Ebola Virus Disease Patients Research Articles

Multi-platform ’Omics Analysis of Human Ebola Virus Disease Pathogenesis

The pathogenesis of human Ebola virus disease (EVD) is complex. EVD is characterized by high levels of virus replication and dissemination, dysregulated immune responses, extensive virus- andhost-mediated tissue damage, and disordered coagulation. To clarify how host responses contribute to EVD pathophysiology, we performed multi-platform 'omics analysis of peripheral blood mononuclear cells and plasma from EVD patients. Our results indicate that EVD molecular signatures overlap with those of sepsis, imply that pancreatic enzymes contribute to tissue damage in fatal EVD, and suggest that Ebola virus infection may induce aberrant neutrophils whose activity could explain hallmarks of fatal EVD. Moreover, integrated biomarker prediction identified putative biomarkers from different data platforms that differentiated survivors and fatalities early after infection. This work reveals insight into EVD pathogenesis, suggests an effective approach for biomarker identification, and provides an important community resource for further analysis of human EVD severity.

A pilot survey of the U.S. medical waste industry to determine training needs for safely handling highly infectious waste

The recent Ebola outbreak led to the development of Ebola virus disease (EVD) best practices in clinical settings. However, after the care of EVD patients, proper medical waste management and disposal was identified as a crucial component to containing the virus. Category A waste-contaminated with EVD and other highly infectious pathogens-is strictly regulated by governmental agencies, and led to only several facilities willing to accept the waste. A pilot survey was administered to determine if U.S. medical waste facilities are prepared to handle or transport category A waste, and to determine waste workers' current extent of training to handle highly infectious waste. Sixty-eight percent of survey respondents indicated they had not determined if their facility would accept category A waste. Of those that had acquired a special permit, 67% had yet to modify their permit since the EVD outbreak. This pilot survey underscores gaps in the medical waste industry to handle and respond to category A waste. Furthermore, this study affirms reports a limited number of processing facilities are capable or willing to accept category A waste. Developing the proper management of infectious disease materials is essential to close the gaps identified so that states and governmental entities can act accordingly based on the regulations and guidance developed, and to ensure public safety.

Acute rhabdomyolysis and delayed pericardial effusion in an Italian patient with Ebola virus disease: a case report

BackgroundDuring the 2013–2016 West Africa Ebola virus disease (EVD) epidemic, some EVD patients, mostly health care workers, were evacuated to Europe and the USA.Case presentationIn May 2015, a 37-year old male nurse contracted Ebola virus disease in Sierra Leone. After Ebola virus detection in plasma, he was medically-evacuated to Italy. At admission, rhabdomyolysis was clinically and laboratory-diagnosed and was treated with aggressive hydration, oral favipiravir and intravenous investigational monoclonal antibodies against Ebola virus. The recovery clinical phase was complicated by a febrile thrombocytopenic syndrome with pericardial effusion treated with corticosteroids for 10 days and indomethacin for 2 months. No evidence of recurrence is reported.ConclusionsA febrile thrombocytopenic syndrome with pericardial effusion during the recovery phase of EVD appears to be uncommon. Clinical improvement with corticosteroid treatment suggests that an immune-mediated mechanism contributed to the pericardial effusion.

Deep Sequencing of RNA from Blood and Oral Swab Samples Reveals the Presence of Nucleic Acid from a Number of Pathogens in Patients with Acute Ebola Virus Disease and Is Consistent with Bacterial Translocation across the Gut.

