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

Improving the quality of COVID-19 care in Sierra Leone: A modified Delphi process and serial nationwide assessments of quality of COVID-19 care in Sierra Leone

INTRODUCTION

Improving the quality of care that patients receive is paramount to improving patient outcomes and engendering trust during infectious disease outbreaks. Whilst Quality Improvement (QI) is well established to drive improvement in routine care and in health systems, there are fewer reports of its use during infectious disease outbreaks.

METHODS

A modified Delphi process was undertaken to create a standardized assessment tool for the quality of COVID-19 care in Sierra Leone. Four rounds of assessment were undertaken between July 2020 and July 2021. To assess change across the four assessment periods compared to baseline we used a mixed effects model and report coefficients and p values.

RESULTS

During the Delphi process, 12/14 participants selected the domains to be assessed within the tool. The final 50 questions included 13 outcome questions, 17 process questions and 20 input questions. A total of 94 assessments were undertaken over four assessment periods at 27 facilities. An increase of 8.75 (p = <0.01) in total score was seen in round 2, 10.67 (p = <0.01) in round 3 and 2.17 (p = 0.43) in round 4 compared to baseline. Mean cumulative scores for COVID-19 Treatment Centres were higher than Hospital Isolation Units (p<0.02) at all four timepoints. Significant improvements were reported in coordination, diagnostics, staffing, infection prevention and control (IPC), nutrition, and vulnerable populations domains, but not in the oxygen, care processes, infrastructure and drugs domains.

CONCLUSION

We demonstrate the feasibility of creating a quality of care assessment tool and conducting sequential nationwide assessments during an infectious disease outbreak. We report significant improvements in quality-of-care scores in round 2 and round 3 compared to baseline, however, these improvements were not sustained. We recommend the use of QI and the creation of standardised assessment tools to improve quality of care during outbreak responses.

Impacts of Ebola disease outbreak in West Africa: Implications for government and public health preparedness and lessons from COVID-19

There has been an increase in the outbreak of communicable diseases in recent times; the most recent ones are Ebola Virus Disease (EVD) and COVID-19. These diseases have had different impacts on society and the ecosystem. However, underlying these impacts are the levels of preparedness of governments and public health institutions to mitigate and control these diseases. Therefore, this paper aims to explore these impacts, government and institutional interventions and their nexus towards the effective management of such crises. A critical review of empirical literature was adopted for the methodological approach and narrative synthesis used for analysis. Results show that EVD had diverse impacts on West Africa; economically through the loss of income from economic activities due to widespread sickness among workers and movement restrictions. EVD also had significant social impacts, such as reduced community cohesion, school and business closures, job losses, food insecurity, and high morbidity and mortality. Though some good efforts have been made by different countries in collaboration with international organisations like the World Health Organization to control disease outbreaks more effectively, the recent COVID-19 pandemic has however exposed major weaknesses in the capacity of most African countries to cope. Poor capacity for testing and treatment, inadequate health facilities, poor incentives for health care workers, poor governance systems, poor border control, and awareness and research capacities impacted negatively on the capacity to control disease outbreaks. There is, therefore, a need to strengthen health systems across Africa through improved resource mobilisation, staff training, and coordination of investment strategies to sustain health system preparedness to manage future emerging or re-emerging outbreaks.

The impact of the COVID-19 pandemic on hospital utilisation in Sierra Leone

INTRODUCTION

The COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on hospital utilisation in a sub-Saharan country, Sierra Leone.

METHODS

Mixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals) and qualitative interviews with healthcare workers and patients. Hospital data were compared across quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity and paediatric) and hospital type (government or private non-profit). Referrals in 2020 were compared with 2019 to assess whether any changes were the result of seasonality. Comparisons were performed using Student's t-test. Qualitative data were analysed using thematic analysis.

RESULTS

From Q1 to Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8% than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8% decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), while caesarean sections and facility-based deliveries showed significant increases: 12.7% (p=0.014) and 7.5% (p=0.03), respectively. In Q3, total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared with 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship.

CONCLUSION

The study demonstrated a decrease in hospital utilisation during COVID-19, the decrease is less than reported in other countries during COVID-19 and less than reported during the Ebola epidemic.

Ebola virus outbreak preparedness plan for developing Nations: Lessons learnt from affected countries

BACKGROUND

Ebola virus (EBOV); a public health emergency of international concern,is known to pose threat of global outbreaks. EBOV has spread in African continent and due to unchecked international travel, importation of cases has been reported in different countries. In this alarming scenario, developing countries need to evaluate and upgrade their preparedness plan to contain the spread of EBOV. The present review lays down the updated preparedness plan for developing countries to contain future EBOV outbreaks.

