The cost of an Ebola case

As the most recent outbreak of Ebola virus disease (EVD) in West Africa continues to grow since its initial recognition as a Public Health Emergency of International Concern, an unanswered question is what is the cost of a case of Ebola? Understanding this cost will help decision makers better understand the impact of each case of EVD, benchmark this against that of other diseases, prioritize which cases may require response, and begin to estimate the cost of Ebola outbreaks. To date, the scientific literature has not characterized this cost per case. Therefore, we developed a mathematical model to estimate the cost of an EVD case from the provider and societal perspectives in the three most affected countries of Guinea, Liberia, and Sierra Leone. Our model estimates the total societal cost of an EVD case with full recovery ranges from $480 to $912, while that of an EVD case not surviving ranges from $5929 to $18 929, varying by age and country. Therefore, as of 10 December 2014, the estimated total societal costs of all reported EVD cases in these three countries range from $82 to potentially over $356 million.

Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak

BACKGROUND

The WHO declared the 2014 west African Ebola epidemic a public health emergency of international concern in view of its potential for further international spread. Decision makers worldwide are in need of empirical data to inform and implement emergency response measures. Our aim was to assess the potential for Ebola virus to spread across international borders via commercial air travel and assess the relative efficiency of exit versus entry screening of travellers at commercial airports.

METHODS

We analysed International Air Transport Association data for worldwide flight schedules between Sept 1, 2014, and Dec 31, 2014, and historic traveller flight itinerary data from 2013 to describe expected global population movements via commercial air travel out of Guinea, Liberia, and Sierra Leone. Coupled with Ebola virus surveillance data, we modelled the expected number of internationally exported Ebola virus infections, the potential effect of air travel restrictions, and the efficiency of airport-based traveller screening at international ports of entry and exit. We deemed individuals initiating travel from any domestic or international airport within these three countries to have possible exposure to Ebola virus. We deemed all other travellers to have no significant risk of exposure to Ebola virus.

FINDINGS

Based on epidemic conditions and international flight restrictions to and from Guinea, Liberia, and Sierra Leone as of Sept 1, 2014 (reductions in passenger seats by 51% for Liberia, 66% for Guinea, and 85% for Sierra Leone), our model projects 2.8 travellers infected with Ebola virus departing the above three countries via commercial flights, on average, every month. 91,547 (64%) of all air travellers departing Guinea, Liberia, and Sierra Leone had expected destinations in low-income and lower-middle-income countries. Screening international travellers departing three airports would enable health assessments of all travellers at highest risk of exposure to Ebola virus infection.

INTERPRETATION

Decision makers must carefully balance the potential harms from travel restrictions imposed on countries that have Ebola virus activity against any potential reductions in risk from Ebola virus importations. Exit screening of travellers at airports in Guinea, Liberia, and Sierra Leone would be the most efficient frontier at which to assess the health status of travellers at risk of Ebola virus exposure, however, this intervention might require international support to implement effectively.

FUNDING

Canadian Institutes of Health Research.

Selecting the right tool for the job

There are competing ethical concerns when it comes to designing any clinical research study. Clinical trials of possible treatments for Ebola virus are no exception. If anything, the competing ethical concerns are exacerbated in trying to find answers to a deadly, rapidly spreading, infectious disease. The primary goal of current research is to identify experimental therapies that can cure Ebola or cure it with reasonable probability in infected individuals. Pursuit of that goal must be methodologically sound, practical and consistent with prevailing norms governing human subjects research. Some maintain that only randomized controlled trials (RCTs) with a placebo or standard-of-care arm can meet these conditions. We maintain that there are alternative trial designs that can do so as well and that sometimes these are preferable to RCTs.

Clinical presentation of patients with Ebola virus disease in Conakry, Guinea

BACKGROUND

In March 2014, the World Health Organization was notified of an outbreak of Zaire ebolavirus in a remote area of Guinea. The outbreak then spread to the capital, Conakry, and to neighboring countries and has subsequently become the largest epidemic of Ebola virus disease (EVD) to date.

