From the Frontline: How unsafe burials impact Ebola transmission

From the Frontline: How unsafe burials impact Ebola transmission

Amanda McClelland works in dangerous places. A pediatric nurse by training, her work caring for children with infectious diseases led her to study public health. “Since then,” she recounts, “I have worked all over the world, focusing on preventing infectious diseases and responding to outbreaks.”

When the Ebola outbreak began in West Africa, Amanda was on the frontline as a senior technical advisor in the International Federation of Red Cross and Red Crescent Societies. She describes the situation as “difficult at times” – perhaps something of an understatement:

“We were working outside, in tented facilities, in all weathers and through the night. It was extremely hot and the protective equipment was claustrophobic. We worked 18-hour days, for weeks at a time.”

Amanda McClelland

Amanda was struck by the dedication of the more than 6,000 Red Cross local staff and volunteers, and told PLOS, “They faced stigma and were ostracized by friends and families. Yet each day they turned up committed to the task, often with a smile, singing songs and supporting the patients and families for whom they cared. Ebola taught me that epidemics begin and end with communities.”

Amanda’s work during the Ebola outbreak won her the 2015 Florence Nightingale Medal for exceptional courage. It also brought home the importance of burial practices in reducing Ebola transmission, and Amanda published a study in PLOS Neglected Tropical Diseases on the impact of unsafe burial of Ebola victims during the epidemic. I interviewed her about her experiences and her research.

Given your firsthand experience of Ebola in West Africa, why do you feel that it is important to study unsafe burial of Ebola victims?

AM: The Red Cross volunteers safely buried over 47,000 people during the outbreak; the large majority of those bodies were Ebola-free. Meanwhile, it became apparent that some funerals served as “super-spreader” events in which many people became infected with Ebola from attending just one unsafe burial. It was important to try to estimate the impact of the volunteers’ hard work with safe burials and to determine whether safe, dignified burials were worth the effort and cost.  It was also important to demonstrate that all aspects of the Ebola response – not just clinical care – contributed to ending the outbreak.

You estimated that the Red Cross safe and dignified burial program averted up to 10,452 secondary Ebola cases. How did you calculate this, and were you surprised by the findings?

AM: Quantifying the impact of the program was challenging, as it was based on data extrapolated from individuals’ recall of events that occurred at a very emotional time. The number of averted cases is based on a calculation of the number of people who had contact with an Ebola-infected person during a funeral, multiplied by the number of Ebola-positive people the Red Cross teams buried. The figure of 10,452, although an upper estimate, did not surprise me. In the beginning of the outbreak, and before good data collection was in place, there were more Ebola-positive burials and people often had more contact with infected community members. Despite the limitations of calculating this figure, it is the best quantified estimate we have and it reflects our experience on the ground during the outbreak.

What more needs to be done to reduce secondary Ebola transmission resulting from unsafe burial practices?

AM: The paper talks about the need for a comprehensive approach to Ebola prevention and for early isolation of cases. This is key. Ideally, there would be no need to conduct safe and dignified burials, because anyone who had Ebola symptoms would be cared for in clinical isolation. The reality, however, is that some people will die in communities thereby increasing the risk of Ebola transmission. To reduce secondary cases from these deaths it is important that we take the time to engage with communities, and build trust based on an understanding of their beliefs and cultural practices, before outbreaks occur.

What impact do you hope your study might have, and what are the next steps for your research?

AM: This research highlights the important role that the safe and dignified burial program teams played in supporting their communities and ending the Ebola outbreak. I hope that the study also showcases the important role of community engagement outside of clinics and ensures that safe burial interventions are prioritized early in the response to any future Ebola outbreak. The next steps are to use these lessons in future epidemics, and to improve methodology to help quantify the impact of safe burials in stopping the spread of Ebola.


Research Article: Tiffany A, Dalziel BD, Kagume Njenge H, Johnson G, Nugba Ballah R, James D, et al. (2017) Estimating the number of secondary Ebola cases resulting from an unsafe burial and risk factors for transmission during the West Africa Ebola epidemic. PLoS Negl Trop Dis 11(4): e0005491. doi:10.1371/journal.pntd.0005491

Images Credits: Amanda McClelland; CDC Global, Flickr, CC-BY 2.0


Beth works at PLOS as Journal Media Manager. She read Natural Sciences, specializing in Pathology, at the University of Cambridge before joining PLOS in 2013. She feels fortunate to be able to read and write about the exciting new research published by PLOS.

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