METHODS

The literature on EBOV outbreaks and preparedness strategies reported were searched on Pubmed and Google Scholar using the MeSH terms such as "Ebola virus disease, Epidemic, Outbreak, Imported case, Preparedness, Public health interventions" combined with Boolean operator (OR) for the period of 2011-2020. Additionally, World Health organization (WHO) and Centers for Disease Control & Prevention (CDC) websites were searched for the guidelines, reports, containment strategies, containment plan of countries, actions taken by countries and international partners, etc. RESULTS: The present review analyzed the EBOV outbreaks between 2011-2020 and containment strategies used by the affected countries. Based on the lessons learned from EBOV outbreaks and personal experience in infectious disease management, we have recommended a preparedness and response plan for EBOV containment in developing countries.

CONCLUSION

Developing countries are particularly vulnerable to major outbreaks of EBOV due to increased international travel and unchecked transmission. The recommended preparedness plan will help developing counties to contain EBOV outbreaks in future.

Meta-analysis of predictive symptoms for Ebola virus disease

INTRODUCTION

One of the leading challenges in the 2013-2016 West African Ebola virus disease (EVD) outbreak was how best to quickly identify patients with EVD, separating them from those without the disease, in order to maximise limited isolation bed capacity and keep health systems functioning.

METHODOLOGY

We performed a systematic literature review to identify all published data on EVD clinical symptoms in adult patients. Data was dual extracted, and random effects meta-analysis performed for each symptom to identify symptoms with the greatest risk for EVD infection.

RESULTS

Symptoms usually presenting late in illness that were more than twice as likely to predict a diagnosis of Ebola, were confusion (pOR 3.04, 95% CI 2.18-4.23), conjunctivitis (2.90, 1.92-4.38), dysphagia (1.95, 1.13-3.35) and jaundice (1.86, 1.20-2.88). Early non-specific symptoms of diarrhoea (2.99, 2.00-4.48), fatigue (2.77, 1.59-4.81), vomiting (2.69, 1.76-4.10), fever (1.97, 1.10-4.52), muscle pain (1.65, 1.04-2.61), and cough (1.63, 1.24-2.14), were also strongly associated with EVD diagnosis.

CONCLUSIONS

The existing literature fails to provide a unified position on the symptoms most predictive of EVD, but highlights some early and late stage symptoms that in combination will be useful for future risk stratification. Confirmation of these findings across datasets (or ideally an aggregation of all individual patient data) will aid effective future clinical assessment, risk stratification tools and emergency epidemic response planning.

Pandemic stricken cities on lockdown. Where are our planning and design professionals [now, then and into the future]?

Chinese cities have been placed upon lockdown in early 2020 in an attempt to contain the novel coronavirus (COVID-19), as increasingly huge demands are being placed upon Chinese and international health professionals to address this pandemic. Surprisingly, planning and design professionals are absent in the discourses about existing and post-COVID-19 strategies and actions even though previous pandemics historically revealed major impacts on the urban fabric from social and economic perspectives. This paper is a call for action for international architectural and urban organisations to include pandemics and similar in their disaster management strategies. This need is very evident in their need to better design creative and relevant protocols in partnership with health discipine organisations, and so that their applied deployment in pandemic stricken cities can be effected integrated seamlessly within normal city environment planning activities and also in incident situations like containing the current COVID-19 pandemic.

A Modified Case Definition to Facilitate Essential Hospital Care During Ebola Outbreaks

During the late phase of the large West-African Ebola virus disease (EVD) outbreak, the majority of patients were cared for in designated treatment centers. However, the preexisting healthcare infrastructure was already overwhelmed by the outbreak. This had a huge impact on other, non-EVD-related diseases, causing an unprecedented increase in morbidity and mortality, which most likely exceeded the toll due to EVD directly. Consequently, a crucial question is how to provide appropriate healthcare and safeguard functionality of a healthcare system that also serves patients not suspected or diagnosed to have EVD. Here, we report on the Lion Heart Medical Center's experience in Sierra Leone and note that a case definition of Ebola that is broader than those commonly applied may be better suited when it is necessary to identify atypically presenting, pauci-symptomatic cases.

Forty-two years of responding to Ebola virus outbreaks in Sub-Saharan Africa: a review

Introduction

Ebola virus disease (EVD) is one of the deadliest haemorrhagic fevers affecting humans and non-human primates. Thirty-four outbreaks have been reported in Africa since it was first recognised in 1976. This review analysed 42 years of EVD outbreaks and identified various challenges and opportunities for its control and prevention in Sub-Saharan Africa.