METHODS

From March 25 to April 26, 2014, we performed a study of all patients with laboratory-confirmed EVD in Conakry. Mortality was the primary outcome. Secondary outcomes included patient characteristics, complications, treatments, and comparisons between survivors and nonsurvivors.

RESULTS

Of 80 patients who presented with symptoms, 37 had laboratory-confirmed EVD. Among confirmed cases, the median age was 38 years (interquartile range, 28 to 46), 24 patients (65%) were men, and 14 (38%) were health care workers; among the health care workers, nosocomial transmission was implicated in 12 patients (32%). Patients with confirmed EVD presented to the hospital a median of 5 days (interquartile range, 3 to 7) after the onset of symptoms, most commonly with fever (in 84% of the patients; mean temperature, 38.6°C), fatigue (in 65%), diarrhea (in 62%), and tachycardia (mean heart rate, >93 beats per minute). Of these patients, 28 (76%) were treated with intravenous fluids and 37 (100%) with antibiotics. Sixteen patients (43%) died, with a median time from symptom onset to death of 8 days (interquartile range, 7 to 11). Patients who were 40 years of age or older, as compared with those under the age of 40 years, had a relative risk of death of 3.49 (95% confidence interval, 1.42 to 8.59; P=0.007).

CONCLUSIONS

Patients with EVD presented with evidence of dehydration associated with vomiting and severe diarrhea. Despite attempts at volume repletion, antimicrobial therapy, and limited laboratory services, the rate of death was 43%.

Nomenclature- and database-compatible names for the two Ebola virus variants that emerged in Guinea and the Democratic Republic of the Congo in 2014

In 2014, Ebola virus (EBOV) was identified as the etiological agent of a large and still expanding outbreak of Ebola virus disease (EVD) in West Africa and a much more confined EVD outbreak in Middle Africa. Epidemiological and evolutionary analyses confirmed that all cases of both outbreaks are connected to a single introduction each of EBOV into human populations and that both outbreaks are not directly connected. Coding-complete genomic sequence analyses of isolates revealed that the two outbreaks were caused by two novel EBOV variants, and initial clinical observations suggest that neither of them should be considered strains. Here we present consensus decisions on naming for both variants (West Africa: "Makona", Middle Africa: "Lomela") and provide database-compatible full, shortened, and abbreviated names that are in line with recently established filovirus sub-species nomenclatures.

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Accomplishment of therapeutic clinical trials in the midst of an uncontrolled and devasta- ting epidemic in resource-poor communities is complex and challenging. Key issues rely to close collaboration between research and clinical teams involved in care in the field. Indeed, it is of prime importance to consider cultural dimensions when aiming to build trust within communities and flexibility to adapt trial procedures to field constraints. The JIKI trial, a sequential single-arm proof-of-concept trial, has been implemented in Guinea in 2014-2015 with the aim to evaluate the efficacy of the antiviralfavipiravir in decreasing mortality and tolerance in patients with acute Ebola virus disease. Research was integrated into care to inform clinical management of patients. This pioneer trial illustrates challenging inputs for producing scientific and ethical gains for the benefit of vulnerable populations in the context of an international emerging or re-emerging infectious disease event.

High prevalence of pfmdr1 N86Y and Y184F mutations in Plasmodium falciparum isolates from Bioko Island, Equatorial Guinea

OBJECTIVE

Drug resistance against Plasmodium falciparum has been recognized as the crucial obstacle to curbing mortality and morbidity from malaria. To investigate the distribution and pattern of multidrug resistance 1 (pfmdr1) gene polymorphisms in P. falciparum, isolates collected from the malaria high-endemic Bioko Island, Equatorial Guinea.

METHODS

Blood samples were collected from 217 patients with P. falciparum malaria during rainy season in 2012 on Bioko Island. These samples were extracted using Chelex to obtain parasite DNA. Nest-polymerase chain reaction (PCR) and sequencing were employed to detect mutations (N86Y, E130K, Y184F, S1034C, N1042D, V1109I, and D1246Y) and haplotypes in pfmdr1 gene.