In this study, samples from the 2013-2016 West African Ebola virus outbreak from patients in Guinea with Ebola virus disease (EVD) were analyzed to discover and classify what other pathogens were present. Throat swabs were taken from deceased EVD patients, and peripheral blood samples were analyzed that had been taken from patients when they presented at the treatment center with acute illness. High-throughput RNA sequencing (RNA-seq) and bioinformatics were used to identify the potential microorganisms. This approach confirmed Ebola virus (EBOV) in all samples from patients diagnosed as acute positive for the virus by quantitative reverse transcription-PCR in deployed field laboratories. Nucleic acid mapping to Plasmodium was also used on the patient samples, confirming results obtained with an antigen-based rapid diagnostic test (RDT) conducted in the field laboratories. The data suggested that a high Plasmodium load, as determined by sequence read depth, was associated with mortality and influenced the host response, whereas a lower parasite load did not appear to affect outcome. The identifications of selected bacteria from throat swabs via RNA-seq were confirmed by culture. The data indicated that the potential pathogens identified in the blood samples were associated with translocation from the gut, suggesting the presence of bacteremia, which transcriptome data suggested may induce or aggravate the acute-phase response observed during EVD. Transcripts mapping to different viruses were also identified, including those indicative of lytic infections. The development of high-resolution analysis of samples from patients with EVD will help inform care pathways and the most appropriate general antimicrobial therapy to be used in a resource-poor setting. IMPORTANCE Our results highlight the identification of an array of pathogens in the blood of patients with Ebola virus disease (EVD). This has not been done before, and the data have important implications for the treatment of patients with EVD, particularly considering antibiotic stewardship. We show that EVD patients who were also infected with Plasmodium, particularly at higher loads, had more adverse outcomes than patients with lower levels of Plasmodium. However, the presence of Plasmodium did not influence the innate immune response, and it is likely that the presence of EBOV dominated this response. Several viruses other than EBOV were identified, and bacteria associated with sepsis were also identified. These findings were indicative of bacterial translocation across the gut during the acute phase of EVD.

Health care workers indicate ill preparedness for Ebola Virus Disease outbreak in Ashanti Region of Ghana

BackgroundThe recent Ebola Virus Disease (EVD) epidemic that hit some countries in West Africa underscores the need to train front line high-risk health workers on disease prevention skills. Although Ghana did not record (and is yet to) any case, and several health workers have received numerous training schemes, there is no record of any study that assessed preparedness of healthcare workers (HCWS) regarding EVD and any emergency prone disease in Ghana. We therefore conducted a hospital based cross sectional study involving 101 HCWs from two facilities in Kumasi, Ghana to assess the level of preparedness of HCWs to respond to any possible EVD.MethodsWe administered a face-to-face questionnaire using an adapted WHO (2015) and CDC (2014) Checklist for Ebola Preparedness and assessed overall knowledge gaps, and preparedness of the Ghanaian HCWs in selected health facilities of the Ashanti Region of Ghana from October to December 2015.ResultsA total 92 (91.09%) HCWs indicated they were not adequately trained to handle an EVD suspected case. Only 25.74% (n = 26) considered their facilities sufficiently equipped to handle and manage EVD patients. When asked which disinfectant to use after attending to and caring for a suspected patient with EVD, only 8.91% (n = 9) could correctly identify the right disinfectant (χ2 = 28.52, p = 0.001).ConclusionOur study demonstrates poor knowledge and ill preparedness and unwillingness of many HCWs to attend to EVD. Beyond knowledge acquisition, there is the need for more training from time to time to fully prepare HCWs to handle any possible EVD case.

The potential impact of a prophylactic vaccine for Ebola in Sierra Leone.

The 2014 outbreak of Ebola virus disease (EVD) in West Africa was multinational and of an unprecedented scale primarily affecting the countries of Guinea, Liberia, and Sierra Leone. One of the qualities that makes EVD of high public concern is its potential for extremely high mortality rates (up to 90%). A prophylactic vaccine for ebolavirus (rVSV-ZEBOV) has been developed, and clinical trials show near-perfect efficacy. We have developed an ordinary differential equations model that simulates an EVD epidemic and takes into account (1) transmission through contact with infectious EVD individuals and deceased EVD bodies, (2) the heterogeneity of the risk of becoming infected with EVD, and (3) the increased survival rate of infected EVD patients due to greater access to trained healthcare providers. Using fitted parameter values that closely simulate the dynamics of the 2014 outbreak in Sierra Leone, we utilize our model to predict the potential impact of a prophylactic vaccine for the ebolavirus using various vaccination strategies including ring vaccination. Our results show that an rVSV-ZEBOV vaccination coverage as low as 40% in the general population and 95% in healthcare workers will prevent another catastrophic outbreak like the 2014 outbreak from occurring.

