J. Daniel Kelly

Social Support as a Predictor of Early Diagnosis, Linkage, Retention, and Adherence to HIV Care: Results From The Steps Study

&NA; Social support predicts adherence to antiretroviral therapy (ART) in some settings but has not been well studied in persons newly diagnosed with HIV infection as a predictor of success through the cascade of HIV care. One hundred sixty‐eight persons newly diagnosed with HIV completed the Medical Outcomes Study Social Support Survey at diagnosis, and 129 were successfully followed for more than 12 months. Outcomes were earlier diagnosis of HIV infection, linkage to care, retention in care, ART use by 1 year, and adherence to ART. Higher social support scores (either overall or on a subscale) were associated with earlier HIV diagnosis, timely linkage to care, and adherence to ART. Social support did not predict use of ART or retention in HIV care. Success navigating some of the steps of HIV care is more likely with social support, but it is not sufficient to ensure success across the continuum of care.

Performance of the GeneXpert Ebola Assay for Diagnosis of Ebola Virus Disease in Sierra Leone: A Field Evaluation Study

Background Throughout the Ebola virus disease (EVD) epidemic in West Africa, field laboratory testing for EVD has relied on complex, multi-step real-time reverse transcription PCR (RT-PCR) assays; an accurate sample-to-answer RT-PCR test would reduce time to results and potentially increase access to testing. We evaluated the performance of the Cepheid GeneXpert Ebola assay on clinical venipuncture whole blood (WB) and buccal swab (BS) specimens submitted to a field biocontainment laboratory in Sierra Leone for routine EVD testing by RT-PCR (“Trombley assay”). Methods and Findings This study was conducted in the Public Health England EVD diagnostic laboratory in Port Loko, Sierra Leone, using residual diagnostic specimens remaining after clinical testing. EDTA-WB specimens (n = 218) were collected from suspected or confirmed EVD patients between April 1 and July 20, 2015. BS specimens (n = 71) were collected as part of a national postmortem screening program between March 7 and July 20, 2015. EDTA-WB and BS specimens were tested with Xpert (targets: glycoprotein [GP] and nucleoprotein [NP] genes) and Trombley (target: NP gene) assays in parallel. All WB specimens were fresh; 84/218 were tested in duplicate on Xpert to compare WB sampling methods (pipette versus swab); 43/71 BS specimens had been previously frozen. In all, 7/218 (3.2%) WB and 7/71 (9.9%) BS samples had Xpert results that were reported as “invalid” or “error” and were excluded, leaving 211 WB and 64 BS samples with valid Trombley and Xpert results. For WB, 22/22 Trombley-positive samples were Xpert-positive (sensitivity 100%, 95% CI 84.6%–100%), and 181/189 Trombley-negative samples were Xpert-negative (specificity 95.8%, 95% confidence interval (CI) 91.8%–98.2%). Seven of the eight Trombley-negative, Xpert-positive (Xpert cycle threshold [Ct] range 37.7–43.4) WB samples were confirmed to be follow-up submissions from previously Trombley-positive EVD patients, suggesting a revised Xpert specificity of 99.5% (95% CI 97.0%–100%). For Xpert-positive WB samples (n = 22), Xpert NP Ct values were consistently lower than GP Ct values (mean difference −4.06, 95% limits of agreement −6.09, −2.03); Trombley (NP) Ct values closely matched Xpert NP Ct values (mean difference −0.04, 95% limits of agreement −2.93, 2.84). Xpert results (positive/negative) for WB sampled by pipette versus swab were concordant for 78/79 (98.7%) WB samples, with comparable Ct values for positive results. For BS specimens, 20/20 Trombley-positive samples were Xpert-positive (sensitivity 100%, 95% CI 83.2%–100%), and 44/44 Trombley-negative samples were Xpert-negative (specificity 100%, 95% CI 92.0%–100%). This study was limited to testing residual diagnostic samples, some of which had been frozen before use; it was not possible to test the performance of the Xpert Ebola assay at point of care. Conclusions The Xpert Ebola assay had excellent performance compared to an established RT-PCR benchmark on WB and BS samples in a field laboratory setting. Future studies should evaluate feasibility and performance outside of a biocontainment laboratory setting to facilitate expanded access to testing.

