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 (Ro).

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 (Ro), 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 Ro 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.

A mixed-methods approach employed qualitative data, structured questionnaires, facility registers, and laboratory records. Although data gathered were operational and not subject to formal institutional review, approval from village leadership was obtained before community discussions and informed verbal consent was obtained for all interviews.

Acceptability of Ebola Community Care Centers

We gathered qualitative data through meetings and discussions organized to monitor community responses to CCCs’ implementation. The aim of the community dialogues, key informant interviews, and focus group discussions were not evaluative; rather, they were intended to inform program operations. Social mobilization activities were recorded in log books and reported weekly.

To document attitudes and perspectives, we conducted focus group discussions, triads, and key informant interviews of community members and nongovernmental implementing partners responsible for social mobilization during the operational phases of the CCCs (February 11–14, 2015). All discussions were conducted in the local languages by a trained facilitator and a data recorder. A field guide developed by UNICEF was provided to the facilitator who was trained on the key thematic areas to explore. Data were collected by audio recording and note taking, and later transcribed from the local language to English for analysis. Focus groups and interviews generally lasted about 45 to 60 minutes.

We conducted qualitative assessments in accordance with established best-practice methods.18 Focus groups comprised 6 participants and triads had 3 participants. We used a convenience sample to select participants from local areas where CCCs were operational. To minimize bias and represent a diversity of perspectives, we grouped participants by age range and gender. Adult male and female groups were interviewed separately, with 1 exception. Youth groups were of mixed gender. Participants were contacted 1 day before through village leaders and their designated focal points.

Grounded theory informed the analysis, with data coded on the basis of descriptive labels applied to categories of respondents’ perceptions, experience, emotions, engagement, and use of the CCCs.19

Use of Ebola Community Care Centers

In all CCCs, facility registers were used to document patient information, patterns of CCC use, the proportion of patients fitting case definitions, and time between symptom onset and isolation. Select indicators were collected on a daily basis through a text message–based application (i.e., RapidPro version 1.0 [UNICEF, New York, NY]).20 Data were stored in an Excel 2013 (Microsoft, Redmond, WA) file to support immediate follow-up and reporting.

Patterns of care-seeking behavior and source of referral were assessed with a structured questionnaire administered to all Ebola suspects at the time of admission in 16 high-volume centers over a 7-day period between January 30 and February 6, 2015. The questionnaire consisted of precoded responses to capture basic knowledge about CCCs, examine motivation for care seeking, and document source of referral.

As laboratories supporting the CCCs varied by district, specimen data were compiled and cross-referenced for accuracy and completeness from multiple sources: daily results obtained directly from laboratories, laboratory technician records, District Ebola Response Centers, and CCC laboratory registers. These data estimate the proportion of triaged patients testing EVD-positive, and the proportion of total positive cases from districts that passed through the CCCs as the point of first contact.

Community Care Centers’ Effects on Early Isolation

We assessed the time between symptom onset and admission for patients attending CCCs from facility registers. We compared this with patients admitted to other Ebola care facilities for the same districts by using the WHO Epi Linelist, which is based on the national Viral Hemorrhagic Fever data set (version January 26, 2015). (The Epi Linelist is a World Health Organization–cleaned version of the Viral Hemorrhagic Fever data set, which is a line listing of all reported suspected, probable, and confirmed EVD cases.) We generated odds ratios for data collected during the peak-transmission period of December 2014 to January 2015 for 2 districts.

We calculated the mean number of days between symptom onset and isolation for the same districts and period for 3 groups: CCC patients, all patients, and patients attending Ebola facilities other than CCCs. To estimate means for CCC patients, we transformed categorical data on symptom onset (i.e., < 48 hours, 2–4 days, and 5 or more days) by using continuous data from the Viral Hemorrhagic Fever data set for the proportion of patients who presented within daily increments. We subsequently removed the CCC patient numbers to generate a mean for patients attending Ebola facilities other than CCCs.

