Global & Disaster Medicine

Archive for the ‘Ebola’ Category

Predictive and easy-to-use prognostic tools, which stratify the risk of EVD mortality at or after EVD triage.

PLOS:  Hartley M-A, Young A, Tran A-M, Okoni-Williams HH, Suma M, Mancuso B, et al. (2017) Predicting Ebola Severity: A Clinical Prioritization Score for Ebola Virus Disease. PLoS Negl Trop Dis 11(2): e0005265. doi:10.1371/journal.pntd.0005265

  • 158 Ebola patients:  Study population
  • The authors were able to accurately predict death at triage 91% of the time and death after triage 97% of the time.
  • Co-infection with malaria was associated with a 2.5-fold increase in the odds of death.
  • Disorientation, hiccups, diarrhea, conjunctivitis, shortness of breath, and muscle aches were also strong predictors of death.
  • Age was also a predictor of mortality.
    • The patient group aged between 5 and 24 years had the lowest mortality rate of 42.5%
    • The over-45’s and under-5’s were particularly vulnerable, being 11.6 and 5.4 fold more likely to die, respectively.

Background

Despite 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 Findings

This 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/Significance  This study proposes highly predictive and easy-to-use prognostic tools, which stratify the risk of EVD mortality at or after EVD triage.

Nearly three years after Ebola hit Sierra Leone, millions of dollars in funds raised to fight the deadly virus have still not been accounted for.

BBC

“…..This led to dramatic strike action in late 2014 at the Kenema hospital. Members of the specialist burial teams brought out corpses from the morgue and placed them at the hospital entry points, demanding unpaid allowances. ……”

 


Long-term clinical, psychosocial, and viral outcomes in Ebola survivors in Guinea.

Lancet

Multidisciplinary assessment of post-Ebola sequelae in Guinea (Postebogui): an observational cohort study.                                                                                                                                                                                                                 Etard, Jean-François et al.                                                                                                                                                                                                                       The Lancet Infectious Diseases

img_9577

Findings

Between March 23, 2015, and July 11, 2016, we recruited 802 patients, of whom 360 (45%) were male, 442 (55%) were female; 158 (20%) were younger than 18 years. The median age was 28·4 years (range 1·0–79·9, IQR 19·4–39·8). The median delay after discharge was 350 days (IQR 223–491). The most frequent symptoms were general symptoms (324 [40%] patients), musculoskeletal pain (303 [38%]), headache (278 [35%]), depression (124 [17%] of 713 responses), abdominal pain (178 [22%]), and ocular disorders (142 [18%]). More adults than children had at least one clinical symptom (505 [78%] vs 101 [64%], p<0·0003), ocular complications (124 [19%] vs 18 [11%], p=0·0200), or musculoskeletal symptoms (274 [43%] vs 29 [18%], p<0·0001). A positive RT-PCR in semen was found in ten (5%) of 188 men, at a maximum of 548 days after disease onset. 204 (26%) of 793 patients reported stigmatization. Ocular complications were more frequent at enrolment than at discharge (142 [18%] vs 61 [8%] patients).

Interpretation

Post-EVD symptoms can remain long after recovery and long-term viral persistence in semen is confirmed. The results justify calls for regular check-ups of survivors at least 18 months after recovery.

 


What is the potential role of lung infection in Ebola and can it be a factor in transmission of the virus from one human to another?

Eureka

Biava M, Caglioti C, Bordi L, Castilletti C, Colavita F, Quartu S, et al. (2017) Detection of Viral RNA in Tissues following Plasma Clearance from an Ebola Virus Infected Patient. PLoS Pathog 13(1): e1006065. doi:10.1371/journal.ppat.1006065

http://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1006065


Prevalence of electrolyte and metabolic abnormalities in Ebola patients

Emerging Infectious Disease Journal

  • Abnormalities were common among patients, particularly hypokalemia, hypocalcemia, hyponatremia, raised creatinine, high anion gap, and anemia.
  • Besides age and PCR cycle threshold value, renal dysfunction, low calcium levels, and low hemoglobin levels were independently associated with increased risk for death.