Community Trust and the Ebola Endgame

In May, Ebola resurfaced in parts of Guinea thought to be free from the virus. Some infections in known hot spots arise from unknown transmission chains, which suggests that other cases may be hidden. Only by building community trust can we bring the epidemic to an end.

Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone

An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the countrys most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIHs experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.

Minimally Symptomatic Infection in an Ebola ‘Hotspot’: A Cross-Sectional Serosurvey

Introduction Evidence for minimally symptomatic Ebola virus (EBOV) infection is limited. During the 2013–16 outbreak in West Africa, it was not considered epidemiologically relevant to published models or projections of intervention effects. In order to improve our understanding of the transmission dynamics of EBOV in humans, we investigated the occurrence of minimally symptomatic EBOV infection in quarantined contacts of reported Ebola virus disease cases in a recognized ‘hotspot.’ Methodology/Principal Findings We conducted a cross-sectional serosurvey in Sukudu, Kono District, Sierra Leone, from October 2015 to January 2016. A blood sample was collected from 187 study participants, 132 negative controls (individuals with a low likelihood of previous exposure to Ebola virus), and 30 positive controls (Ebola virus disease survivors). IgG responses to Ebola glycoprotein and nucleoprotein were measured using Alpha Diagnostic International ELISA kits with plasma diluted at 1:200. Optical density was read at 450 nm (subtracting OD at 630nm to normalize well background) on a ChroMate 4300 microplate reader. A cutoff of 4.7 U/mL for the anti-GP ELISA yielded 96.7% sensitivity and 97.7% specificity in distinguishing positive and negative controls. We identified 14 seropositive individuals not known to have had Ebola virus disease. Two of the 14 seropositive individuals reported only fever during quarantine while the remaining 12 denied any signs or symptoms during quarantine. Conclusions/Significance By using ELISA to measure Zaire Ebola virus antibody concentrations, we identified a significant number of individuals with previously undetected EBOV infection in a ‘hotspot’ village in Sierra Leone, approximately one year after the village outbreak. The findings provide further evidence that Ebola, like many other viral infections, presents with a spectrum of clinical manifestations, including minimally symptomatic infection. These data also suggest that a significant portion of Ebola transmission events may have gone undetected during the outbreak. Further studies are needed to understand the potential risk of transmission and clinical sequelae in individuals with previously undetected EBOV infection.