Ebola management centre proximity associated with reduced delays of healthcare of Ebola Virus Disease (EVD) patients, Tonkolili, Sierra Leone, 2014-15.

Between August-December 2014, Ebola Virus Disease (EVD) patients from Tonkolili District were referred for care to two Médecins Sans Frontières (MSF) Ebola Management Centres (EMCs) outside the district (distant EMCs). In December 2014, MSF opened an EMC in Tonkolili District (district EMC). We examined the effect of opening a district-based EMC on time to admission and number of suspect cases dead on arrival (DOA), and identified factors associated with fatality in EVD patients, residents in Tonkolili District. Residents of Tonkolili district who presented between 12 September 2014 and 23 February 2015 to the district EMC and the two distant EMCs were identified from EMC line-lists. EVD cases were confirmed by a positive Ebola PCR test. We calculated time to admission since the onset of symptoms, case-fatality and adjusted Risk Ratios (aRR) using Binomial regression. Of 249 confirmed Ebola cases, 206 (83%) were admitted to the distant EMCs and 43 (17%) to the district EMC. Of them 110 (45%) have died. Confirmed cases dead on arrival (n = 10) were observed only in the distant EMCs. The median time from symptom onset to admission was 6 days (IQR 4,8) in distant EMCs and 3 days (IQR 2,7) in the district EMC (p<0.001). Cases were 2.0 (95%CI 1.4–2.9) times more likely to have delayed admission (>3 days after symptom onset) in the distant compared with the district EMC, but were less likely (aRR = 0.8; 95%CI 0.6–1.0) to have a high viral load (cycle threshold ≤22). A fatal outcome was associated with a high viral load (aRR 2.6; 95%CI 1.8–3.6) and vomiting at first presentation (aRR 1.4; 95%CI 1.0–2.0). The opening of a district EMC was associated with earlier admission of cases to appropriate care facilities, an essential component of reducing EVD transmission. High viral load and vomiting at admission predicted fatality. Healthcare providers should consider the location of EMCs to ensure equitable access during Ebola outbreaks.

A Bayesian Belief Network Model Assessing the Risk to Wastewater Workers of Contracting Ebola Virus Disease During an Outbreak.

During an outbreak of Ebola virus disease (EVD), hospitals' connections to municipal wastewater systems may provide a path for patient waste bearing infectious viral particles to pass from the hospital into the wastewater treatment system, potentially posing risks to sewer and wastewater workers. To quantify these risks, we developed a Bayesian belief network model incorporating data on virus behavior and survival along with structural characteristics of hospitals and wastewater treatment systems. We applied the model to assess risks under several different scenarios of workers' exposure to wastewater for a wastewater system typical of a mid-sized U.S. city. The model calculates a median daily risk of developing EVD of approximately 6.1×10-12 (90% confidence interval: 1.0×10-12 to 5.4×10-9 ; mean 1.8×10-6 ) when no prior exposure conditions are specified. Under a worst-case scenario in which a worker stationed in the sewer adjacent to the hospital accidentally ingests several drops (0.35 mL) of wastewater, median risk is 5.8×10-4 (90% CI: 8.8×10-7 to 9.5×10-2 ; mean 3.2×10-2 ) . Disinfection of patient waste with peracetic acid for 15 minutes prior to flushing decreases the estimated median risk to 3.8×10-7 (90% CI: 4.1×10-9 to 8.6×10-5 ; mean 2.9×10-5 ). The results suggest that requiring hospitals to disinfect EVD patient waste prior to flushing may be advisable. The modeling framework can provide insight into managing patient waste during future outbreaks of highly virulent infectious pathogens.

Epidemiology of ebolavirus disease (EVD) and occupational EVD in health care workers in Sub-Saharan Africa: Need for strengthened public health preparedness.

