Marta Lado

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.

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.

The impact of the 2014–15 Ebola virus disease epidemic on emergency care attendance and capacity at a tertiary referral hospital in Freetown, Sierra Leone: a retrospective observational study

Abstract Background The Ebola virus disease epidemic in West Africa has infected 28 457 people and claimed more than 11 000 lives. Many more people may have died from the indirect effects of the epidemic and closure of normal health-care facilities. Unlike other facilities in West Africa, the emergency department in Connaught Hospital, Freetown, Sierre Leone, protected by an onsite Ebola holding unit, continued to provide emergency care throughout the outbreak. We aimed to assess the effect of the outbreak on emergency department attendance and presentation. We also analysed emergency care capacity across Freetown. Methods Attendance data from the emergency department and Ebola holding unit at Connaught Hospital were collected from June 1, 2014, to June 1, 2015. Severity of presentation was derived from South African Triage Score (SATS) assigned at first presentation to the emergency department. A mean severity score was calculated by dividing the number of presentations with a SATS of 1–2 by the total number of presentations. Local prevalence of the disease was counted as RT-PCR positive cases at the Ebola holding unit. Emergency care capacity was assessed at the seven principal hospitals in Freetown in May, 2013, and in April, 2015, with a standardised tool, the Emergency Care Capacity Score (ECCS), specifically designed for the low-income setting. All data were collected in Excel (2013). Stata (version 13) was used for statistical analysis. Findings 8935 patients presented to the emergency department; mean attendance was 172 patients per week (95% CI 153–191), with attendance varying from 41 patients in the week beginning July 28, 2014, to 284 patients in the week beginning May 11, 2015. Emergency department attendance had a negative correlation with local prevalence of Ebola virus disease ( r =–0·640, p Interpretation The reduction in attendance probably demonstrates both a change in health-seeking behaviour—ie, great public fear of hospitals because of the perceived risk of nosocomial transmission of the virus—and a reduction in access to care. The decrease in emergency care capacity was expected and reflects the closure of many health services other than those for Ebola virus disease. Overall, this is an important case study of the impact of an infectious disease outbreak on a tertiary referral hospital in a low-income setting. Funding None.

Ebola and provision of critical care

Following an expert meeting convened in November, 2014, by the UK Chief Medical Officer, Michael Jacobs and colleagues argue there is “no evidence that addition of ventilatory or renal support would result in substantial overall benefit for patients who receive the optimum supportive care” for Ebola. Critical care support for volunteers who treat Ebola will therefore not be routinely provided in Sierra Leone or through repatriation to the UK. This recommendation contradicts our experience and that of colleagues in Germany and the USA who have managed Ebola and provided both ventilation and dialysis to patients who required it. It also goes against expert opinion from the fi eld which suggests many acutely unwell patients, and some recovering from viraemia, become anuric. Much sudden death might be attributed to renal failure and subsequent electrolyte imbalance in addition to respiratory compromise. Though priority should lie on staff safety and immediate basic care, many healthy individuals deteriorate rapidly and might undoubtedly die without organ support. As of December 2014—when we wrote this Correspondence—22 Ebola cases had been treated outside west Africa. To our knowledge where critical care support was provided, fi ve out of eight made a complete recovery. The two US and one German patients who died received late critical care intervention. As Bruce Ribner—who leads the team at Emory University Hospital Atlanta—stated: “[they] can get sick enough to need those interventions and [they] can still walk out of the hospital”. The Centers for Disease Control and Prevention and international nephrologists have produced guidelines for safe provision of haemodialysis in Ebola care. Importantly, no virus was detected in dialysis effl uent. Though ideally we would want critical care to be available for all Ebola patients, we argue that there is no medical reason against providing intensive organ support in Ebola-induced organ failure to all international volunteers whose home countries can provide it.