Contribution of Community Care Centers on Transmission

As Ro is proportional to the duration of infectiousness, we estimated effects on Ro by examining the contribution of early isolation to the duration of infectiousness in districts where CCCs were operational. We generated a range of effects on the duration of infectiousness and Ro based on varying assumptions regarding the proportion of EVD cases detected at CCCs in which patients would eventually seek treatment elsewhere (see Appendix available as a supplement to the online version of this article at http://www.ajph.org). We conducted statistical analyses in Stata version IC 12.1 (StataCorp, College Station, TX).

A total of 46 CCCs were established across 5 predominantly rural districts over one third of Sierra Leone (Figure 1; Figure B, available as a supplement to the online version of this article at http://www.ajph.org). Sites were prepared and CCCs constructed by local nongovernmental organizations or private contractors with design specifications, materials, and oversight provided by UNICEF. The CCCs were opened in a phased manner during a 2-month period from mid-November 2014 to mid-January 2015, at a pace of 7 new operational beds and nearly 1 CCC per day.

A total of 942 staff were recruited and trained to support 404 beds. Staff were employed by the Ministry of Health and Sanitation. In general, CCCs were staffed by nurses in training and junior nurses not yet formally absorbed by the Ministry. Nongovernmental organizations and District Health Management Teams provided regular site supervision and monitoring. All supplies including personal protective equipment and medicines were procured and shipped to the sites directly by UNICEF. Mobile laboratory technicians collected patient specimens and transported them to the nearest laboratory for testing. Laboratory results were communicated by telephone. Partnerships were developed to improve access to safe and dignified burials, nutritional support, and rapid case investigation through District Ebola Response Centers.


A total of 6 focus groups, 3 community dialogues, and 3 triads were conducted. Five key informant interviews took place with village leadership structures and an additional 3 with nongovernmental implementing partners. Focus groups and triads were conducted with 4 male groups, 4 female groups, 1 mixed group, and 4 groups with young people younger than 18 years. The profile of social mobilization activities pertaining to CCCs is presented in Table A, available as a supplement to the online version of this article at http://www.ajph.org.

During the preestablishment phase, fears and misconceptions existed about CCCs and EVD care seeking in general despite previous community consultation. As CCCs were being established, respondents noted “being scared” and that CCCs reflected “their villages being affected by Ebola,” despite having the knowledge and information that “it’s a holding center where sick people with Ebola can go before they go to the health center.” In communities that were far from the CCC, people were not motivated to go to the “white tents” and were of the opinion that their elders and the paramount chiefs had the capacity and “secret powers” to manage Ebola cases within the community. One focus group respondent stated,

We take care of sick at home and have always done that. Our traditional practices are very effective. We never took the sick to the hospital, unless in an emergency. We are trying to change that now.

Many women preferred going to the Primary Health Units, as the common perception was that a CCC was a “place where people were getting injected with the Ebola virus.”

Over the course of the implementation and as experience with the CCCs grew, attitudes started to shift. Men interviewed were generally content that they had a “center” inside their community where they could take sick individuals in the event of illness. Female respondents, however, diverged in their opinions. In some areas, women were reassured of the safety of CCCs, which they attributed to community involvement in construction and care. In others, women expressed concerns in approaching CCCs because of fears of contracting Ebola. In addition, women also expressed a fear for their children’s health, as schools were closed and it was difficult to keep them occupied at home.

Focus groups with village leaders and councilors suggested that the CCCs became a part of the community and that it was their responsibility to ensure that the people from the communities were accessing care.

It is a part of our community now. We were a part of the community talks even when it was not built. It is built now to take care of us and we, as the custodians of our community, will make the treatment of Ebola available through our CCCs.

There is evidence that social mobilization activities played a role in fostering community acceptance. Most of the respondents mentioned that the CCCs were less intimidating and more accessible and acceptable than other levels of care. A key informant interview with a social mobilizer noted

now the scenario has changed. The communities are so mobilized that people want to access CCCs and want to get early treatment of their loved ones and get more information on how they can protect their families from Ebola.

