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handling potentially infectious bodies, including the donning and removal of personal protective equipment (PPE) • Self-discipline to follow the correct procedures without exception Health promotion and communication interventions from the CDC and West African governments Regarding viral hemorrhagic fever (VHF), including Ebola, the CDC issued interim guidance in 2005 for managing patients with VHF who were admitted to hospitals in the United States [55]. During the Ebola outbreak in West Africa, 1,450 CDC staff members were deployed to Guinea, Liberia, and Sierra Leone from the beginning of the response in July 2014 to the end of March 2016. They assisted the Ministries of Health in providing technical support for infection control and health communication at the prefecture (Guinea), country (Liberia), and district (Sierra Leone) levels [56]. The CDC’s response to the Ebola outbreak varied by country [56]. In Liberia, for instance, the organization issued a culturally sensitive burial protocol entitled ‘Ebola Must Go: Bury All Dead Bodies Safely’ in December 2014 [57]. This guideline encouraged people to call the national hotline number 4455 to report a death and alert the burial team to take the body for free burial [57]. It is questionable whether the guideline convinced people to stay away from the bodies of Ebola victims. Although the protocol asserted that “all burials will be safe, free, and respect the families” [57], there was no explanation of how burial teams would pay respect without touching Journal of Health and Social Sciences 2020; 5,1:073-090 The Italian Journal for Interdisciplinary Health and Social Development 82 the body. The efficacy of this protocol is unknown because there was no follow-up evaluation of the system. Nonetheless, the system itself seemed highly popular; according to a United States Agency of International Development report, nearly 1,000 people called the call center with queries during the first 2 days of operation [58]. The CDC put a great deal of effort into implementing health promotion and communications on the ground. Emergency risk communication specialists were included in the CDC field teams, charged with not only designing and disseminating accurate information, decreasing stigma, addressing rumors, and reducing unsafe burial practices but also responding to community needs [59]. To reduce resistance to safe burials, CDC staff in Liberia and Sierra Leone identified and promulgated culturally acceptable burial practices that met community needs [36, 60]. The government of Liberia designed a National Ebola Response Strategy in September 2014 and planned to increase the number of burial teams in the highly affected areas of Montserrado and the leeward counties [61]. An algorithm for the management of human remains and a decision tree for contract tracing was designed but incompletely adopted in Liberia [62]. In Lofa County, Liberia, an area with some of the highest numbers of reported Ebola cases in West Africa, the CDC implemented a strategy to reduce the transmission of the Ebola virus in September 2014 [60]. In collaboration with the Liberian Ministry of Health and Social Welfare, the CDC placed a high value on transparency in activities and engagement with the community [60]. The ETC in Lofa County was built without high or opaque walls to reduce fear of the facility. In addition, family members were permitted to visit their loved ones by walking with burial teams across a fence or inside the ward while wearing PPE [60]. They could be present when their loved one was buried at a designated burial site and could hold grieving ceremonies according to local customs [60]. Engagement with the local population raised confidence and trust in response activities; villagers could request help to transport ill persons quickly to the ETC [60]. These initial efforts in Lofa and Montserrado counties were expanded nationwide [63]. The government of Sierra Leone designed a National Communication Strategy for Ebola Response in September 2014 in an effort to provide safe and dignified burial practices for up to 90% of suspected Ebola casualties by the end of December 2014 [64]. Additionally, the CDC and the Sierra Leone Ministry of Health and Sanitation assessed safe and nontraditional burial practices, cemetery management, and adherence to recommended practices by directly observing them [36]. Findings from the assessment were used by the Sierra Leone Emergency Operations Center to develop a national standard operating procedure (SOP) for safe, dignified medical burials on October 1, 2014 [36]. The SOP was designed to provide operational guidance during the Ebola outbreak and is described in the following instructions [36, 65]: • In high-incidence areas, all deceased persons should be buried by burial teams within 24 hours, regardless of laboratory results. • Because of limited laboratory capacity, it is recommended to swab only bodies of 1) suspected or probable Ebola victims and 2) those who have died from an unknown cause. There is no need to conduct swab testing for those who have clearly died from another cause or were Ebola positive. • It is recommended to increase the number of burial teams in the country to 120 to enable each team to collect a manageable number of bodies, five or fewer each day, and to put on and remove PPE a reasonable
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