Make diagnostic centres a priority for Ebola crisis

I will never forget the first time I walked into an Ebola isolation ward at Connaught Hospital in Freetown, Sierra Leone. It was 20 August. Inside, eight people thought to have the disease were organized into three patient-care rooms. Patients in the first room appeared to be healthy, and we greeted each other. In the second room, patients barely had the strength to sit. Still, they were able to articulate how they felt. In the last room there were two patients. One was a woman who seemed confused and agitated, and was later confirmed to have the disease. On the other side of the room, a young man was curled into the corner of his bed. He seemed healthy but was terrified. He had been deathly ill when he was admitted three days earlier. He recovered, but had watched Ebola kill two others in that room. I could only imagine how I would feel in that situation, watching others get sick and die, wondering if I would be next. Then I considered the deplorable conditions — no visitors were allowed, and a bucket served as a bathroom — and how I, wearing my protective ‘spacesuit’, must have looked to the curled man. The idea of becoming sick with Ebola in Sierra Leone frightened me. It frightened him too, and much of his fear could have been avoided. It took four days for his blood to be tested and shown to be free of Ebola. At that point, Sierra Leone had two facilities able to diagnose the virus. The nearest — Kenema Government Hospital — was five hours away and was overloaded with blood samples from around the country. The evening the curled man arrived at Connaught, there was no nursing staff to oversee patient care. The Sierra Leonean doctor who had supervised the ward had died, and no Sierra Leonean doctor had taken his place. The man was locked in this terrifying environment until someone could draw his blood for testing. Blood samples and sick patients were sent to Kenema by ambulance only at the end of each day. Even after the man’s blood sample arrived in Kenema, it was not tested until the next day. I began working in Sierra Leone eight years ago, when I co-founded Wellbody Alliance, a non-profit health-care organization in Kono, so I am familiar with the logistical challenges facing the country’s collapsing health-care system. But the desperate shortage of Ebola diagnostic centres in Sierra Leone is fuelling the Ebola outbreak. People who think that they might have the disease do not want to spend several days trapped in an isolation unit, away from their families and surrounded by workers in spacesuits. This fear means that patients go to isolation wards only when their symptoms are severe, if they go at all. If Sierra Leone’s Ministry of Health and Sanitation could scale up diagnostic facilities, it would reduce fear and help to curb transmission from very sick people who are reluctant to seek treatment. Take Freetown, for example. A four-person team from South Africa arrived there on the same flight that I did. They came with a machine for analysing viral RNA and created a diagnostic site in the outskirts of Freetown at the National Laboratory of Sierra Leone. Within a week, the team was sending Ebola test results to the isolation ward twice a day. Some patients did not even have to stay overnight. That kind of experience feels less daunting and more acceptable. Even though Freetown now has a faster turnaround time on test results, Port Loko, the latest Ebola hot spot, is still sending blood samples to Kenema. In Kono, where I have also visited, three patients had to wait for their blood sample results to come back from Kenema for confirmation of diagnosis. The delay meant that all three died before they could be transferred to a treatment centre. Two weeks ago, Tom Frieden, director of the US Centers for Disease Control and Prevention (CDC), warned that it was only a matter of time before the Ebola outbreak in Sierra Leone would escalate to match the situation in Liberia. The World Health Organization (WHO) and other modelling experts have predicted 20,000–100,000 Ebola infections before the epidemic is over. We need to minimize delays in care and if we cannot speed up the health system’s lethargy, then we need to bring diagnostics closer to the people. That means we need more diagnostic sites. So far, all such sites have been developed as adjunctive services to treatment centres. We need to expand these services to every district, even those that have only an isolation centre. Because most of the clinical-care focus has been on isolation and treatment centres, the strategy for diagnostic sites has been overlooked. One of the challenges is the need to standardize equipment, techniques and results. The Ministry of Health and Sanitation wants standard diagnostics, and international agencies such as the CDC and the WHO agree. Standardization takes time, but it is necessary. Sierra Leone uses at least four different types of donated protective suit in its isolation wards, which can change the decontamination process and confuse health workers. As the number of suspected Ebola infections in Sierra Leone rises, its health system will be under increasing strain to deliver test results in a timely fashion. Three diagnostic sites are not enough. ■

Housing equity for health equity: a rights-based approach to the control of Lassa fever in post-war Sierra Leone

Poor quality housing is an infringement on the rights of all humans to a standard of living adequate for health. Among the many vulnerabilities of those without adequate shelter is the risk of disease spread by rodents and other pests. One such disease is Lassa fever, an acute and sometimes severe viral hemorrhagic illness endemic in West Africa. Lassa virus is maintained in the rodent Mastomys natalensis, commonly known as the “multimammate rat,” which frequently invades the domestic environment, putting humans at risk of Lassa fever. The highest reported incidence of Lassa fever in the world is consistently in the Kenema District of Sierra Leone, a region that was at the center of Sierra Leone’s civil war in which tens of thousands of lives were lost and hundreds of thousands of dwellings destroyed. Despite the end of the war in 2002, most of Kenema’s population still lives in inadequate housing that puts them at risk of rodent invasion and Lassa fever. Furthermore, despite years of health education and village hygiene campaigns, the incidence of Lassa fever in Kenema District appears to be increasing. We focus on Lassa fever as a matter of human rights, proposing a strategy to improve housing quality, and discuss how housing equity has the potential to improve health equity and ultimately economic productivity in Sierra Leone. The manuscript is designed to spur discussion and action towards provision of housing and prevention of disease in one of the world’s most vulnerable populations.