It is important to note that, in some instances, motivation to use the CCCs was linked to the availability of free medicines and the facility being larger and cleaner than a primary health unit.


Between late November 2014 and mid-February 2015, 6129 patients were triaged at 46 CCCs across 5 districts (Tables 1 and 2). While numbers of patients triaged increased in parallel to CCC opening, use rates increased even as numbers of EVD cases in CCC districts declined. Twelve percent of patients accessing CCCs were identified as EVD suspects, with the proportion decreasing as EVD caseloads declined. Overall, 73% of suspects were admitted with 27% immediately transferred to Ebola Treatment Centers. Among patients admitted and those immediately transferred who were tracked, 17% tested EVD-positive. The average time between admission and receipt of results was 1.76 days. Because severely ill patients were quickly transferred from the CCCs, lab results were not traceable in some instances.


TABLE 1— Characteristics of Community Care Centers Related to Use and Transmission: Sierra Leone, 2014–2015

TABLE 1— Characteristics of Community Care Centers Related to Use and Transmission: Sierra Leone, 2014–2015

CharacteristicsNo. (%)
Use: triaged, suspect, and case identification facility register and laboratory records (Nov 2014–Feb 2015)
 No. of CCCs46
 No. of districts5
 No. of triaged patients (13 epidemic wk)6129
 Ebola suspects identified among triaged patients719 (12)
 Ebola suspects admitted526/719 (73)
 Ebola suspects immediately transferred193/719 (27)
 Ebola suspects testing positive78/474 (17)
Use: care-seeking behavior and source of referral, structured questionnaire (Jan 30–Feb 6, 2015)
 Presented to CCC outside national “alert” system226/228 (99)
 Distance from home < 2 km138/228 (61)
 Attending CCC for health-related Ebola concerns216/228 (95)
 Attending CCC for free health care115/228 (50)
Transmission: estimated reduction in EVD reproduction number (Ro; Nov 2014–Jan 2015)(13–32)

Note. CCC = Community Care Center; EVD = Ebola virus disease.


TABLE 2— Characteristics of Community Care Centers Related to Early Isolation: Sierra Leone, 2014–2015

TABLE 2— Characteristics of Community Care Centers Related to Early Isolation: Sierra Leone, 2014–2015

CharacteristicCCCs, No. (%) or MeanOther Ebola Facilities,a No. (%) or MeanOR (95% CI)
Early isolation: time to isolation among patients accessing CCCs vs other Ebola facilities, CCC database vs national Viral Hemorrhagic Fever data set (Nov 2014–Jan 2015)
 Proportion of EVD suspects detected322/699 (46)377/699 (54)
 Proportion of confirmed EVD cases detected62/206 (30)144/206 (70)
 Time between symptom onset and isolation < 4 d194/228b (85)342/699 (49)6.0 (4.0, 9.1)
 Estimated days between symptom onset and isolation2.95.8

Note. CCC = Community Care Center; CI = confidence interval; EVD = Ebola virus disease; OR = odds ratio.

aIncludes Ebola treatment centers and holding centers.

bSymptom onset information only collected for patients admitted to CCCs and not for suspected cases that were immediately transferred. For some patients, symptom-onset information was uninterpretable and removed.

Among the 228 patients who responded to a structured questionnaire on care-seeking behavior and source of referral, nearly all (99%) used CCCs outside the national alert system for suspect identification and referral. The majority (61%) of patients who used CCCs resided within 2 kilometers of the facility. Most (71%) had heard about CCCs through social mobilization efforts including directly from facilitators or alternatively from targeted community groups such as churches, mosques, or community leaders. Nearly all patients (95%) reported coming to CCCs for their intended purpose—to screen for EVD because of sickness, contact with an EVD-affected person, or attendance at a funeral. Half of patients mentioned access to free medicine or health care as a reason for attending a CCC.