RESULTS

A total of 151 samples were successfully detected for pfmdr1 mutations from the 217 patients. Pfmdr1 mutations were found in 91·39% (138/151) P. falciparum isolates. However, no mutation at 130 and 1109 was identified from these samples. Four haplotypes coding 86, 184, 1034, 1,042, and 1,246 were found including NYSND, YYSND, NFSND, and YFSND, which accounted for 8·61% (13/151), 2·65% (4/151), 29·80% (45/151), and 58·94% (89/151), respectively.

CONCLUSIONS

Our results exhibited hypersensitivity to lumefantrine (LU) and mefloquine (MQ) and resistance to chloroquine (CQ) and amodiaquine (AQ) in P. falciparum isolates from Bioko Island. This information will be useful for anti-malarial drug policy in Equatorial Guinea.

Emergence of Zaire Ebola virus disease in Guinea

In March 2014, the World Health Organization was notified of an outbreak of a communicable disease characterized by fever, severe diarrhea, vomiting, and a high fatality rate in Guinea. Virologic investigation identified Zaire ebolavirus (EBOV) as the causative agent. Full-length genome sequencing and phylogenetic analysis showed that EBOV from Guinea forms a separate clade in relationship to the known EBOV strains from the Democratic Republic of Congo and Gabon. Epidemiologic investigation linked the laboratory-confirmed cases with the presumed first fatality of the outbreak in December 2013. This study demonstrates the emergence of a new EBOV strain in Guinea.

[Ebola hemorrhagic fever: its extension reflects the African sanitary disaster]

Ebola virus, described in 1976 in Zaire, causes severe hemorrhagic fever with a high mortality rate in humans and nonhuman primates. Epidemics occurred since this time to nowadays in Sudan, Gabon, Congo and currently in Guinea, Liberia, Sierra-Leone, Nigeria and Senegal. Specific treatment and vaccine are not available. So, to prevent the virus transmission with live and dead patients, we must use strict individual and collective measures which are not always understood by local populations and make contact tracing; it is the only way to curb the epidemic.

[Scorpion envenomation treated in the Infectious and Tropical Diseases at the Donka National Hospital, Guinea]

A retrospective descriptive study was conducted from 1(st) October 2010 to 30 November 2012 on the records of patients admitted for scorpion envenomation in the Department of Infectious and Tropical Diseases at the Donka National Hospital. The objective of this study is to describe the epidemiological profile and clinical characteristics of scorpion envenomation in Maritime Guinea, from scorpion stings recently covered in this service. We collected 75 cases of scorpion envenomation. The median age was 21.5 with interquartile 8 and 20 and sex ratio was 1.29. The upper limbs were involved in 55% of cases, followed by the lower limbs (35%), trunk (6%), head and neck (4%). We observed 63% of patients with local signs, 30% mild and general clinical signs of 7% severe systemic symptoms. All patients received an analgesic and a heterologous antitoxin, associated with an antibiotic (87% of patients), a corticosteroid (72%), diazepam (13%) and furosemide (34.6%). The incidence of scorpion envenomation is not negligible despite underreporting of cases, most often treated in traditional medicine.

Seroprevalence investigation of bovine brucellosis in Macenta and Yomou, Guinea

Brucellosis is one of the world's major zoonotic diseases associated with reproductive disorders and a potential infection of human. Brucellosis leads to serious economic losses due to late-term abortion, stillbirth, weak calves, and sterility. In Guinea, the data on brucellosis was only detected as far back as 10 years ago. The purpose of this study was to estimate the prevalence of bovine brucellosis in the provinces of Macenta and Yomou of Guinea. A structured questionnaire was used in the clinical study, and 345 cattle were clinically examined. Three hundred serum samples were initially subjected to the Rose Bengal test (RBT); the positive results of which were confirmed by the complement fixation test (CFT). The investigation indicated that farmers had little information on brucellosis. Hygroma, abortion, sterility, and placental retention were the observed symptoms. Of the 29 RBT-positive samples, 26 were confirmed by CFT. The prevalence of brucellosis in Macenta and Yomou was 12 and 5.33 %, respectively. In both provinces, the prevalence mean was 8.67 %. This study highlighted the immediate necessity to carry out a strengthened surveillance of human and animal brucellosis to obtain as many data as possible in order to establish strategies for prevention and management of brucellosis in Guinea.