The Ebola suspect's dilemma

In 1950, Merrill Flood and Melvin Dresher of the RAND Corporation developed a theoretical model of cooperation and confl ict, which was later formalised by Albert W Tucker as the prisoner’s dilemma. This model represents a situation in which two prisoners each have the option to confess or not, but their sentencing outcomes depend crucially on the simultaneous choice of the other (fi gure). Fittingly, it has become the paradigmatic example of individual versus group rationality and is an often used heuristic when conveying introductory social theory to students. Although not a homologous predicament, the Ebola virus disease suspect also faces a consequential dilemma (fi gure). The ‘rational’—that is, not informed by superstition or baseless rumour—aversion to West Africa’s ill-equipped and poorly sanitised hospitals was described even before the 2014–16 Ebola outbreak. This characterisation could a fortiori be extended to those Ebola virus disease suspects who eschewed presentation to an Ebola treatment unit, especially those units that off ered little in the way of aggressive intravenous resuscitation or management of electrolyte disturbances. Consider the situation in which you are an Ebola virus disease suspect (you have fever, vomiting, muscle pain, and headache), but don’t know whether you have Ebola virus disease: (1) if you have undiagnosed malaria and stay at home, your chance of dying is 0·2%; (2) if you have undiagnosed malaria and go to an Ebola treatment unit, your chance of dying from Ebola virus disease is 16·1% (around 25% chance of nosocomial Ebola virus transmission with 64·3% mortality); or (3) if you have Ebola virus disease, stay at home, and self-isolate, your chance of dying is 70·8%. Given equal chances of having malaria (West Africa is the region with the world’s highest incidence of malaria) or Ebola virus disease, your overall mortality risk for staying at home is 35·5% versus 40·2% for going to a Ebola treatment unit. Thus, you would be acting in your rational self-interest by staying at home, since the suspect who is uninfected might become so nosocomially through ambulance transport with actual cases or unsafe triage at an Ebola treatment unit—not factoring in (1) rational desires to die at home rather than in (or in the queue in front of) a far off tent; (2) rational fears that you might never see your family again; (3) rational responses to the pervasive messaging that Ebola has no cure; or (4) the irony that, once admitted to an Ebola treatment unit that does not off er intravenous volume replacement, a rational decision might be to deliberately infect yourself with malaria: emerging evidence suggests that Plasmodium parasitemia off ers a greater survival benefi t than the oral rehydration approach used at many Ebola treatment units in 2014. And therein lies the Ebola suspect’s dilemma—at least according to the rational choice lens that refracts the world around us into binary options for our moral retinas. Now consider a Special Report by the WHO Ebola Response Team. In it, the authors rightly—if not tautologically—suggest that shortening the delay to isolation of Ebola virus disease suspects would lead to quicker overall outbreak containment, yet they fail to adequately discuss the reality that suspects will continue to be “unwilling to seek medical care,” when such care is non-existent. Indeed, our extensive interviews with survivors of Ebola virus disease and their families reveal—among a variety of reasons for Ebola treatment unit avoidance early in the outbreak—the common suggestion that international non-governmental organisations in future epidemics not be allowed to set up Ebola treatment units if they do not provide intravenous resuscitation as standard of care. Conversely, if Ebola suspects maximise their chances of survival (by staying at home in the case above), they risk—according to the methodological individualist

Multiple self-report measures of antiretroviral adherence correlated in Sierra Leone, but did they agree?:

In resource-poor settings, studies validating multiple self-report measures of adherence are limited and do not include data from West Africa. We prospectively assessed the associations between multiple self-report measures of adherence in 58 patients receiving antiretroviral therapy. Self-report measures included a 30-day visual analog scale, 30-day qualitative single-item measure, Adult AIDS Clinical Trial Group 4-day recall, and 3-level categorical 7-day qualitative measure. Unannounced pill count was the objective measure. Spearmans rho correlation coefficients, Bland-Altman plots, and receiver operator curve analyses were performed. Median and mean adherence by pill count were 81.8% and 78.6%, respectively. All self-report measures had either intermediate or high correlation with the pill count, and the 7-day measure had the highest level of correlation with pill count (r = 0.72). All self-report measures demonstrated good agreement when mean pill count adherence was greater than 90%. All but the 7-day measure posed challenges to patient understanding and administration of the measure. In this sample of participants that displayed largely suboptimal adherence, the 7-day measure was preferable, but all self-report measures demonstrated relatively good agreement with the objective criterion pill count measure and are adequate for clinical use in settings such as Sierra Leone.

Use of Ultrasound to Diagnose and Manage a Five-Liter Empyema in a Rural Clinic in Sierra Leone

We report the case of a dyspneic patient with a five-liter pleural empyema that was diagnosed and managed in a resource-limited clinic in a rural part of Sierra Leone. The diagnosis and management of this condition are usually guided by imaging modalities such as X-rays or CT scans. However, these resources may not be available in austere settings in developing countries. Because emergency physicians work in a variety of clinical settings, they should be well versed in the use of portable ultrasound machines to diagnose, treat, and manage many different conditions.