Early Isolation

We compared patients accessing CCCs with those admitted to other Ebola care facilities. Eighty-five percent of CCC patients presented within 4 days of symptom onset compared with 61% of patients in other facilities, generating an odds ratio of 3.7 (95% confidence interval [CI] = 2.5, 5.6).

As the Viral Hemorrhagic Fever data set represents all reported EVD cases including CCC patients, when the number of CCC patients was excluded, the respective proportions were 85% and 49%, respectively, with an odds ratio of 6.0 (95% CI = 4.0, 9.1). The mean number of days from symptom onset to isolation was estimated to be 2.9 days for CCC patients, 5.1 days for all patients, and 5.8 days for non-CCC patients.


In 2 districts where CCCs were deployed from mid-November to mid-January, the proportion of EVD suspects detected by CCCs was 46% and the proportion of EVD-positive patients identified through CCCs was 30%.

For all EVD cases, the duration of infectiousness without CCCs was estimated to be between 7.1 and 7.9 days, and between 4.8 and 6.9 days where CCCs were available. In these districts, the contribution of CCCs toward reducing Ro was estimated to be between 13% and 32%.

Community-based Ebola care centers are a new strategy for Ebola prevention and control initiated in response to the unprecedented scale and complexity of the current EVD epidemic in West Africa. Experience in Sierra Leone suggests that a decentralized, rapidly deployed, community-owned strategy for Ebola control was feasible and acceptable. In just 8 weeks, 46 Ebola CCCs across 5 districts were operational and networked with other response services, with most sites being active within 2 weeks of site selection. The CCCs adhered to stringent infection-prevention and -control protocols for patients and health worker safety, with no staff infections reported.21 Despite little preexisting laboratory infrastructure, mobile teams were able to work with specialized laboratories to support rapid diagnosis.

We assessed the potential for CCCs to influence Ebola transmission in a number of ways. First, although communities were initially fearful, early consultation and social mobilization enhanced acceptability. Second, levels of use were high. Within the first months, more than 6000 patients were triaged—with the vast majority of patients using facilities appropriately for Ebola-related care and support. Nearly all patients lived nearby and were self-referred, accessing CCCs outside the national alert system, suggesting that close-to-home community-based services have the potential to draw out hidden cases. Twelve percent of patients triaged were identified as EVD suspects—with higher ratios during peak transmission periods. Third, we observed substantially shorter periods between symptom onset and isolation among patients accessing CCCs compared with those admitted to more centralized facilities. Finally, CCCs contributed to an estimated 13% to 32% reduction in Ro in districts where they were deployed.

The CCC model was heavily influenced by evidence suggesting that community-based approaches that work across disciplines to identify and address complex health and development challenges can be highly effective.22,23 In the case of HIV/AIDS, there is strong evidence that community engagement and political support have been key ingredients in the success of HIV treatment24 as well as national efforts to change behavior and prevent new infections.25 Similarly, building community capacity for early case detection and treatment support have long been pillars of tuberculosis prevention and control.26,27 Community involvement has shown similar promise in mitigating preventable maternal and newborn deaths and intimate partner violence.28–30

Although CCC implementation in Sierra Leone was largely consistent with the original model,14 there were also important differences. The model allowed for the use of community health workers, whereas CCCs in Sierra Leone were staffed by junior nurses with at least 2 to 3 years of training. The availability of this cadre was important in light of the complexity of infection-prevention and -control standards, the clinical experience required for effective triage and care, and for instilling confidence in the system. Although the model called for CCCs to act as semiautonomous hubs for prevention services such as safe burial and case finding, in practice, these efforts were embedded within wider District Ebola Response Center activities. Most importantly, CCCs operated primarily as outpatient triage, early isolation, testing, and referral facilities, rather than as inpatient units. This was a consequence of declining EVD caseloads alongside the expansion of specialized Ebola Treatment Center beds and ambulance services that came online at a similar time. In the future, early deployment will be critical for maximizing the contribution of CCCs toward reducing transmission.