Deciphering the origin of the 2012 cholera epidemic in Guinea by integrating epidemiological and molecular analyses

Cholera is typically considered endemic in West Africa, especially in the Republic of Guinea. However, a three-year lull period was observed from 2009 to 2011, before a new epidemic struck the country in 2012, which was officially responsible for 7,350 suspected cases and 133 deaths. To determine whether cholera re-emerged from the aquatic environment or was rather imported due to human migration, a comprehensive epidemiological and molecular survey was conducted. A spatiotemporal analysis of the national case databases established Kaback Island, located off the southern coast of Guinea, as the initial focus of the epidemic in early February. According to the field investigations, the index case was found to be a fisherman who had recently arrived from a coastal district of neighboring Sierra Leone, where a cholera outbreak had recently occurred. MLVA-based genotype mapping of 38 clinical Vibrio cholerae O1 El Tor isolates sampled throughout the epidemic demonstrated a progressive genetic diversification of the strains from a single genotype isolated on Kaback Island in February, which correlated with spatial epidemic spread. Whole-genome sequencing characterized this strain as an "atypical" El Tor variant. Furthermore, genome-wide SNP-based phylogeny analysis grouped the Guinean strain into a new clade of the third wave of the seventh pandemic, distinct from previously analyzed African strains and directly related to a Bangladeshi isolate. Overall, these results highly suggest that the Guinean 2012 epidemic was caused by a V. cholerae clone that was likely imported from Sierra Leone by an infected individual. These results indicate the importance of promoting the cross-border identification and surveillance of mobile and vulnerable populations, including fishermen, to prevent, detect and control future epidemics in the region. Comprehensive epidemiological investigations should be expanded to better understand cholera dynamics and improve disease control strategies throughout the African continent.

Knowledge, attitudes and practices of malaria control among communities from the health district of Forécariah in the Republic of Guinea, West Africa

BACKGROUND & OBJECTIVES

Malaria is the leading cause of death in children under 5-yr of age in the Republic of Guinea. This study aimed at investigating the knowledge, attitudes and practices of malaria control in urban and rural communities in Guinea in order to better target future health interventions.

METHODS

A cross-sectional survey of 200 randomly selected households was conducted in an urban site and in three rural villages within the health district of Forιcariah using two semi-structured questionnaires.

RESULTS

Only 18.5% of the respondents were aware of the role of mosquitoes in the transmission of malaria in both urban and rural households. Mosquito nets were identified as a malaria prevention method by 11.5% of the participants and only 8.5% of the respondents mentioned stagnant water as a potential mosquito breeding site. Households' heads were more aware of mosquito control methods, with 56 and 42% of the respondents recognizing that bednets or insecticidal coils can protect from mosquitoes, respectively. Despite the limited knowledge of malaria transmission and prevention, 55% of the households owned at least one long-lasting insecticide-treated net (LLIN) and 79% of the net-owning households slept under a net/LLIN the night before the survey.

INTERPRETATION & CONCLUSION

In order to maximize the benefits of malaria control strategies, health education should be implemented, building on the higher awareness of mosquito control methods and stressing the role of vectors in transmitting the disease.

Use of Vibrio cholerae vaccine in an outbreak in Guinea

BACKGROUND

The use of vaccines to prevent and control cholera is currently under debate. Shanchol is one of the two oral cholera vaccines prequalified by the World Health Organization; however, its effectiveness under field conditions and the protection it confers in the first months after administration remain unknown. The main objective of this study was to estimate the short-term effectiveness of two doses of Shanchol used as a part of the integrated response to a cholera outbreak in Africa.

METHODS

We conducted a matched case-control study in Guinea between May 20 and October 19, 2012. Suspected cholera cases were confirmed by means of a rapid test, and controls were selected among neighbors of the same age and sex as the case patients. The odds of vaccination were compared between case patients and controls in bivariate and adjusted conditional logistic-regression models. Vaccine effectiveness was calculated as (1-odds ratio)×100.