Ebolavirus disease (EVD) is a severe contagious disease in humans, and health care workers (HCW) are at risk of infection when caring for EVD patients. This paper highlights the epidemiologic profile of EVD and its impact on the health care workforce in Africa. A documentary study was conducted which consisted of a review of available literature regarding the epidemiology of EVD, occupational EVD (OEVD), and work safety issues in Sub-Saharan Africa; the literature findings are enriched by field experiences from the authors. EVD outbreaks have already caused 30,500 cases in humans of whom 12,933 died (as of September 9, 2015), and the number of infected HCW has dramatically increased. All eight HCW infected during the 2014 outbreak in Democratic Republic of the Congo died, whereas during the recent West African EVD epidemic more than 890 HCW were infected, with a case fatality rate of 57%. Occupational exposure to blood and other body fluids due to inadequate use of personal protective equipment and needle stick or sharp injuries are among factors that contribute to the occurrence of OEVD. Prevention of OEVD should be one of the top priorities in EVD outbreak preparedness and management, and research should be conducted to elucidate occupational and other factors that expose HCW to EVD. In addition to regularly training HCW to be adequately prepared to care for patients with EVD, it is critical to strengthen the general health care system and improve occupational safety in medical settings of countries at risk.

Are We There Yet? Laboratory Preparedness for Emerging Infectious Diseases.

The West African Ebola virus epidemic of 2013–2016 was the most widespread epidemic of this disease in history; it is estimated that this occurrence contributed to more than 11000 deaths. During the epidemic, healthcare workers (HCW)8 (including laboratorians) were mobilized to care for individuals with suspected or confirmed Ebola virus disease (EVD). However, at the height of the epidemic, guidance on appropriate safety measures for laboratory workers manipulating specimens from EVD patients was sparse. This highlighted the need for data and guidelines for laboratories testing specimens not only for patients with EVD, but for any emerging infectious disease. During the Ebola epidemic, questions were raised about the roles and responsibilities of laboratories in responding to highly infectious diseases, and the burden of ongoing readiness for rare events. As the outbreak decelerates, laboratorians must regroup, gather data, and prepare for future outbreaks. We have asked 4 experts in this field to share their thoughts on contemporary challenges in laboratory preparedness for emerging infectious diseases. During the recent Ebola epidemic, what laboratory testing did your hospital offer for patients with suspected EVD? Who performed this testing and where was the testing performed? Did you have dedicated equipment for laboratory testing or did you utilize existing core laboratory equipment? Eileen Burd: Patients with clinical symptoms and appropriate epidemiologic risk factors for EVD were stratified as high, intermediate, or low risk by the provider seeing the patient. If evaluation revealed low risk or no identifiable risk, standard tests were generally ordered that included tests for diagnoses other than EVD including complete blood count (CBC) with differential, complete metabolic profile (CMP), and malaria testing. Other tests that were ordered as indicated by the patient's symptoms included blood cultures, respiratory virus testing, urinalysis, urine culture, and molecular gastrointestinal panels. Blood and other specimens were collected …

Chemically Modified Human Serum Albumin Potently Blocks Entry of Ebola Pseudoviruses and Viruslike Particles.

Ebola virus (EBOV), the causative pathogen of the deadly Ebola virus disease (EVD), can be transmitted via contact with EVD patients, including sexual contact with EVD survivors. At present, no licensed vaccine or therapeutic is available. In this study, we compared eight anhydride-modified proteins for their entry-inhibitory activity against the pseudovirus (PsV) carrying the envelope glycoprotein (GP) of the EBOV Zaire or Sudan species (Zaire PsV and Sudan PsV, respectively). We found that 3-hydroxyphthalic anhydride-modified human serum albumin (HP-HSA) was the most effective in inhibiting the entry of both Zaire PsV and Sudan PsV, with the 50% effective concentration being at the nanomolar level and with HP-HSA being more potent than EBOV-neutralizing antibody MIL77-2 (4G7, a component antibody of the ZMapp drug cocktail). The combination of HP-HSA and MIL77-2 exhibited a synergistic effect. HP-HSA had no obvious in vitro or in vivo toxicity. The EBOV PsV entry-inhibitory activity of HP-HSA remained intact after storage at 45°C for 8 weeks, suggesting that HP-HSA has the potential for worldwide use, including tropical regions in African countries, as either a therapeutic to treat EBOV infection or a prophylactic microbicide to prevent the sexual transmission of EBOV.