There were also limitations to this assessment that are important to underscore. Early lessons are provisional as many sites remain operational, and the role of CCCs may shift as transmission patterns change in this ongoing epidemic. In addition, the comparison of CCC data with the national Viral Hemorrhagic Fever data set was limited by an inability to specifically extract data on individual CCC patients. Finally, because the data collected are operational and descriptive in nature, definitive statements regarding the overall impact of CCCs relative to alternative approaches cannot be made.

In summary, the experience with CCCs in Sierra Leone suggests that rapid deployment of a community-based Ebola response at scale is both feasible and effective, contributing to reductions in EVD transmission. Within the overall Ebola response architecture, such decentralized triage and referral networks are a vital complement to more centralized treatment centers. Experience gained through this initiative has informed rapid-response systems to better address hotspots in remote and poorly accessible cross-border areas that are now a focus of attention during the elimination phase. There are also areas where the approach adopted may contribute to wider health systems strengthening. Foremost, CCCs were managed by government, which was critical for ownership, capacity building, and sustainability. Employing national staff through the Ministry, as opposed to through parallel institutions, has also shaped discussions on how to reposition this new capacity to sustain effective surveillance, triage, and isolation. Moving forward, it will be imperative to harness and translate emerging lessons to support the post-Ebola recovery period. The prevention and control of future outbreaks will rely less on Ebola-specific strategies, and more on collective efforts to forge strong and resilient health systems.


The UK Department for International Development provided financial resources to deploy and operationalize the Community Care Centers.

We would like to thank the Sierra Leone Ministry of Health and Sanitation for their support. We would also like to thank colleagues at World Health Organization, United Nations Population Fund, and US Centers for Disease Control and Prevention, as well as key Community Care Centers’ implementing partners (Concern Worldwide, World Hope International, Action Aid, Marie-Stopes International, and Partners in Health). Finally, we appreciate the support of Caitlin Rivers who provided analytical advice.

The following are the contributing members of the UNICEF Sierra Leone Ebola Response Team: UNICEF Headquarters, New York, NY: Aline Simen Kapeu; UNICEF Supply Division, Copenhagen, Denmark: Francisco Blanco, Rudolf Schwenk; and UNICEF Sierra Leone, Freetown, Sierra Leone: Aregawi Tedella, Cormac Rooney, Kshitij Joshi, Liya Aklilu, Lucille Knight, Michele Roessler, Muhadili Shemsanga, Nuhu Maksha, Patrick Nyeko, Regina Sia Saffa, Robert Moikowa, Wesner Toussaint, Faraja Chiwile, Nathalie Daries, Patrick Okoth, and Shane O’Connor.

Note. The UK Department for International Development was not involved in the design of the study or interpretation of data.


Operational data were used for this assessment, which did not require institutional review board approval.


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Paul Pronyk, MD, PhD, Braeden Rogers, MIA, MPH, Sylvia Lee, MSc, MPH, Aarunima Bhatnagar, MSc, Yaron Wolman, MD, MBA, Roeland Monasch, MA, David Hipgrave, MBBS, PhD, Peter Salama, MBBS, Adam Kucharski, PhD, and Mickey Chopra, PhD, on behalf of the UNICEF Sierra Leone Ebola Response TeamPaul Pronyk, Braeden Rogers, Mickey Chopra, David Hipgrave, and Peter Salama are with UNICEF Headquarters, New York, NY. Paul Pronyk is also with the School of Public Health, University of the Witwatersrand, Johannesburg, South Africa. Sylvia Lee, Aarunima Bhatnagar, Yaron Wolman, and Roeland Monasch are with UNICEF Sierra Leone, Freetown. Adam Kucharski is with Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, England. “The Effect of Community-Based Prevention and Care on Ebola Transmission in Sierra Leone”, American Journal of Public Health 106, no. 4 (April 1, 2016): pp. 727-732.


PMID: 26890176