A systematic review and meta-analysis of patient data from the West Africa (2013-16) Ebola virus disease epidemic

Sudan virus disease - A quick review

The recent Sudan virus disease (SVD) outbreak in Uganda is a reminder of threat from Filovirus diseases. Unlike Ebola virus disease, no effective antiviral and vaccine is available for SVD. The outbreak was declared over after 115 days, with 142 confirmed cases and case fatality rate of 39%, before any dose of candidate vaccine could be used on contacts. We provide a quick review of up-to-date information on the Uganda outbreak, summary of previous outbreaks, and detail the existing SVD treatment and vaccine candidates. Evolution of disease attributes and the impact on public health were also discussed. For high consequence infectious disease like SVD, it takes international collaboration to be better prepared for the next outbreak.

Case fatality rate for Ebola disease, 1976-2022: A meta-analysis of global data

An up-to-date pooled case fatality rate (CFR) for Ebola disease (EBOD) at the global level is lacking. We abstracted EBOD data from 1976 to 2022 for 16 countries and 42 outbreaks to conduct a meta-analysis. The pooled CFR was 60.6% (95% confidence interval (CI) 51.6-69.4; 95% prediction interval 12.9-99.1). Of the four ebolaviruses, Zaire virus was the most lethal (CFR = 66.6%, 95% CI 55.9-76.8), then Sudan virus (CFR=48.5%, 95% CI 38.6-58.4), Bundibugyo virus (CFR=32.8%, 95% CI 25.8-40.2) and Tai Forest virus (CFR= 0%, 95% CI 0.0-97.5). The CFR in sub-Saharan Africa was 61.3% (95% CI 52.8-69.6) and for the rest of the world was 24.5% (95% CI 0.0-67.9%). CFR declined over time but stabilized at 61.0% (95% CI, 52.0-69.0) between 2014 and 2022. Overall, the EBOD CFR is still high and heterogeneous. Accordingly, early diagnosis, early treatment if available, and supportive care are important to prevent significant morbidity and mortality.

Standard of care for viral haemorrhagic fevers (VHFs): a systematic review of clinical management guidelines for high-priority VHFs

The Sudan virus disease outbreak in Uganda in 2022 showed our vulnerability to viral haemorrhagic fevers (VHFs). Although there are regular outbreaks of VHFs with high morbidity and mortality, which disproportionally affect low-income settings, our understanding of how to treat them remains inadequate. In this systematic review, we aim to explore the availability, scope, standardisation, and quality of clinical management guidelines for VHFs. We identified 32 guidelines, 25 (78%) of which were low quality and did not have supporting evidence and eight (25%) of which had been produced or updated in the past 3 years. Guidance on supportive care and therapeutics had little detail and was sometimes contradictory. Guidelines based on uncertain evidence are a risk to patients, an ethical challenge for clinicians, and a challenge to implementing trials due to heterogeneous standards of care. We recommend a standard living guideline framework to improve the quality, scope, and applicability of guidelines. Furthermore, investments into trials should aim to identify optimal treatment strategies for VHFs and prioritise affordable and scalable interventions to improve outcomes globally.

Remote-Controlled and Pulse Pressure-Guided Fluid Treatment for Adult Patients with Viral Hemorrhagic Fevers

Circulatory shock, caused by severe intravascular volume depletion resulting from gastrointestinal losses and profound capillary leak, is a common clinical feature of viral hemorrhagic fevers, including Ebola virus disease, Marburg hemorrhagic fever, and Lassa fever. These conditions are associated with high case fatality rates, and they carry a significant risk of infection for treating personnel. Optimized fluid therapy is the cornerstone of management of these diseases, but there are few data on the extent of fluid losses and the severity of the capillary leak in patients with VHFs, and no specific guidelines for fluid resuscitation and hemodynamic monitoring exist. We propose an innovative approach for monitoring VHF patients, in particular suited for low-resource settings, facilitating optimizing fluid therapy through remote-controlled and pulse pressure–guided fluid resuscitation. This strategy would increase the capacity for adequate supportive care, while decreasing the risk for virus transmission to health personnel.

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.

Treatment of Ebola-related critical illness

PURPOSE

To explore contemporary clincial case management of patients with Ebola virus disease.

METHODS

A narrative review from a clinical perspective of clinical features, diagnostic tests, treatments and outcomes of patients with Ebola virus disease.

RESULTS

Substantial advances have been made in the care of patients with Ebola virus disease (EVD), precipitated by the unprecedented extent of the 2014-2016 outbreak. There has been improved point-of-care diagnostics, improved characterization of the clinical course of EVD, improved patient-optimized standards of care, evaluation of effective anti-Ebola therapies, administration of effective vaccines, and development of innovative Ebola treatment units. A better understanding of the Ebola virus disease clinical syndrome has led to the appreciation of a central role for critical care clinicians-over 50% of patients have life-threatening complications, including hypotension, severe electrolyte imbalance, acute kidney injury, metabolic acidosis and respiratory failure. Accordingly, patients often require critical care interventions such as monitoring of vital signs, intravenous fluid resuscitation, intravenous vasoactive medications, frequent diagnostic laboratory testing, renal replacement therapy, oxygen and occasionally mechanical ventilation.

CONCLUSION

With advanced training and adherence to infection prevention and control practices, clinical interventions, including critical care, are feasible and safe to perform in critically ill patients. With specific anti-Ebola medications, most patients can survive Ebola virus infection.

Core Minimal Datasets to Advance Clinical Research for Priority Epidemic Diseases

The Ebola virus disease outbreak in west Africa has prompted significant progress in responding to the clinical needs of patients affected by emerging infectious disease outbreaks. Among the noteworthy successes of vaccine trials, and the commendable efforts to implement clinical treatment trials during Ebola outbreaks, we should also focus on strengthening the collection and curation of epidemiological and observational data that can improve the conception and design of clinical research.

Recurrent Ebolavirus disease in the Democratic Republic of Congo: update and challenges

The current Ebolavirus disease (EVD) outbreak in the provinces of North Kivu and Ituri is the tenth outbreak affecting the Democratic Republic of Congo (DRC); the first outbreak occurring in a war context, and the second most deadly Ebolavirus outbreak on record following the 2014 outbreak in West Africa. The DRC government's response consisted of applying a package of interventions including detection and rapid isolation of cases, contact tracing, population mapping, and identification of high-risk areas to inform a coordinated effort. The coordinated effort was to screen, ring vaccinate, and conduct laboratory diagnoses using GeneXpert (Cepheid) polymerase chain reaction. The effort also included ensuring safe and dignified burials and promoting risk communication, community engagement, and social mobilization. Following the adoption of the “Monitored Emergency Use of Unregistered Products Protocol,” a randomized controlled trial of four investigational treatments (mAb114, ZMapp, and REGN-EB3 and Remdesivir) was carried out with all consenting patients with laboratory-confirmed EVD. REGN-EB3 and mAb114 showed promise as treatments for EVD. In addition, one investigational vaccine (rVSV-ZEBOV-GP) was used first, followed by a second prophylactic vaccine (Ad26.ZEBOV/MVA-BN-Filo) to reinforce the prevention. Although the provision of clinical supportive care remains the cornerstone of EVD outbreak management, the DRC response faced daunting challenges including general insecurity, violence and community resistance, appalling poverty, and entrenched distrust of authority. Ebolavirus remains a public health threat. A fully curative treatment is unlikely to be a game-changer given the settings of transmission, zoonotic nature, limits of effectiveness of any therapeutic intervention, and timing of presentation.