Characteristics and survival of patients with Ebola virus infection, malaria, or both in Sierra Leone: a retrospective cohort study

The 2014-15 Ebola virus disease (EVD) epidemic strained health systems in west Africa already overburdened with other diseases, including malaria. Because EVD and malaria can be difficult to distinguish clinically, and rapid testing was not available in many Ebola Treatment Units (ETUs), guidelines recommended empirical malaria treatment. Little is known, however, about the prevalence and characteristics of patients entering an ETU who were infected with malaria parasites, either alone or concurrently with Ebola virus. Data for sociodemographics, disease characteristics, and mortality were analysed for patients with suspected EVD admitted to three ETUs in Sierra Leone using a retrospective cohort design. Testing for Ebola virus was done by real-time PCR and for malaria by a rapid diagnostic test. Characteristics of patients were compared and survival analyses were done to evaluate the effect of infection status on mortality. Between Dec 1, 2014, and Oct 15, 2015, 1524 cases were treated at the three ETUs for suspected EVD, of whom 1368 (90%) had diagnostic data for malaria and EVD. Median age of patients was 29 years (IQR 20-44) and 715 (52%) were men. 1114 patients were EVD negative, of whom 365 (33%) tested positive for malaria. Of 254 EVD positive patients, 53 (21%) also tested positive for malaria. Mortality risk was highest in patients diagnosed with both EVD and malaria (35 [66%] of 53 died) and patients diagnosed with EVD alone (105 [52%] of 201 died). Compared with patients presenting to ETUs without malaria or EVD, mortality was increased in the malaria positive and EVD positive group (adjusted hazard ratio 9·36, 95% CI 6·18-14·18, p<0·0001), and the malaria negative and EVD positive group (5·97, 4·44-8·02, p<0·0001), but reduced in the malaria positive and EVD negative group (0·37, 0·20-1·23, p=0·0010). Malaria parasite co-infection was common in patients presenting to ETUs and conferred an increased mortality risk in patients infected with Ebola virus, supporting empirical malaria treatment in ETUs. The high mortality among patients without EVD or malaria suggests expanded testing and treatment might improve care in future EVD epidemics. International Medical Corps.

Predicting Ebola Severity: A Clinical Prioritization Score for Ebola Virus Disease.

BackgroundDespite the notoriety of Ebola virus disease (EVD) as one of the world’s most deadly infections, EVD has a wide range of outcomes, where asymptomatic infection may be almost as common as fatality. With increasingly sensitive EVD diagnosis, there is a need for more accurate prognostic tools that objectively stratify clinical severity to better allocate limited resources and identify those most in need of intensive treatment.Methods/Principal FindingsThis retrospective cohort study analyses the clinical characteristics of 158 EVD(+) patients at the GOAL-Mathaska Ebola Treatment Centre, Sierra Leone. The prognostic potential of each characteristic was assessed and incorporated into a statistically weighted disease score. The mortality rate among EVD(+) patients was 60.8% and highest in those aged <5 or >25 years (p<0.05). Death was significantly associated with malaria co-infection (OR = 2.5, p = 0.01). However, this observation was abrogated after adjustment to Ebola viral load (p = 0.1), potentially indicating a pathologic synergy between the infections. Similarly, referral-time interacted with viral load, and adjustment revealed referral-time as a significant determinant of mortality, thus quantifying the benefits of early reporting as a 12% mortality risk reduction per day (p = 0.012). Disorientation was the strongest unadjusted predictor of death (OR = 13.1, p = 0.014) followed by hiccups, diarrhoea, conjunctivitis, dyspnoea and myalgia. Including these characteristics in multivariate prognostic scores, we obtained a 91% and 97% ability to discriminate death at or after triage respectively (area under ROC curve).Conclusions/SignificanceThis study proposes highly predictive and easy-to-use prognostic tools, which stratify the risk of EVD mortality at or after EVD triage.

Febrile illness in healthcare workers caring for Ebola virus disease patients in a high-resource setting.

