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Jain V, Charlett A, Brown CS. Meta-analysis of predictive symptoms for Ebola virus disease. PLoS Negl Trop Dis 2020; 14:e0008799. [PMID: 33095771 PMCID: PMC7641466 DOI: 10.1371/journal.pntd.0008799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 11/04/2020] [Accepted: 09/16/2020] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Vageesh Jain
- North East and North Central London Health Protection Team, Public Health England, London, United Kingdom
- Institute for Global Health, University College London (UCL), London, United Kingdom
- * E-mail:
| | - Andre Charlett
- National Infection Service, Public Health England, London, United Kingdom
| | - Colin S. Brown
- National Infection Service, Public Health England, London, United Kingdom
- King’s Sierra Leone Partnership, King’s Centre for Global Health, King’s Health Partners and King’s College London, London, United Kingdom
- Department of Infection, Royal Free London NHS Foundation Trust, London, United Kingdom
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2
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Huizenga E, van der Ende J, Zwinkels N, Jimissa A, van der Ende-Bouwman C, van Rooijen R, Kargbo B, Agnandji ST, Hanscheid T, Goorhuis A, Grobusch MP. A Modified Case Definition to Facilitate Essential Hospital Care During Ebola Outbreaks. Clin Infect Dis 2020; 68:1763-1768. [PMID: 30239602 DOI: 10.1093/cid/ciy798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 09/12/2018] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Brima Kargbo
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Selidji T Agnandji
- Institute of Tropical Medicine, University of Tübingen, Germany.,Centre de Recherches Médicales en Lambaréné, Gabon
| | - Thomas Hanscheid
- Instituto de Microbiologia, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Abraham Goorhuis
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Hospital, University of Amsterdam, the Netherlands.,Masanga Medical Research Unit, Masanga Hospital, Sierra Leone
| | - Martin P Grobusch
- Institute of Tropical Medicine, University of Tübingen, Germany.,Centre de Recherches Médicales en Lambaréné, Gabon.,Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Hospital, University of Amsterdam, the Netherlands.,Masanga Medical Research Unit, Masanga Hospital, Sierra Leone
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3
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Abstract
The West African outbreak of 2013 to 2016 was the largest Ebola epidemic in history. With tens of thousands of patients treated during this outbreak, much was learned about how to optimize clinical care for children with Ebola. In anticipation of inevitable future outbreaks, a firsthand summary of the major aspects of pediatric Ebola case management in austere settings is presented. Emphasis is on early and aggressive critical care, including fluid resuscitation, electrolyte repletion, antimicrobial therapy, and nutritional supplementation.
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Affiliation(s)
- Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Lao PDR; Department of Pediatrics, One Children's Place, Campus Box 8116, St Louis, MO 63110, USA; Maforki Ebola Holding and Treatment Centre, Port Loko, Sierra Leone.
| | - Stephanie C De Silva
- Department of Pediatrics, One Children's Place, Campus Box 8116, St Louis, MO 63110, USA
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4
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Colebunders R, Jacob ST, van Griensven J. The predicament of patients with suspected Ebola. THE LANCET GLOBAL HEALTH 2017; 5:e658. [DOI: 10.1016/s2214-109x(17)30214-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022] Open
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5
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The predicament of patients with suspected Ebola. LANCET GLOBAL HEALTH 2017; 5:e659. [DOI: 10.1016/s2214-109x(17)30209-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 04/18/2017] [Indexed: 11/17/2022]
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Fitzgerald F, Wing K, Naveed A, Gbessay M, Ross JCG, Checchi F, Youkee D, Jalloh MB, Baion D, Mustapha A, Jah H, Lako S, Oza S, Boufkhed S, Feury R, Bielicki J, Williamson E, Gibb DM, Klein N, Sahr F, Yeung S. Risk in the "Red Zone": Outcomes for Children Admitted to Ebola Holding Units in Sierra Leone Without Ebola Virus Disease. Clin Infect Dis 2017; 65:162-165. [PMID: 28369236 PMCID: PMC5693324 DOI: 10.1093/cid/cix223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/10/2017] [Indexed: 11/13/2022] Open
Abstract
We collected data on 1054 children admitted to Ebola Holding Units in Sierra Leone and describe outcomes of 697/1054 children testing negative for Ebola virus disease (EVD) and accompanying caregivers. Case-fatality was 9%; 3/630 (0.5%) children discharged testing negative were readmitted EVD-positive. Nosocomial EVD transmission risk may be lower than feared.