RESULTS

Between June 8 and October 19, 2012, we enrolled 40 case patients and 160 controls in the study for the primary analysis. After adjustment for potentially confounding variables, vaccination with two complete doses was associated with significant protection against cholera (effectiveness, 86.6%; 95% confidence interval, 56.7 to 95.8; P=0.001).

CONCLUSIONS

In this study, Shanchol was effective when used in response to a cholera outbreak in Guinea. This study provides evidence supporting the addition of vaccination as part of the response to an outbreak. It also supports the ongoing efforts to establish a cholera vaccine stockpile for emergency use, which would enhance outbreak prevention and control strategies. (Funded by Médecins sans Frontières.).

An evaluation of the 2012 measles mass vaccination campaign in Guinea

INTRODUCTION

To estimate the post-campaign level of measles vaccination coverage in Guinea.

METHODS

Interview of parents and observation of measles vaccination cards of children aged 9 to 59 months during the mass measles campaign. A nationwide cluster randomized sample under health District stratification.

RESULTS

64.2% (95%CI = 60.9% to 67.4%) of children were vaccinated and had their measles vaccination card. With respect to card and history 90.5% (95%CI = 88.3% to 92.3%) were vaccinated. The estimation was found to be between 72.7% and 81.9%. Coverage with card increased from 55.5% to 79.30% with the level of education of parents but that was not statistically significant, (X(2)(trend) =3.087 P= 0.07). However coverage with card significantly increased with profession from 55.1% for farmers followed by 59.2% for other manual workers to 73.8% for sellers, ending by 74.5% for settled technicians (X(2) (trend) =12.16 P= 0.0005). For unvaccinated children, lack of information accounted for the main reason (37.03%) followed by parents' occupation (23.45%), parents' sickness (8.6%), children's sickness (4.9%) and others including vaccinators absent in the post or parents' belief that it was a door to door campaign.

CONCLUSION

The mass measles vaccination campaign achieved an approximate coverage of 75%. Although not enough for effective control of measles, it has covered an important gap left over by the routine immunization coverage 42%. Appropriate measures are needed to improve coverage in routine immunization and specific actions should be taken to target farmers and other manual workers' families but also uneducated groups for both routine immunization and mass campaigns.

Expérience oto-rhino-laryngologique de l’hôpital marocain de campagne en Guinée Conakry

Il s'agit d'une étude prospective et descriptive portant sur les patients admis en consultation d'oto-rhino-laryngologie, au sein de l'hôpital marocain médico-chirurgical de campagne, déployé en Guinée Conakry, du 24 février au 24 mai 2014. Les critères d'inclusion étaient l’âge, le sexe, le type et la localisation de l'affection. L'objectif de notre étude est d’établir un regroupement diagnostique et topographique des principales affections otorhinolaryngologiques rencontrées en Guinée Conakry. Ont été examinés 1877 patients, soit une incidence de 8,14% si l'on rapporte au nombre total de la consultation pluridisciplinaire. La série comprenait 56,04% de femmes (n =1052) et 43,96% d'hommes (n = 825). L’âge de nos patients variait de 9 mois à 73 ans avec une moyenne de 33 ans, la tranche d’âge la plus touchée était celle de 20 ans à 29 ans et 53,54% des patients avaient un âge compris entre 20 ans et 39 ans. Au plan diagnostique, la pathologie infectieuse était la plus fréquente (54,51%), suivie de la pathologie ototologique non infectieuse et non tumorale entrainant surdité ou acouphènes (18,96%), de la pathologie inflammatoire rhino-sinusienne et pharyngée (18,01%), de la pathologie tumorale (6,34%), des corps étrangers de la sphère ORL (0,69%), des chéloïdes (0,43%) et de la pathologie malformative (0,37%). Au plan topographique, les affections rhino-sinusiennes étaient les plus fréquentes (37,93%), suivies des affections otologiques (33,46%), des affections oro-pharyngées et laryngées (21,20%) et des affections cervicales (6,34%).