Regan H. Marsh

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.

Measuring access to emergency obstetric care in rural Zambia

BackgroundGlobal health experts identify emergency obstetric care (EmOC) as the most important intervention to improve maternal survival in low- and middle-income countries. In Zambia, 1 in 27 women will die of maternal causes, yet the level of availability of EmOC is not known at the provincial level.AimsOur goal was to develop a tool to measure the availability of EmOC in rural Zambia in order to estimate pregnant women’s access to this life-saving intervention.MethodsWe created an instrument for determining the availability of EmOC based on the supplies and medicines in stock at health facilities as well as the skill level of health workers. We then surveyed a random sample of 35 health centres in the Central Province of Zambia using our novel instrument.ResultsWe graded health centres based on their ability to provide the six basic functions of EmOC: administering parenteral antibiotics, administering parenteral oxytocics, administering parenteral anticonvulsants, performing manual removal of the placenta, removing retained products of conception and performing assisted vaginal delivery. Of the 29 health centres providing delivery care, 65% (19) were graded as level 1 or 2, 28% (8) as level 3 or 4 and 7% (2) as level 5. No health centre received a grade of level 6.ConclusionThe availability of EmOC in the Central Province of Zambia is extremely limited; the majority of health centres provide only one or two basic functions of EmOC, and no health centres perform all six functions. Our grading system allows for inter- and intra-country comparisons by providing a systematic process for monitoring access to EmOC in rural, low-income countries similar to Zambia.

Strengthening emergency care: experience in central Haiti.

www.thelancet.com/lancetgh Vol 3 (S2) April 2015 S5 world is no easy task. WHO has long advocated a set of interventions to fortify a nation’s blood supply, but countries will have diffi culty solving these problems on their own. Nations with the lowest donation rates also have high rates of malnutrition, chronic anaemia, and TTIs, severely restricting the donor pool. Blood availability must be addressed as a global priority. Until the international community develops feasible equity-based transnational strategies, billions will continue to lack access to life-saving transfusions. First, we must build a donor pool fi t for donation by combating malnutrition as aggressively as TTIs. Next, we must establish well distributed blood bank infrastructure capable of meeting demand. Although these eff orts might lack a profi t motive, global public– private partnerships have had success in developing drugs for neglected diseases, and should be considered as a structural response to this crisis. As these changes lay the foundation for a better donor pool, so too must we change the fear and trepidation that surrounds blood donation in many regions of the world. We must engage local community leaders in concert with clerics in churches, temples, and mosques, both to dispel myths about blood donation and to encourage it as a civic responsibility.

Characteristics that distinguish adolescents who present to a children's hospital emergency department from those presenting to a general emergency department.

Objective: To identify characteristics of adolescents who access health care in a childrens hospital emergency department (ED) compared with a general ED. Methods: We performed a retrospective comparative study of an urban childrens ED and the adjacent general ED. Participants included randomly selected ED visits of adolescents aged 15 to 19 years who presented during a 1-year period. Demographic data, triage category, chief complaint, and comorbid conditions were collected and analyzed by site of care. Results: Ten percent of visits to each location was reviewed. Adolescents in the general ED were more often female (72% vs 60%), uninsured (32% vs 12%), and presented with abdominal pain (46% vs 17%). Adolescents in the childrens ED more frequently identified a primary care provider (94% vs 58%) and were triaged as nonurgent (40% vs 22%). In the childrens ED, more complaints were injury-related (30% vs 19%). The prevalence of complaints related to violence or chronic diseases did not vary. Through logistic regression analysis, adolescents using the general ED were more likely to be older (odds ratio [OR], 4.1, 95% confidence interval [CI], 3.2-5.3) and to complain of abdominal pain (OR, 5.0; 95% CI, 2.8-8.8); those using the childrens ED were more likely to present with a nonurgent complaint (OR, 2.7; 95% CI, 1.5-4.9) and identify a primary care provider (OR, 16.6; 95% CI, 17.6-36.4). Conclusions: When a childrens and general ED are in close proximity, there are unique characteristics of the adolescents at each site. Understanding the differences can assist clinicians to provide care tailored to meet the needs of each group.