Methods

A literature search of relevant articles on EVD was done in PubMed, Web of Science and Google Scholar electronic databases. Articles published from 1976 to 2019 were reviewed to document reports of EVD outbreaks in Sub-Saharan Africa. Data extraction focused on the year of outbreak, geographical spread, virus strain involved, number of cases and deaths, case fatality, and outbreak management. Analyses of trends in case fatality were performed by calculating ORs between times.

Results

In the past four decades, a total of 34 EVD outbreaks affecting 34 356 cases and causing 14 823 deaths were reported in 11 countries in Sub-Saharan Africa. The overall case fatality rate (95% CI) was 66% (62 to 71) and did not change substantially over time (OR in 2019 vs 1976=1.6 (95% CI 1.5 to 1.8), p<0.001). The results of this review indicate that challenges to control EVD outbreaks are related to epidemiological, sociocultural and health system factors.

Conclusions

Sub-Saharan Africa continues to face considerable challenges in EVD control, whereby there are no significant changes in case fatality rates observed during the past four decades. Socioeconomic and cultural processes need to be critically considered to shape the community behaviours that lead to exposure to EVD outbreaks. Areas that need to be addressed to prevent future EVD outbreaks include a broad-based, one-health approach, effective communication, social mobilisation, and strengthening of the health systems.

Principles and Practices of Establishing a Hospital-Based Ebola Treatment Unit

Outbreaks of Ebola virus disease and high-risk transmissible infections are increasing and pose threats to health care workers and global health systems. Previous outbreaks offer lessons for health system preparedness and response, including establishment of hospital-based high-risk pathogen treatment units. Their creation demands early preparation and interprofessional coordination; infection prevention and control; case management training; prepositioning of supplies; conversion of existing structures to treatment units; and strengthening communication and research platforms. Hospital-based Ebola and high-risk pathogen treatment units may improve case detection, interrupt transmission, and improve staff safety and patient care.

Infection Rates and Risk Factors for Infection Among Health Workers During Ebola and Marburg Virus Outbreaks: A Systematic Review

Background

Infection in health workers (HWs) has characterized outbreaks of Ebola virus disease (EVD) and Marburg virus disease (MVD). We conducted a systematic review to investigate infection and mortality rates and common exposure risks in HWs in EVD and MVD outbreaks.

Methods

We searched the EMBASE and PubMed databases to identify articles posted before 27 December 2017, with no language restrictions. Data on the number, frequency, and mortality of HW infection and exposure risks were extracted.

Results

Ninety-four articles related to 22 outbreaks were included. HW infections composed 2%-100% of cases in EVD and 5%-50% of cases in MVD outbreaks. Among exposed HWs, 0.6%-92% developed EVD, and 1%-10% developed MVD. HW infection rates were consistent through outbreaks. The most common exposure risk situations were inadequate personal protective equipment and exposure to patients with unrecognized EVD/MVD. Similar risks were reported in past EVD/MVD outbreaks and in the recent outbreak in West Africa.

Conclusions

Many outbreaks reported high proportions of infected HWs. Similar HW infection rates and exposure risk factors in both past and recent EVD and MVD outbreaks emphasize the need to improve the implementation of appropriate infection control measures consistently across all healthcare settings.

Development of a Pediatric Ebola Predictive Score, Sierra Leone1

We compared children who were positive for Ebola virus disease (EVD) with those who were negative to derive a pediatric EVD predictor (PEP) score. We collected data on all children <13 years of age admitted to 11 Ebola holding units in Sierra Leone during August 2014–March 2015 and performed multivariable logistic regression. Among 1,054 children, 309 (29%) were EVD positive and 697 (66%) EVD negative, with 48 (5%) missing. Contact history, conjunctivitis, and age were the strongest positive predictors for EVD. The PEP score had an area under receiver operating characteristics curve of 0.80. A PEP score of 7/10 was 92% specific and 44% sensitive; 3/10 was 30% specific, 94% sensitive. The PEP score could correctly classify 79%–90% of children and could be used to facilitate triage into risk categories, depending on the sensitivity or specificity required.

The Binds of Global Health Partnership: Working out Working Together in Sierra Leone

Global health partnerships (GHPs) are the conceptual cousin of partnerships in the development sphere. Since their emergence in the 1990s, the GHP mode of working and funding has mainly been applied to single-disease, vertical interventions. However, GHPs are increasingly being used to enact Health Systems Strengthening and to address the global health worker shortage. In contrast to other critical explorations of GHPs, we explore in this article how the fact, act, and aspiration of binding different actors together around the ideology and modes of partnership working produces the perpetual state of being in a bind. This is an original analytical framework drawing on research in Sierra Leone and London. We offer new insights into the ways in which GHPs function and are experienced, showing that along with the successes of partnership work, such arrangements are often and unavoidably tense, uncomfortable, and a source of frustration and angst.

