-Ebola-related mortality in Monrovia was not higher than previous national estimates of mortality for Liberia. However, excess mortality directly resulting from Ebola did occur in the population. Importantly, the small proportion of sick household members presenting to official health facilities when sick might pose a challenge for future outbreak detection and mitigation. Substantial reported health-seeking behaviour outside of health facilities may also suggest the need for adapted health messaging and improved access to health care.Author Summary: During the Ebola outbreak in 2014/2015 more than 4,800 people died of Ebola in Liberia. Health care providers in the field have assumed that closure of health facilities and mistrust in existing structures resulted not only substantial additional deaths from Ebola but also impacted on death rate of other diseases and on the way people tried to seek health care. We conducted a mobile phone survey in Monrovia to identify deaths and diseases a household had faced since the beginning of the Ebola outbreak and the kind of health care they sought. We estimated that the non-Ebola-related death rate in Monrovia was not higher than previous national estimates for Liberia. However, additional deaths occurred in the population of Monrovia directly resulting from Ebola. Of the household members that were sick of any disease during the survey period, 43% did not visit any health care facility. The high proportion among the sick household members that sought health care in pharmacies or drug stores or by health care workers among their peers but outside health facilities emphasizes the importance of ensuring access to non-Ebola-related health care as outbreak control is challenged by sick community members staying undiagnosed and untreated.