The 2014–2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: Time-series analyses for 2010–2016

The aim of this study is to estimate the immediate and lasting effects of the 2014–2015 Ebola virus disease (EVD) outbreak on public-sector primary healthcare delivery in Liberia using 7 years of comprehensive routine health information system data. We analyzed 10 key primary healthcare indicators before, during, and after the EVD outbreak using 31,836 facility-month service outputs from 1 January 2010 to 31 December 2016 across a census of 379 public-sector health facilities in Liberia (excluding Montserrado County). All indicators had statistically significant decreases during the first 4 months of the EVD outbreak, with all indicators having their lowest raw mean outputs in August 2014. Decreases in outputs comparing the end of the initial EVD period (September 2014) to May 2014 (pre-EVD) ranged in magnitude from a 67.3% decrease in measles vaccinations (95% CI: ？77.9%, ？56.8%, p < 0.001) and a 61.4% decrease in artemisinin-based combination therapy (ACT) treatments for malaria (95% CI: ？69.0%, ？53.8%, p < 0.001) to a 35.2% decrease in first antenatal care (ANC) visits (95% CI: ？45.8%, ？24.7%, p < 0.001) and a 38.5% decrease in medroxyprogesterone acetate doses (95% CI: ？47.6%, ？29.5%, p < 0.001). Following the nadir of system outputs in August 2014, all indicators showed statistically significant increases from October 2014 to December 2014. All indicators had significant positive trends during the post-EVD period, with every system output exceeding pre-Ebola forecasted trends for 3 consecutive months by November 2016. Health system outputs lost during and after the EVD outbreak were large and sustained for most indicators. Prior to exceeding pre-EVD forecasted trends for 3 months, we estimate statistically significant cumulative losses of ？776,110 clinic visits (95% CI: ？1,480,896, ？101,357, p = 0.030); ？24,449 bacille Calmette–Guérin vaccinations (95% CI: ？45,947, ？2,020, p = 0.032); ？9,129 measles vaccinations (95% CI: ？12,312, ？5,659, p < 0.001); ？17,191 postnatal care (PNC) visits within 6 weeks of birth (95% CI: ？28,344, ？5,775, p = 0.002); and ？101,857 ACT malaria treatments (95% CI: ？205,839, ？2,139, p = 0.044) due to the EVD outbreak. Other outputs showed statistically significant cumulative losses only through December 2014, including losses of ？12,941 first pentavalent vaccinations (95% CI: ？20,309, ？5,527, p = 0.002); ？5,122 institutional births (95% CI: ？8,767, ？1,234, p = 0.003); and ？45,024 acute respiratory infections treated (95% CI: ？66,185, ？24,019, p < 0.001). Compared to pre-EVD forecasted trends, medroxyprogesterone acetate