 


Treatment of EVD with T-705 (favipiravir) was associated with prolonged survival and markedly reduced viral load

Clin Infect Dis

Chang-Qing Bai, Jin-Song Mu, David Kargbo, Ya-Bin Song, et al.  Clinical and Virological Characteristics of Ebola Virus Disease Patients Treated with favipiravir (T-705), Sierra Leone, 2014 Clin Infect Dis. ciw571 first published online August 23, 2016 doi:10.1093/cid/ciw571

“…..Among the 35 patients who finished all designed endpoint observations, the survival rate in T-705 treatment group (64.8%, 11/17) was higher than that of control group (27.8%, 5/18). Furthermore, the average survival time of the treatment group (46.9±5.6 days) was longer than that of the control group (28.9±4.7 days). Most symptoms of patients in the treatment group improved significantly. Additionally, 52.9% of patients who received T-705 had over a 100 fold viral load reduction, compared to only 16.7% of patients in the control group. …..”


Summary: CDC’s Detailed History of the 2014-2016 Ebola Response

Press Release
                                               
Thursday, July 7, 2016
                                                                                          
404-639-3286
 
CDC Releases Detailed History of the 2014-2016 Ebola Response in MMWR
 
The Centers for Disease Control and Prevention (CDC) today will release a detailed account of the agency’s work on the largest, longest outbreak response in the agency’s history: the Ebola epidemic of 2014-2016. The series of articles, in a special supplement to CDC’s Morbidity and Mortality Weekly Report (MMWR), comes on the second anniversary of the official activation of the agency’s emergency response to Ebola.
 
“The Ebola epidemic in West Africa killed thousands and directly or indirectly harmed millions of people living in the region,” said CDC Director Tom Frieden, M.D., M.P.H. “The resilience of those affected; the hard work by ministries of health and international partners; and the dedication, hard work, and expertise of mission-driven CDC employees helped avoid a global catastrophe. We must work to ensure that a preventable outbreak of this magnitude never happens again.”
 
The 2014-2016 Ebola epidemic was the first and largest epidemic of its kind, with widespread urban transmission and a massive death count of more than 11,300 people in Guinea, Liberia, and Sierra Leone. The epidemic took a devastating toll on the people of West Africa. Ending it took an extraordinary international effort in which the U.S. government played a major role.
 
CDC’s response was directed simultaneously at controlling the epidemic in West Africa and strengthening preparedness for Ebola in the United States. The new MMWR Ebola special supplement primarily focuses on the agency’s work during the first year and a half of the response. CDC activated its Emergency Operations Center (EOC) for the Ebola response on July 9, 2014. On August 5, 2014, CDC elevated the EOC to a Level 1 activation, its highest level. On March 31, 2016, CDC officially deactivated the EOC for the 2014-2016 Ebola response.
 
“The world came together in an unprecedented way—nations, organizations, and individuals—to respond to this horrible epidemic,” said Inger Damon, M.D., Ph.D., who served as incident manager for the CDC Ebola response during its first eight months. “CDC staff performed heroically and were an integral part of the U.S. all-government response, which involved many other agencies and branches of government.”
 
By the end of the CDC 2014-2016 Ebola response on March 31, 2016, more than 3,700 CDC staff, including all 158 Epidemic Intelligence Service Officers, had participated in international or domestic response efforts. There were 2,292 total deployments to Guinea, Liberia, and Sierra Leone and 3,544 total deployments overall (domestic and international) to support the response. Approximately 1,558 CDC responders have deployed to Guinea, Liberia, and Sierra Leone since the start of the response in July 2014 to the close of the response at the end of March 2016 – including 454 responders with repeat deployments. Even after the deactivation of the CDC 2014-2016 Ebola response, CDC continues its work to better understand and combat the Ebola virus and to assist Guinea, Liberia and Sierra Leone in the aftermath of the 2014-2016 Ebola epidemic; currently, CDC staff remain in CDC country offices in Guinea, Liberia, and Sierra Leone to help support the Global Health Security Agenda.
 
Experience responding to approximately 20 Ebola outbreaks since 1976 provided CDC and other international responders with an understanding of the disease and how to stop its spread. But unlike those shorter, self-limited outbreaks, the 2014-2016 Ebola epidemic in West Africa presented new and formidable challenges.
 
“This outbreak is a case study in why the Global Health Security Agenda is so important,” said Beth Bell, M.D., M.P.H., director of CDC’s National Center for Emerging and Zoonotic Infectious Diseases. “By the time the world understood there was an outbreak, it was already widespread – and had ignited the world’s first urban Ebola epidemic, with devastating results.”
 