Ebola virus disease (EVD) patients treated in high-resource facilities are cared for by large numbers of healthcare staff. Monitoring these healthcare workers (HCWs) for any illness that may represent transmission of Ebola virus is important both for the individuals and to minimise the community risk. International policies for monitoring HCWs vary considerably and their effectiveness is unknown. Here we describe the United Kingdom (UK) experience of illness in HCWs who cared for three patients who acquired EVD in West Africa. Five of these 93 high-level isolation unit (HLIU) HCWs presented with fever within 21 days of working on the unit; one of these five presented outside of the UK. This article discusses different approaches to monitoring of HCW symptom reporting. The potential impact of these approaches on HLIU staff recruitment, including travel restrictions, is also considered. An international surveillance system enhancing collaboration between national public health authorities may assist HLIU HCW monitoring in case they travel.

PP006 Ebola In The Netherlands: Costs Of Preparedness And Response

INTRODUCTION:Between December 2013 and April 2016, an unprecedented epidemic of Ebola Virus Disease (EVD) took place. This epidemic urged countries all over the world to be prepared for the possibility of having an EVD patient (1). Besides morbidity and mortality of the disease, containment efforts also have economic consequences for society. In this study, costs of preparedness for and response to EVD made by the Dutch health system were estimated.METHODS:We used an activity-based costing method in which cost of personnel time targeted at preparedness, and response activities was based on a time recording system and interviews with key professionals of the organizations involved. In addition, patient days of hospitalizations, laboratory tests, personal protective equipment (PPE), as well as costs for additional cleaning and disinfection were acquired via the organizations. All costs are expressed at the 2015-euro price level.RESULTS:The estimated total costs of EVD preparedness and response in the Netherlands were averaged at EUR14.1 million, ranging from EUR7.6 to EUR24.9 million. There were thirteen possible cases clinically evaluated and one confirmed case, admitted through an international evacuation request, corresponding to approximately EUR1 million per case (2). Preparedness activities of personnel, especially of all ambulance care services and hospitals that could possibly receive a case, and expenditures on PPE, were the main cost drivers.CONCLUSIONS:The estimated total cost of EVD preparedness and response in the Netherlands was substantial. Costs made by healthcare organizations were higher than among public health organizations (3). Designating one ambulance care service and fewer hospitals for the assessment of possible patients with viral hemorrhagic fever or other highly infectious disease of high consequence might improve efficiency and reduce future costs. The experiences and collaboration of healthcare organizations that managed patients with possible EVD can serve as a valuable resource for future outbreaks of other highly infectious diseases.

Clinical Management of Ebola Virus Disease Patients in Low-Resource Settings.

The low-resource environment deprives healthcare providers caring for patients with Ebola virus disease (EVD) of many of the means employed for the critically ill that are available in better resourced settings, such as advanced therapeutic interventions and abundant staff. In addition to these limitations may be added those imposed by the remote tropical locations, where EVD outbreaks occur. In this setting, a safe environment is created where healthcare workers may care for their patients over the evolving course of their acute illness into their convalescent period. Clinical management of EVD combines supportive and symptomatic care while also addressing the patient's emotional and mental health needs. A variety of specific therapies directly targeting the virus has become available, but none of these has, as of yet, conclusively demonstrated an impact. Healthcare workers caring for EVD patients must be constantly aware that they are part of a larger epidemic control operation, and their actions have consequences that go beyond their patients to their families and the community affected by the outbreak.

Ebola Virus Disease: Biology, Diagnosis, Treatment and Prevention of Epidemics

Ebola virus disease (EVD) is a highly lethal contagious disease caused by the negative RNA strand Ebola virus. Reservoired in wild forest animals of Africa, Ebola virus infects humans that come in direct contact of diseased animals and outbreaks of EVD result from person to person spread of infection. A recent EVD outbreak in West Africa has killed several thousand persons. Since Ebola infection will persist in animals, EVD epidemics are expected to continue to occur in future. Infected travellers from Africa can initiate/import outbreaks in countries of other continents. This review describes the properties of the Ebola virus and EVD, the ongoing attempts to develop diagnostics, vaccines and medicines for prevention and cure of EVD and the supportive care that saves some EVD patients. Also discussed are measures that can stop and prevent EVD outbreaks. Need for inclusion of EVD in the education, research, drug and medical equipment manufacturing programmes, of the densly populated countries such as India, is emphasised.

Australia's response to Ebola Virus disease in West Africa, 2014-15.