Neurological and psychiatric manifestations of post Ebola syndrome in Sierra Leone

Abstract Background Neurological and psychiatric sequelae in survivors of Ebola virus disease have been noted in previous epidemics, but few details have been documented. One case-report reported abnormal CT brain findings in one survivor. We aimed to document full neurological history and clinical examination findings, psychiatric screening, and the need for brain imaging in people who survived Ebola virus disease. Methods Adults (>16 years) in Sierra Leone who had survived Ebola virus disease with defined criteria of confirmed disease and one major or two minor symptoms were invited to attend clinic. Patients underwent full history, neurological examination, and psychiatric screening. Patients were referred, as necessary, to a tertiary neurology and psychiatric clinic, where brain CT scans were requested. Findings 87 (25%) of 354 patients in the initial cohort fitted the defined criteria. 38 of 45 patients who were contactable attended our screening clinic (24 women [63%], median age 34 years [IQR 25–43]). Median length of initial stay in hospital during Ebola virus disease was 21 days (13–28) and median time to our screening clinic post discharge was 431 days (402–497). 17 (45%) of the 38 clinic attenders reported loss of consciousness and seven (18%) reported seizures during their acute phase. In the screening clinic, 14 (50%) of 28 patients with headache reported eye symptoms (eye pain, itching, redness, blurred vision, or altered vision), seven (25%) photophobia, six (21%) intermittent fevers, five (18%) dizziness or vertigo, two (7%) tinnitus, and two (7%) scotoma. Headaches were usually intermittent and localised as frontal, unilateral, or band-like. 23 (61%) of the clinic attenders were offered referral to a tertiary neurological and psychiatric clinic, and 17 (42%) required CT brain scanning. At the screening clinic, psychiatric symptoms included insomnia (21/38, 55%), depression (12/38, 32%), and anxiety (11/38, 29%). Interpretation A broad range of important neurological and psychiatric sequelae were present in our selected group of Ebola virus disease survivors over a year after initial discharge. Intermittent headaches, associated with photophobia, intermittent fever, and dizziness or vertigo, were the most frequent neurological features. Common psychiatric symptoms included insomnia, depression, and anxiety. Our experience suggests that there is a need for tertiary level neurological and psychiatric clinics. Funding JTS is supported by the Wellcome Trust. MGS is supported by the UK National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections. This project is supported by the Enhancing Research Activity in Epidemic Situations.

Case Series of Severe Neurologic Sequelae of Ebola Virus Disease during Epidemic, Sierra Leone

We describe a case series of 35 Ebola virus disease (EVD) survivors during the epidemic in West Africa who had neurologic and accompanying psychiatric sequelae. Survivors meeting neurologic criteria were invited from a cohort of 361 EVD survivors to attend a preliminary clinic. Those whose severe neurologic features were documented in the preliminary clinic were referred for specialist neurologic evaluation, ophthalmologic examination, and psychiatric assessment. Of 35 survivors with neurologic sequelae, 13 had migraine headache, 2 stroke, 2 peripheral sensory neuropathy, and 2 peripheral nerve lesions. Of brain computed tomography scans of 17 patients, 3 showed cerebral and/or cerebellar atrophy and 2 confirmed strokes. Sixteen patients required mental health followup; psychiatric disorders were diagnosed in 5. The 10 patients who experienced greatest disability had co-existing physical and mental health conditions. EVD survivors may have ongoing central and peripheral nervous system disorders, including previously unrecognized migraine headaches and stroke.

What Do We Know About Controlling Ebola Virus Disease Outbreaks

The West African Ebola Virus Disease outbreak was unprecedented in size, dwarfing all previous outbreaks by some magnitude. Nearly, more than 28 000 people had been infected, with more than 11 000 deaths recorded. This review article will highlight some of the major public health and therapeutic advances realised during this outbreak, as well as pointing readers to key review articles on the different aspects of disease control. It will describe the multifaceted international response and detail how the response efforts allied traditional public health approaches and novel models of intervention. It will review the shift from a humanitarian response paradigm to real-time evidence-based decision making, including modelling of potential interventions, novel interventional treatment studies, and pragmatic vaccine trials.