Colin S Brown

Clinical features of patients isolated for suspected Ebola virus disease at Connaught Hospital, Freetown, Sierra Leone: a retrospective cohort study

BACKGROUND The size of the west African Ebola virus disease outbreak led to the urgent establishment of Ebola holding unit facilities for isolation and diagnostic testing of patients with suspected Ebola virus disease. Following the onset of the outbreak in Sierra Leone, patients presenting to Connaught Hospital in Freetown were screened for suspected Ebola virus disease on arrival and, if necessary, were admitted to the on-site Ebola holding unit. Since demand for beds in this unit greatly exceeded capacity, we aimed to improve the selection of patients with suspected Ebola virus disease for admission by identifying presenting clinical characteristics that were predictive of a confirmed diagnosis. METHODS In this retrospective cohort study, we recorded the presenting clinical characteristics of suspected Ebola virus disease cases admitted to Connaught Hospitals Ebola holding unit. Patients were subsequently classified as confirmed Ebola virus disease cases or non-cases according to the result of Ebola virus reverse-transcriptase PCR (EBOV RT-PCR) testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of every clinical characteristic were calculated, to estimate the diagnostic accuracy and predictive value of each clinical characteristic for confirmed Ebola virus disease. RESULTS Between May 29, 2014, and Dec 8, 2014, 850 patients with suspected Ebola virus disease were admitted to the holding unit, of whom 724 had an EBOV RT-PCR result recorded and were included in the analysis. In 464 (64%) of these patients, a diagnosis of Ebola virus disease was confirmed. Fever or history of fever (n=599, 83%), intense fatigue or weakness (n=495, 68%), vomiting or nausea (n=365, 50%), and diarrhoea (n=294, 41%) were the most common presenting symptoms in suspected cases. Presentation with intense fatigue, confusion, conjunctivitis, hiccups, diarrhea, or vomiting was associated with increased likelihood of confirmed Ebola virus disease. Three or more of these symptoms in combination increased the probability of Ebola virus disease by 3·2-fold (95% CI 2·3-4·4), but the sensitivity of this strategy for Ebola virus disease diagnosis was low. In a subgroup analysis, 15 (9%) of 161 confirmed Ebola virus disease cases reported neither a history of fever nor a risk factor for Ebola virus disease exposure. INTERPRETATION Discrimination of Ebola virus disease cases from patients without the disease is a major challenge in an outbreak and needs rapid diagnostic testing. Suspected Ebola virus disease case definitions that rely on history of fever and risk factors for Ebola virus disease exposure do not have sufficient sensitivity to identify all cases of the disease. FUNDING None.

Ebola Virus Disease Complicated by Late-Onset Encephalitis and Polyarthritis, Sierra Leone.

To the Editor: Ebola virus (EBOV) disease is usually an acute illness, but increasing evidence exists of persistent infections and post-Ebola syndromes. We report a case of EBOV encephalitis.

Assessment of environmental contamination and environmental decontamination practices within an Ebola holding unit, Freetown, Sierra Leone

Evidence to inform decontamination practices at Ebola holding units (EHUs) and treatment centres is lacking. We conducted an audit of decontamination procedures inside Connaught Hospital EHU in Freetown, Sierra Leone, by assessing environmental swab specimens for evidence of contamination with Ebola virus by RT-PCR. Swabs were collected following discharge of Ebola Virus Disease (EVD) patients before and after routine decontamination. Prior to decontamination, Ebola virus RNA was detected within a limited area at all bedside sites tested, but not at any sites distant to the bedside. Following decontamination, few areas contained detectable Ebola virus RNA. In areas beneath the bed there was evidence of transfer of Ebola virus material during cleaning. Retraining of cleaning staff reduced evidence of environmental contamination after decontamination. Current decontamination procedures appear to be effective in eradicating persistence of viral RNA. This study supports the use of viral swabs to assess Ebola viral contamination within the clinical setting. We recommend that regular refresher training of cleaning staff and audit of environmental contamination become standard practice at all Ebola care facilities during EVD outbreaks.