 
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CDC Releases Detailed History of the 2014-2016 Ebola Response in MMWR

CDC

The Centers for Disease Control and Prevention (CDC) today will release a detailed account of the agency’s work on the largest, longest outbreak response in the agency’s history: the Ebola epidemic of 2014-2016. The series of articles, in a special supplement to CDC’s Morbidity and Mortality Weekly Report (MMWR), comes on the second anniversary of the official activation of the agency’s emergency response to Ebola.

“The Ebola epidemic in West Africa killed thousands and directly or indirectly harmed millions of people living in the region,” said CDC Director Tom Frieden, M.D., M.P.H. “The resilience of those affected; the hard work by ministries of health and international partners; and the dedication, hard work, and expertise of mission-driven CDC employees helped avoid a global catastrophe. We must work to ensure that a preventable outbreak of this magnitude never happens again.”

The 2014-2016 Ebola epidemic was the first and largest epidemic of its kind, with widespread urban transmission and a massive death count of more than 11,300 people in Guinea, Liberia, and Sierra Leone. The epidemic took a devastating toll on the people of West Africa. Ending it took an extraordinary international effort in which the U.S. government played a major role.

CDC’s response was directed simultaneously at controlling the epidemic in West Africa and strengthening preparedness for Ebola in the United States. The new MMWR Ebola special supplement primarily focuses on the agency’s work during the first year and a half of the response. CDC activated its Emergency Operations Center (EOC) for the Ebola response on July 9, 2014. On August 5, 2014, CDC elevated the EOC to a Level 1 activation, its highest level. On March 31, 2016, CDC officially deactivated the EOC for the 2014-2016 Ebola response.

“The world came together in an unprecedented way—nations, organizations, and individuals—to respond to this horrible epidemic,” said Inger Damon, M.D., Ph.D., who served as incident manager for the CDC Ebola response during its first eight months. “CDC staff performed heroically and were an integral part of the U.S. all-government response, which involved many other agencies and branches of government.”

By the end of the CDC 2014-2016 Ebola response on March 31, 2016, more than 3,700 CDC staff, including all 158 Epidemic Intelligence Service Officers, had participated in international or domestic response efforts. There were 2,292 total deployments to Guinea, Liberia, and Sierra Leone and 3,544 total deployments overall (domestic and international) to support the response. Approximately 1,558 CDC responders have deployed to Guinea, Liberia, and Sierra Leone since the start of the response in July 2014 to the close of the response at the end of March 2016 – including 454 responders with repeat deployments. Even after the deactivation of the CDC 2014-2016 Ebola response, CDC continues its work to better understand and combat the Ebola virus and to assist Guinea, Liberia and Sierra Leone in the aftermath of the 2014-2016 Ebola epidemic; currently, CDC staff remain in CDC country offices in Guinea, Liberia, and Sierra Leone to help support the Global Health Security Agenda.

Experience responding to approximately 20 Ebola outbreaks since 1976 provided CDC and other international responders with an understanding of the disease and how to stop its spread. But unlike those shorter, self-limited outbreaks, the 2014-2016 Ebola epidemic in West Africa presented new and formidable challenges.

“This outbreak is a case study in why the Global Health Security Agenda is so important,” said Beth Bell, M.D., M.P.H., director of CDC’s National Center for Emerging and Zoonotic Infectious Diseases. “By the time the world understood there was an outbreak, it was already widespread – and had ignited the world’s first urban Ebola epidemic, with devastating results.”

This supplement tells the story of CDC’s contributions and shows the importance of partnerships among the international community. Some of the key CDC key activities detailed in this supplement include:

