Tom E. Fletcher

Clinical presentation, biochemical, and haematological parameters and their association with outcome in patients with Ebola virus disease: an observational cohort study

BACKGROUND Clinical management of Ebola virus disease remains challenging. Routine laboratory analytics are often unavailable in the outbreak setting, and few data exist for the associated haematological and biochemical abnormalities. We aimed to assess laboratory and clinical data from patients with Ebola virus disease to better inform clinical management algorithms, improve understanding of key variables associated with outcome, and provide insight into the pathophysiology of Ebola virus disease. METHODS We recruited all patients, alive on arrival, with confirmed Ebola virus disease who were admitted to the Kerry Town Ebola treatment centre in Sierra Leone. At admission, all patients had clinical presentation recorded and blood taken for Ebola confirmation using reverse-transcriptase-PCR (RT-PCR) and for haematological and biochemical analysis. We studied the association between these and clinical outcome. The primary outcome was discharge from the Ebola treatment centre. FINDINGS 150 patients were admitted to the treatment centre between Dec 8, 2014, and Jan 9, 2015. The mean age of patients was 26 years (SD 14·7). Case fatality rate was 37% (55/150). Most patients presented with stage 2 (gastrointestinal involvement, 72/118 [61%]) and stage 3 (severe or complicated, 12/118 [10%]) disease. Acute kidney injury was common (52/104 [50%]), as were abnormal serum potassium (32/97 [33%]), severe hepatitis (54/92 [59%]), and raised C-reactive protein (21/100 [21%]). Haematological abnormalities were common, including raised haematocrit (15/100 [15%]), thrombocytopenia (47/104 [45%]), and granulocytosis (44/104 [42%]). Severe acute kidney injury, low RT-PCR cycle threshold (<20 cycles), and severe hepatitis were independently associated with mortality. INTERPRETATION Ebola virus disease is associated with a high prevalence of haematological and biochemical abnormalities, even in mild disease and in the absence of gastrointestinal symptoms. Clinical care that targets hypovolaemia, electrolyte disturbance, and acute kidney injury is likely to reduce historically high case fatality rates. FUNDING None.

Understanding organ dysfunction in Ebola virus disease.

This is an excerpt from the content. Ebola viruses are single-stranded RNA filoviruses which are maintained in nature in fruit bats [1]. The genus includes five strains that are clinically distinguished by their usual geographic location and severity of disease in humans. The Reston strain does not appear to cause human disease, and asymptomatic human infections can also occur with other strains. The current West African outbreak is caused by the Zaire strain,which is typically associated with mortality rates of 50–90 % [2, 3]. This short review summarises knowledge about the pathogenesis of organ dysfunction in Ebola virus disease (EVD).

Healthcare-associated Crimean-Congo haemorrhagic fever in Turkey, 2002-2014: a multicentre retrospective cross-sectional study.

Healthcare-related transmission of Crimean-Congo haemorrhagic fever (CCHF) is a well-recognized hazard. We report a multicentre retrospective cross-sectional study undertaken in Turkey in 2014 in nine hospitals, regional reference centres for CCHF, covering the years 2002 to 2014 inclusive. Data were systematically extracted from charts of all personnel with a reported health care injury/accident related to CCHF. Blood samples were tested for CCHF IgM/IgG by enzyme-linked immunosorbent assay and/or viral nucleic acid detection by PCR after the injury. Fifty-one healthcare-related exposures were identified. Twenty-five (49%) of 51 resulted in laboratory-confirmed infection, with a 16% (4/25) overall mortality. The main route of exposure was needlestick injury in 32/51 (62.7%). A potential benefit of post-exposure prophylaxis with ribavirin was identified.