Ebola Holding Units at government hospitals in Sierra Leone: evidence for a flexible and effective model for safe isolation, early treatment initiation, hospital safety and health system functioning

The 2014-2015 West African outbreak of Ebola Virus Disease (EVD) claimed the lives of more than 11,000 people and infected over 27,000 across seven countries. Traditional approaches to containing EVD proved inadequate and new approaches for controlling the outbreak were required. The Ministry of Health & Sanitation and King’s Sierra Leone Partnership developed a model for Ebola Holding Units (EHUs) at Government Hospitals in the capital city Freetown. The EHUs isolated screened or referred suspect patients, provided initial clinical care, undertook laboratory testing to confirm EVD status, referred onward positive cases to an Ebola Treatment Centre or negative cases to the general wards, and safely stored corpses pending collection by burial teams. Between 29th May 2014 and 19th January 2015, our five units had isolated approximately 37% (1159) of the 3097 confirmed cases within Western Urban and Rural district. Nosocomial transmission of EVD within the units appears lower than previously documented at other facilities and staff infection rates were also low. We found that EHUs are a flexible and effective model of rapid diagnosis, safe isolation and early initial treatment. We also demonstrated that it is possible for international partners and government facilities to collaborate closely during a humanitarian crisis.

Diagnostics in Ebola Virus Disease in Resource-Rich and Resource-Limited Settings

The Ebola virus disease (EVD) outbreak in West Africa was unprecedented in scale and location. Limited access to both diagnostic and supportive pathology assays in both resource-rich and resource-limited settings had a detrimental effect on the identification and isolation of cases as well as individual patient management. Limited access to such assays in resource-rich settings resulted in delays in differentiating EVD from other illnesses in returning travellers, in turn utilising valuable resources until a diagnosis could be made. This had a much greater impact in West Africa, where it contributed to the initial failure to contain the outbreak. This review explores diagnostic assays of use in EVD in both resource-rich and resource-limited settings, including their respective limitations, and some novel assays and approaches that may be of use in future outbreaks.

Ebola virus disease: where are we now and where do we go?

Despite its vivid place in the popular imagination, conjuring up images of germ warfare and Hollywood blockbusters, Ebola has previously affected a relatively small number of people. Prior to 2014, approximately 2400 people were infected, with just over 1500 deaths in the four decades since its 1976 discovery in Zaire and Sudan. 1 Smaller outbreaks occurred in the late 1970s, with sporadic, larger ones each numbering under 500 cases seen in the Democratic Republic of Congo (Zaire) and Uganda in the 1990s, 2000s and early 2010s. Ebola virus disease (EVD) was therefore largely thought to be an exotic, tropical disease confined to self-limiting outbreaks in rural central Africa. It was considered a terrifying but unsuccessful virus, killing off its hosts too quickly to transmit it to many others. It felt remote. The 2014 outbreak has forever changed those perceptions. In early March 2014, Guinea announced that an outbreak of unexplained illness with high mortality around Gueckedou and Macenta, near the country’s south-western border with Sierra Leone and Liberia, was due to EVD. Cases soon emerged in northern Liberia and were seen in eastern Sierra Leone by the end of May. This was to be expected, given that the early epicentre of the outbreak mapped exactly on to the homelands of the Kissi people, whose shared culture is blind to national borders. Nigeria and Senegal have since seen imported cases, further exacerbating the regional crisis. The West African virus has been confirmed to be part of the Zaire ebolavirus (EBOV) lineage, with a probable separation around 2004 from the central African virus.

Fit for the future? The place of global health in the UK's postgraduate medical training: a review.

