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Objective: To describe Ebola cases in the district Ebola management centre of in Kailahun, a remote rural district of Sierra Leone, in terms of geographic origin, patient and hospitalisation characteristics, treatment outcomes and time from symptom onset to admission. Methods: Data of all Ebola cases from June 23rd to October 5th 2014 were reviewed. Ebola was confirmed by reverse-transcriptase-polymerase-chain-reaction assay. Results: Of 489 confirmed cases (51% male, median age 28 years), 166 (34%) originated outside Kailahun district. Twenty-eight (6%) were health workers: 2 doctors, 11 nurses, 2 laboratory technicians, 7 community health workers and 6 other cadres. More than 50% of patients had fever, headache, abdominal pain, diarrhoea/vomiting. An unusual feature was cough in 40%. Unexplained bleeding was reported in 5%. Outcomes for the 489 confirmed cases were 227 (47%) discharges, 259 (53%) deaths and 3 transfers. Case fatality in health workers (68%) was higher than other occupations (52%, P = 0.05). The median community infectivity time was 6.5 days for both general population and health workers (P = 0.4). Conclusions: One in three admitted cases originated outside Kailahun district due to limited national access to Ebola management centres – complicating contact tracing, safe burial and disinfection measures. The comparatively high case fatality among health workers requires attention. The community infectivity time needs to be reduced to prevent continued transmission.
This observational study in November 2014 included all patients who were enrolled consecutively at arrival at the Ebola management centre between 23rd June and 5th October 2014. Follow-up was censured on 10th November 2014. Sierra Leone has an estimated population of six million and despite decades of mining of diamonds, titanium, bauxite and gold, 70% of its people live in poverty [12]. The 1991–2002 civil war devastated the country and its health system; Sierra Leone ranks 5th highest for maternal mortality and 11th for infant mortality worldwide [12]. Even before the Ebola outbreak, which resulted in the deaths of many health workers, there were only 0.2 doctors and 1.7 nurses per 10 000 population, mostly located in urban areas [12]. The study site was the only Ebola management centre in Kailahun town in rural Kailahun district of Sierra Leone, which has 400 000 inhabitants and a surface area of 4859 km2. It lies in the north-east of Sierra Leone and is bordered by Liberia to the east and Guinea to the north. The district health management team of the Ministry of Health and Sanitation is responsible for overall coordination of Ebola control activities and partners. Partners include the International Federation of the Red Cross (involved with safe burials and home disinfection), Save the Children (contact tracing), WHO (safe burials, support to contact tracing, surveillance, logistic support and training), the World Food Programme (providing food for households under quarantine), the National Microbiological Laboratory, Winnipeg, Canada (laboratory diagnosis of Ebola) and MSF (management of the Ebola management centre, health promotion). A national Ebola call centre receives alerts and despatches teams to investigate and implement control activities. This includes investigating alerts of suspect cases and deaths in the community. At the time of this report, only three dedicated ambulances were available in the whole district for patient transfers to the Ebola management centre. Confirmed and suspected Ebola cases from Kailahun and those referred from neighbouring districts were admitted to the Ebola management centre, which progressively increased its bed capacity from 72 to 94 beds. The set-up and functioning of the centre has been previously described [13]. In brief, approximately 25 people per day – doctors, nurses, disinfection teams, cooks, cleaners, health promotion, counselling teams and logisticians – ensure six-hourly shifts. The centre has its independent water supply, 24-h electricity supply and an on-site kitchen. Patients arrive by ambulances and are assessed in a triage area. Their clinical signs are then recorded, and they are admitted to the suspect or probable area of the centre depending on their case classification [13]. All cases undergo on-site laboratory confirmation by real time polymerase chain reaction (RT-PCR, Public Health Agency, Winnipeg, Canada). Confirmed Ebola cases are then moved to the confirmed area of the centre. Supportive care is provided until the PCR turns negative. Those with two negative PCR tests for Ebola are discharged to seek care from the general health services. All cases receive a systematic course of antimalarials, a broad-spectrum antibiotic and symptomatic care for fever, diarrhoea and vomiting. Treatment outcomes were standardised and documented as recovered (showed clinical improvement and was discharged PCR-negative); death after being admitted; abandoned (left without medical consent); transferred (transferred to another facility). A patient admitted as an Ebola suspect but found negative on repeated PCRs was classified as a non-case. An epidemiologist gathered data from patient files daily and encoded them into a password-protected database used for the analysis. Information on contacts was sourced from the district health office. Treatment outcomes for the period June 23rd to October 5th 2014 were censured on 10th November 2014. The cumulative incidence of death was estimated and expressed graphically using the Kaplan–Meier method. The number of days from onset of symptoms to admission at the Ebola management centre was considered the community infectivity time. Differences between groups were compared using chi-square and Wilcoxon Rank-sum test. The level of significance was set at P ≤ 0.05, and 95% confidence intervals (CIs) were used. Data analysis was performed using STATA 11 software (Stata Corporation, College Station, TX, USA). The study used data collected during surveillance and response activities for Ebola at district level and stripped of patient identifiers. Informed consent was not applicable. The study satisfied the MSF Ethics Review Board criteria for studies using routinely collected data (Geneva, Switzerland); the Ebola interventions were approved by the Ministry of Health, Sierra Leone.
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