In March 2016, the World Health Organization declared the 2014-15 Ebola virus disease (EVD) outbreak officially over. With around 29 000 cases and 11 000 deaths in 27 months, this EVD outbreak was more than 60 times larger than any before, and unique in its cross-border spread and involvement of urban centres. Local and international responses were slow and initially inadequate, but establishment of the United Nations Mission for Ebola Emergency Response, 9 months after the outbreak began, allowed a coordinated effort that slowed and eventually controlled the spread of disease. Internationally, there were fears that EVD would spread widely beyond Africa, despite reassurances from public health authorities. However, after nurses in the US became infected, public fear and concern for the safety of healthcare workers led to political intervention and varied, sometimes excessive, border controls, quarantine arrangements and hospital preparations. Altogether, fewer than 30 EVD cases were managed in countries outside Africa, all but three of which were acquired in West Africa. In Australia, the Australian Health Protection Principal Committee led the internal response, including enhanced screening of incoming passengers at international airports and development of public health and laboratory testing protocols by expert subcommittees. States and territories nominated designated hospitals to care for EVD patients. Development of EVD infection prevention and control (IPC) guidelines was initially poorly coordinated within and between jurisdictions, often with significant discrepancies, causing confusion and fear among healthcare workers. The Infection Prevention and Control Expert Advisory Group was established to develop national IPC guidelines. There were no confirmed cases in Australia, but investigation of several people with suspected EVD provided valuable experience in use of protocols and high-level containment facilities. The Australian Government was initially reluctant to send aid workers to West Africa, but later contracted a private company to staff and manage a treatment centre in Sierra Leone, which treated 91 patients with EVD during 4 months of operation. Among the lessons learnt for Australia was the need to increase awareness of routine IPC practices in hospitals, where significant deficiencies were exposed, and to maintain a high enough level of preparedness to protect healthcare workers and the public from the next, inevitable, infectious disease emergency.

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. We followed up a cohort of 543 patients discharged with a negative EVD test from five EHUs in the Western Area, Sierra Leone, and examined all line-listed subsequent EVD tests from any facility in the Western Area to see whether the patient was retested within 30 days, matching by name, age and address. We defined possible readmissions as having the same name and age but uncertain address, and confirmed readmissions where name, age and address matched. We found a positive readmission rate of 3.3% (18 cases), which included 1.5% confirmed readmissions (8 cases) and 1.8% possible readmissions (10 cases). This is lower than rates previously reported. We cannot ascertain whether EVD was acquired within the EHUs or from re-exposure in the community. No demographic or clinical variables were identified as risk factors for positive readmission, likely due to our small sample size. These findings support the EHU model as a safe method for isolation of suspect EVD patients and their role in limiting the spread of EVD.

The predictor of mortality outcome in adult patients with Ebola virus disease during the 2014-2015 outbreak in Guinea.

The purpose of this study was to examine the association of any demographic and clinical factors with mortality outcome among adult patients with Ebola virus disease (EVD) in Guinea. This retrospective observational study analyzed medical records of laboratory confirmed EVD adult patients during the 2014-2015 EVD outbreak in Guinea. The associations between any demographic or clinical variables and mortality outcome of EVD were assessed using univariate and multivariate logistic regression analyses. Of 2,310 EVD adult patients included for analysis, the overall case fatality rate was 68.1%. Univariate analyses identified factors possibly associated with mortality outcome, including patient age (p < 0.001), history of visiting or close contact with a suspected or confirmed EVD patient (p = 0.035), and seven clinical symptoms on admission, i.e., fever (p = 0.003), hiccups (p < 0.001), vomiting (p = 0.003), diarrhea (p < 0.001), cough (p = 0.001), sore throat (p = 0.016), and unexplained bleeding (p = 0.021). The multivariate analysis showed that patient age was independently associated with mortality outcome of EVD (OR = 1.06; 95%CI = 1.03-1.09; p < 0.001), while none the of clinical symptoms on admission were significantly associated with the mortality outcome. Our analysis indicates that older age was the only independent factor associated with death among EVD adult patients in Guinea. This suggests that older EVD patients should receive intensive medical care and be carefully monitored.