Objectives That health is now global is increasingly accepted. However, a ‘mismatch between present professional competencies and the requirements of an increasingly interdependent world’ has been identified. Postgraduate training should take account of the increasingly global nature of health; this paper examines the extent to which they currently do. Design Trainees across 11 medical specialties reviewed the content of their postgraduate curriculum. Setting Not relevant. Partcipants None. Main outcome measures Competencies were coded as ‘UK’ (statement only relevant to UK work), ‘global’ (statement with an explicit reference to aspects of health outside the UK) or generic (relevant both to the UK and international settings). Results Six of the 11 curricula reviewed contained global health competencies. These covered the global burden or determinants of disease and appropriate policy responses. Only one College required trainees to ‘be aware of the World Health Organization’, or ‘know the local, national and international structures for health care’. These cross-cutting competencies have applicability to all specialties. All 11 curricula contained generic competencies where a global health perspective and/or experience could be advantageous, e.g. caring for migrant or culturally different patients. Conclusion Trainees in all specialties should achieve a minimum requirement of global health awareness. This can be achieved through a small number of common competencies that are consistent across core curricula. These should lead on from equivalent undergraduate competencies. Addressing the current gap in the global health content of postgraduate medical curricula will ensure that the UK has health professionals that are trained to meet the health challenges of the future.

Quantifying the risk of nosocomial infection within Ebola Holding Units: a retrospective cohort study of negative patients discharged from five Ebola Holding Units in Western Area, Sierra Leone

A central pillar in the response to the 2014 Ebola virus disease (EVD) epidemic in Sierra Leone was the role of Ebola Holding Units (EHUs). These units isolated patients meeting a suspect case definition, tested them for EVD, initiated appropriate early treatment and discharged negative patients to onward inpatient care or home. Positive patients were referred to Ebola Treatment Centres. We aimed to estimate the risk of nosocomial transmission within these EHUs.

Ebola virus disease: the ‘Black Swan’ in West Africa

Ebola virus disease (EVD) was first discovered in the Democratic Republic of the Congo in 1976, and by 2013 had caused approximately 20 recorded outbreaks across East and Central Africa. These had been restricted to rural areas and confined to small clusters of villages. In each case containment was achieved within a few months and after fewer than 500 confirmed cases. The world assumed that EVD was too efficient at killing its hosts, doomed to quickly burn out wherever it arose. The 2014 West African outbreak has changed everything. It was the ‘Black Swan’ – the inevitable consequence we did not foresee. By midDecember 2014, there had been over 17,000 reported cases spread across nearly every region in three adjacent countries, and approximately 6,000 people are known to have died. It spread to the US, Mali, Senegal and Nigeria. Cases have been treated across Western Europe. Until early November 2014, there was no sign of a reduction in transmission, and case numbers were rising exponentially. This is still true of Sierra Leone where over one hundred health care workers have died, and there is no certainty the other affected countries will not again see an upsurge in new cases. Estimates of how many people could be affected have varied widely and include up to 1,400,000, or up to 25,000 cases per day by midJanuary 2015. This has increased dramatically since the World Health Organization (WHO) projected a maximum of 20,000 cases in August 2014, highlighting how difficult it is to predict the future epidemic direction, though organisations such as Medecins Sans Frontieres highlighted their concern as early as March 2014. Mathematical modelling is challenging and cannot easily account for conflict, mass movement of people, or breakdown of civil society, but though the very high case numbers may not be reached, one thing is certain: this will be a terrifyingly large outbreak, something never before faced on a global scale.

Novel surveillance methods for the control of Ebola virus disease

The unprecedented scale of the 2013-2016 West African Ebola virus disease (EVD) outbreak was in a large part due to failings in surveillance: contacts of confirmed cases were not systematically identified, monitored and diagnosed early, and new cases appearing in previously unaffected communities were similarly not rapidly identified, diagnosed and isolated. Over the course of this epidemic, traditional surveillance methods were strengthened and novel methods introduced. The wealth of experience gained, and the systems introduced in West Africa, should be used in future EVD outbreaks, as well as for other communicable diseases in the region and beyond.