Ebola Virus Disease in Children, Sierra Leone, 2014-2015

Children died rapidly, more than half in Ebola holding units before transfer to treatment units.

Little is known about potentially modifiable factors in Ebola virus disease in children. We undertook a retrospective cohort study of children <13 years old admitted to 11 Ebola holding units in the Western Area, Sierra Leone, during 2014–2015 to identify factors affecting outcome. Primary outcome was death or discharge after transfer to Ebola treatment centers. All 309 Ebola virus–positive children 2 days–12 years old were included; outcomes were available for 282 (91%). Case-fatality was 57%, and 55% of deaths occurred in Ebola holding units. Blood test results showed hypoglycemia and hepatic/renal dysfunction. Death occurred swiftly (median 3 days after admission) and was associated with younger age and diarrhea. Despite triangulation of information from multiple sources, data availability was limited, and we identified no modifiable factors substantially affecting death. In future Ebola virus disease epidemics, robust, rapid data collection is vital to determine effectiveness of interventions for children.

Novel surveillance methods for the control of Ebola virus disease

The unprecedented scale of the 2013-2016 West African Ebola virus disease (EVD) outbreak was in a large part due to failings in surveillance: contacts of confirmed cases were not systematically identified, monitored and diagnosed early, and new cases appearing in previously unaffected communities were similarly not rapidly identified, diagnosed and isolated. Over the course of this epidemic, traditional surveillance methods were strengthened and novel methods introduced. The wealth of experience gained, and the systems introduced in West Africa, should be used in future EVD outbreaks, as well as for other communicable diseases in the region and beyond.

The UK's multidisciplinary response to an Ebola epidemic

The West African Ebola virus disease (EVD) epidemic was the largest and most devastating outbreak of EVD the world has ever seen. Its impact was felt far from the shores of Guinea, Liberia and Sierra Leone, with public health systems and clinicians across the globe confronted with an international response both in the affected region and within their own borders. The UK had a prominent role in response efforts, particularly in Sierra Leone. This article highlights how UK academic, health service, military, commercial and public health professionals all played a significant role both at home and abroad.

'Once there is life, there is hope' Ebola survivors' experiences, behaviours and attitudes in Sierra Leone, 2015

Background

In Sierra Leone, over 4000 individuals survived Ebola since the outbreak began in 2014. Because Ebola survivorship was largely unprecedented prior to this outbreak, little is known about survivor experiences during and post illness.

Methods

To assess survivors' experiences and attitudes related to Ebola, 28 in-depth interviews and short quantitative surveys with survivors from all four geographic regions of Sierra Leone were conducted in May 2015.

Results

Survivor experiences, emotions and attitudes changed over time as they moved from disease onset to treatment, discharge and life post-discharge. Survivors mentioned experiencing acute fear and depression when they fell ill. Only half reported positive experiences in holding centres but nearly all were positive about their treatment centre experiences. Survivor euphoria on discharge was followed by concerns about their financial situation and future. While all reported supportive attitudes from family members, about a third described discrimination and stigma from their communities. Over a third became unemployed, especially those previously engaged in petty trade. Survivor knowledge about sexual transmission risk reflected counselling messages. Many expressed altruistic motivations for abstinence or condom use. In addition, survivors were strongly motivated to help end Ebola and to improve the healthcare system. Key recommendations from survivors included improved counselling in holding centres and long-term government support for survivors, including opportunities for participation in Ebola response efforts.

Conclusions

Survivors face myriad economic, social and health challenges. Addressing survivor concerns, including the discrimination they face, could facilitate their reintegration into communities and their contributions to future Ebola responses.

Ebola response in Sierra Leone: The impact on children

The West African Ebola virus disease (EVD) outbreak is the largest ever seen, with over 28,000 cases and 11,300 deaths since early 2014. The magnitude of the outbreak has tested fragile governmental health systems and non-governmental organizations (NGOs) to their limit. Here we discuss the outbreak in the Western Area of Sierra Leone, the shape of the local response and the impact the response had on caring for children suspected of having contracted EVD. Challenges encountered in providing clinical care to children whilst working in the "Red Zone" where risk of EVD is considered to be highest, wearing full personal protective equipment are detailed. Suggestions and recommendations both for further research and for operational improvement in the future are made, with particular reference as to how a response could be more child-focused.