  • In West Africa
    • Establishing CDC teams in Guinea, Liberia, and Sierra Leone that transitioned into permanent CDC country offices in support of the Global Health Security Agenda and supporting the incident management systems in each of the affected countries
    • Improving case detection and contact tracing; maintaining infection control in Ebola treatment units and general health care facilities; conducting detailed epidemiologic analyses of Ebola trends and transmission patterns
    • Promoting the use of safe and dignified burial services to help stop spread of Ebola
    • Fostering hope for a long-term solution for Ebola, including rollout of the STRIVE (Sierra Leone Trial to Introduce a Vaccine against Ebola) trial
    • Strengthening surveillance and response capacities in surrounding, at-risk countries, and working with international partners to establish exit and entry risk assessment procedures at borders
  • In the United States
    • Reducing the likelihood of spread of Ebola through travel, including working with federal and state health officials to establish entry risk assessment procedures
    • Establishing entry screening and monitoring of all travelers entering the U.S. from Ebola-affected areas
    • Assisting state health departments in responding to domestic Ebola concerns
    • Establishing trained and ready hospitals in the United States capable of safely caring for possible Ebola patients
    • Forming CDC Rapid Ebola Preparedness (REP) response teams that could provide assistance within 24 hours to a health care facility managing a patient with Ebola.
    • Identifying and distributing to state and local public health laboratories a laboratory assay that could reliably detect infection with the Ebola virus strain circulating in West Africa, and working with the Food and Drug Administration, the U.S. Department of Defense, and the Association of Public Health Laboratories to rapidly introduce and validate the assay in public health laboratories across the United States
  • At CDC
    • Modeling, in real time, predictions for the course of the epidemic that helped galvanize international support and generated estimates on various topics related to the response in West Africa and the risk for importation of cases into the United States
    • Providing logistics support for the most ambitious CDC deployment in history
    • Supporting laboratory needs at CDC’s Atlanta headquarters and transferring CDC laboratory expertise to the field
    • Creating risk communication materials designed to help change behavior, decrease rates of transmission, and confront stigma, in West Africa and the United States

“This outbreak highlighted how much more we have to learn about Ebola, and it demonstrated that all countries are connected. An outbreak in one country is not just a national emergency, but a global one. This supplement’s detailed review of the 2014-2016 Ebola epidemic and CDC’s response, with many partners, shows the importance of preparedness. It is vital that countries are ready to quickly detect and respond to infectious disease outbreaks, and the international community is committed to increasing that readiness through the Global Health Security Agenda,” Dr. Frieden said. “Through our newly established country offices in Guinea, Liberia, and Sierra Leone, CDC will continue to help West Africa prevent an outbreak of this magnitude from happening again.”

The full MMWR Supplement on the response to the 2014-2016 Ebola virus disease epidemic and related information on the individual chapters available at http://www.cdc.gov/mmwr/ind2016_su.html.

###


HHS Expert Ebola Panel: The US government was not prepared to rapidly respond to the domestic or international threat of Ebola

HHS Ebola Panel Report

Findings of the Independent Panel

1. The lack of strong leadership and response coordination from WHO hindered HHS and international response efforts.

2. The U.S. government was not well prepared to respond to emergent crises that require a rapid, integrated domestic and international response.

3. The U.S. government did not use all coordination elements of the National Response Framework during the Ebola response.

4. HHS did not apply existing pandemic plans and coordination mechanisms during the Ebola response.

5. HHS’s early communications did not demonstrate an appreciation of the public’s perceptions and fear, or discuss the possibility of isolated U.S. Ebola cases.

6. In the initial months of the crisis, the U.S. government was not prepared to deploy response personnel at the scale or rate required for the Ebola epidemic.

7. Differing perspectives on the most appropriate ways to use and evaluate investigational vaccines and treatments contributed to incomplete evaluation of the efficacy of these products.

8. The U.S. government did not anticipate the complications associated with establishing domestic Ebola Treatment Centers and other domestic preparedness measures.

9. Screening passengers at selected U.S. airports enabled local authorities to identify and monitor individuals who might have been exposed to Ebola.

10. The Public Health Emergency Medical Countermeasures Enterprise collaborated to expedite research, development, manufacturing, and provision of Ebola vaccines and treatments.

11. HHS initially had difficulty developing credible guidance for, and ensuring an adequate supply of, personal protective equipment for healthcare workers.

12. Federal, state, and local governments applied different—and, at times, conflicting—policies and authorities for specific response measures, such as waste management and quarantine.

13. HHS is not configured or funded to respond to a prolonged public health or medical emergency overseas or at home.

 


Epidemiologic characteristics, clinical manifestations, and risk factors of 139 patients with Ebola virus disease in western Sierra Leone

Am J Infect Control

The median age of investigated patients was 29 years

55.4% were women.

76 patients (54.7%) died

63 patients (45.3%) were cured.

Case fatality rate among male patients was higher than in female patients (69.4% vs 42.9%).

Fatigue (82.0%), anorexia (70.5%), abdominal pain (59.7%), diarrhea (58.3%), vomiting (56.1%), fever (55.4%), and muscle pain (54.0%) were the most common symptoms.

55.4% of investigated patients reported fever.

Bleeding was seen in 10.8% of patients.

The difference between patients with fever who died and those who survived was statistically significant (68.4% vs 39.7%; P = 0.001), as was the difference in those with hiccups (38.2% vs 6.3%, P < 0.001).


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