Ebola and other viral haemorrhagic fevers

Be prepared, with new guidance featuring old and well established principles

A fatal case of healthcare associated Crimean-Congo haemorrhagic fever with severe disease and multi-organ failure

Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University Medical School, Samsun, Turkey Liverpool School of Tropical Medicine, Liverpool, United Kingdom, Department of Intensive Care, Ondokuz Mayis University Medical School, Samsun, Turkey Department of Haematology, Ondokuz Mayis University Medical School, Samsun, Turkey NIHR Helalth Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool L69 7BE, United Kingdom

Infection prevention and control practice for Crimean-Congo hemorrhagic fever—A multi-center cross-sectional survey in Eurasia

Background Crimean Congo Hemorrhagic Fever (CCHF) is a life threatening acute viral infection that presents significant risk of nosocomial transmission to healthcare workers. Aim Evaluation of CCHF infection prevention and control (IP&C) practices in healthcare facilities that routinely manage CCHF cases in Eurasia. Methods A cross-sectional CCHF IP&C survey was designed and distributed to CCHF centers in 10 endemic Eurasian countries in 2016. Results Twenty-three responses were received from centers in Turkey, Pakistan, Russia, Georgia, Kosovo, Bulgaria, Oman, Iran, India and Kazakhstan. All units had dedicated isolation rooms for CCHF, with cohorting of confirmed cases in 15/23 centers and cohorting of suspect and confirmed cases in 9/23 centers. There was adequate personal protective equipment (PPE) in 22/23 facilities, with 21/23 facilities reporting routine use of PPE for CCHF patients. Adequate staffing levels to provide care reported in 14/23 locations. All centers reported having a high risk CCHFV nosocomial exposure in last five years, with 5 centers reporting more than 5 exposures. Education was provided annually in most centers (13/23), with additional training requested in PPE use (11/23), PPE donning/doffing (12/23), environmental disinfection (12/23) and waste management (14/23). Conclusions Staff and patient safety must be improved and healthcare associated CCHF exposure and transmission eliminated. Improvements are recommended in isolation capacity in healthcare facilities, use of PPE and maintenance of adequate staffing levels. We recommend further audit of IP&C practice at individual units in endemic areas, as part of national quality assurance programs.

Formulating and improving care while mitigating risk in a military Ebola virus disease treatment unit.

This paper describes the development of the UK militarys Ebola Virus Disease Treatment Unit (EVD TU) that was deployed to Sierra Leone as part of the UK response to the West African Ebola virus disease (EVD) epidemic in 2014 and 2015. It highlights specific challenges faced within this unique Field Hospital environment. The military EVD TU was initially established to provide confidence to international healthcare workers coming to Sierra Leone to assist in the international response to the EVD epidemic and formed a key part of the action plan by the UKs Department for International Development. It was designed and staffed to provide a high level of care to those admitted with suspected or confirmed EVD and was prepared to admit the first patient within 6 weeks of the original activation order by the Ministry of Defence. This article outlines the main hazards perceived at the outset of the operation and the methods used to mitigate the risk to the healthcare workers at the EVD TU. The article examines the mechanisms that enabled the hospital to respond positively to challenges that emerged during the deployment, while simultaneously reducing the risk to the healthcare workers involved in care delivery.

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone

Highlights • EVD is associated with life-threatening electrolyte imbalance and organ dysfunction.• Clinical staging/early warning scores can be useful EVD prognostic indicators.• Enhanced protocolized care is a blueprint for future treatment in low-resource settings.

Crimean-Congo hemorrhagic fever in pregnancy: A systematic review and case series from Russia, Kazakhstan and Turkey.

Highlights • CCHF in pregnancy is rare but has high rates of maternal (34%) and fetal mortality (59%).• Maternal hemorrhage is associated with maternal and fetal/neonatal death.• Nosocomial transmission of CCHF from 6/37 index pregnant cases resulted in 38 cases.• Early recognition and risk-assessment allows appropriate IP & C precautions and supportive care provision.

Ebola Worker's Foot

The best-known example of an immersion foot syndrome in military personnel is ‘trench foot’, which occurs in temperate or cold climates.1 However, tropical immersion foot syndrome or ‘paddy field foot’ was a significant problem in the Far East during World War II and the Vietnam War.2 The condition initially affects the sole of the foot …