A Research Agenda for Acute Care Services Delivery in Low‐ and Middle‐income Countries

Delivery of acute care services at every level of the health system is essential to ensure appropriate evaluation and management of emergent illness and injury in low- and middle-income countries (LMICs). The health services breakout group at the 2013 Academic Emergency Medicine consensus conference developed recommendations for a research agenda along the following themes: infrastructure, implementation, and sustainable provision of acute care services. Based on these recommendations, a set of priorities was created to promote and guide future research on acute care services.

Facing the Shortage of IV Fluids — A Hospital-Based Oral Rehydration Strategy

Facing the Shortage of IV Fluids Emergency departments are substantial consumers of IV fluids, so in the face of the worsened U.S. saline shortage, a hospital ED team developed an oral rehydration protocol for patients with mild dehydration that has since been adopted hospital-wide.

Evaluation of the implementation of the South African Triage System at an academic hospital in central Haiti

BACKGROUND Effective triage is an important part of high quality emergency care, yet is frequently lacking in resource-limited settings. The South African Triage Scale (SATS) is designed for these settings and consists of a numeric score (triage early warning score, TEWS) and a list of clinical signs (known as discriminators). Our objective was to evaluate the implementation of SATS at a new teaching hospital in Haiti. METHODS A random sample of emergency department charts from October 2013 were retrospectively reviewed for the completeness and accuracy of the triage form, correct calculation of the triage score, and final patient disposition. Over and under triage were calculated. Comparisons were evaluated with chi-squared analysis. RESULTS Of 390 charts were reviewed, 385 contained a triage form and were included in subsequent analysis. The final triage color was recorded for 68.4% of patients, clinical discriminators for 48.6%, and numeric score for 96.1%. The numeric score was calculated correctly 78.3% of the time; in 13.2% of patients a calculation error was made that would have changed triage priority. In 23% of cases, chart review identified clinical discriminators should have been circled but were not recorded. Overtriage and undertriage were 75.6% and 7.4% respectively. CONCLUSION This study demonstrates that with limited structured training, SATS was widely adopted, but the clinical discriminators were used less commonly than the numeric score. This should be considered in future implementations of SATS.

Blunt Cardiac Rupture

*Department of Emergency Medicine, North Shore Medical Center, Salem, Massachusetts, †Department of Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, ‡Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and §Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Eric S. Nadel, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115

Rabies exposure--implications for wilderness travelers.

Abstract Rabies is a preventable, fatal infectious disease. Successful vaccination programs for domestic animals in developed countries have drastically decreased the risk of exposure to rabies. Yet awareness of rabies needs to remain high as important reservoirs still exist in our backyards, the wilderness, and abroad. Recognizing the risk before and after a potential exposure, so that appropriate medical care can be sought, is critical to preventing a fatal complication. This case report involves an exposure of a medical student to an ill-appearing and likely rabid gray fox in the Gila Wilderness Area of New Mexico. The student was a member of a 28-day wilderness medicine course taught by the National Outdoor Leadership School/Wilderness Medicine Institute in collaboration with the Harvard Affiliated Emergency Medicine Residency. On the first night in the field, the student awoke to a gray fox biting his foot through his sleeping bag in the early morning hours. Subsequently the student was evacuated for medical evaluation. Further care consisted of rabies postexposure prophylaxis, including thorough wound cleansing, injection of human rabies immunoglobulin, and initiation of a rabies vaccination schedule. Immediate wound care with soap and water and a viricidal agent is of utmost importance for any animal bite, but especially so in the prevention of rabies. Indications for rabies prophylaxis are complex and require prompt evaluation by a medical professional and consultation with local epidemiology to guide treatment.