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Affiliation(s)
- F Fitzgerald
- Infection, Immunity, Inflammation and Physiological Medicine, UCL Great Ormond Street Institute of Child Health, United Kingdom
- Save the Children, Sierra Leone and United Kingdom
| | - K Wing
- Save the Children, Sierra Leone and United Kingdom
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, and
| | - A Naveed
- Save the Children, Sierra Leone and United Kingdom
| | - M Gbessay
- Save the Children, Sierra Leone and United Kingdom
| | - JCG Ross
- Save the Children, Sierra Leone and United Kingdom
| | - F Checchi
- Save the Children, Sierra Leone and United Kingdom
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, and
| | - D Youkee
- Kings Sierra Leone Partnership, Kings Centre for Global Health, Kings College London, United Kingdom
| | - MB Jalloh
- 34 Military Hospital, Republic of Sierra Leone Armed Forces, Freetown
| | - D Baion
- Ola During Children’s Hospital, Sierra Leone Ministry of Health, Freetown
| | - A Mustapha
- Ola During Children’s Hospital, Sierra Leone Ministry of Health, Freetown
| | - H Jah
- Cap Anamur (German Emergency Doctors), Ola During Children’s Hospital, Freetown, and
| | - S Lako
- Welbodi Partnership, Ola During Children’s Hospital, Freetown, Sierra Leone
| | - S Oza
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, and
| | - S Boufkhed
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
| | - R Feury
- Western Area Emergency Response Centre, Freetown, Sierra Leone
| | | | - E Williamson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine
- Farr Institute of Health Informatics, London, and
| | | | - N Klein
- Infection, Immunity, Inflammation and Physiological Medicine, UCL Great Ormond Street Institute of Child Health, United Kingdom
| | - F Sahr
- 34 Military Hospital, Republic of Sierra Leone Armed Forces, Freetown
| | - S Yeung
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, United Kingdom
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Houlihan CF, McGowan CR, Dicks S, Baguelin M, Moore DAJ, Mabey D, Roberts CH, Kumar A, Samuel D, Tedder R, Glynn JR. Ebola exposure, illness experience, and Ebola antibody prevalence in international responders to the West African Ebola epidemic 2014-2016: A cross-sectional study. PLoS Med 2017; 14:e1002300. [PMID: 28510604 PMCID: PMC5433702 DOI: 10.1371/journal.pmed.1002300] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 04/04/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Healthcare and other front-line workers are at particular risk of infection with Ebola virus (EBOV). Despite the large-scale deployment of international responders, few cases of Ebola virus disease have been diagnosed in this group. Since asymptomatic or pauci-symptomatic infection has been described, it is plausible that infections have occurred in healthcare workers but have escaped being diagnosed. We aimed to assess the prevalence of asymptomatic or pauci-symptomatic infection, and of exposure events, among returned responders to the West African Ebola epidemic 2014-2016. METHODS AND FINDINGS We used snowball sampling to identify responders who had returned to the UK or Ireland, and used an online consent and questionnaire to determine their exposure to EBOV and their experience of illness. Oral fluid collection devices were sent and returned by post, and samples were tested using an EBOV IgG capture assay that detects IgG to Ebola glycoprotein. Blood was collected from returnees with reactive samples for further testing. Unexposed UK controls were also recruited. In all, 300 individuals consented, of whom 268 (89.3%) returned an oral fluid sample (OFS). The majority had worked in Sierra Leone in clinical, laboratory, research, and other roles. Fifty-three UK controls consented and provided samples using the same method. Of the returnees, 47 (17.5%) reported that they had had a possible EBOV exposure. Based on their free-text descriptions, using a published risk assessment method, we classified 43 (16%) as having had incidents with risk of Ebola transmission, including five intermediate-risk and one high-risk exposure. Of the returnees, 57 (21%) reported a febrile or diarrhoeal illness in West Africa or within 1 mo of return, of whom 40 (70%) were not tested at the time for EBOV infection. Of the 268 OFSs, 266 were unreactive. Two returnees, who did not experience an illness in West Africa or on return, had OFSs that were reactive on the EBOV IgG capture assay, with similar results on plasma. One individual had no further positive test results; the other had a positive result on a double-antigen bridging assay but not on a competitive assay or on an indirect EBOV IgG ELISA. All 53 controls had non-reactive OFSs. While the participants were not a random sample of returnees, the number participating was high. CONCLUSIONS This is the first study, to our knowledge, of the prevalence of EBOV infection in international responders. More than 99% had clear negative results. Sera from two individuals had discordant results on the different assays; both were negative on the competitive assay, suggesting that prior infection was unlikely. The finding that a significant proportion experienced "near miss" exposure events, and that most of those who experienced symptoms did not get tested for EBOV at the time, suggests a need to review and standardise protocols for the management of possible exposure to EBOV, and for the management of illness, across organisations that deploy staff to outbreaks.
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Affiliation(s)
- Catherine F. Houlihan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Faculty of Medical Sciences, University College London, London, United Kingdom
| | - Catherine R. McGowan
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Humanitarian Public Health Technical Unit, Save the Children UK, London, United Kingdom
| | - Steve Dicks
- Transfusion Microbiology, National Health Service Blood and Transplant, London, United Kingdom
- NHSBT/PHE Blood Borne Virus Unit, Serology Development Unit, Public Health England, London, United Kingdom
| | - Marc Baguelin
- Centre of Infectious Disease Surveillance and Control, Public Health England, London, United Kingdom
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David A. J. Moore
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David Mabey
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Chrissy h. Roberts
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alex Kumar
- Department of Infection and Tropical Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Dhan Samuel
- NHSBT/PHE Blood Borne Virus Unit, Serology Development Unit, Public Health England, London, United Kingdom
| | - Richard Tedder
- Transfusion Microbiology, National Health Service Blood and Transplant, London, United Kingdom
- NHSBT/PHE Blood Borne Virus Unit, Serology Development Unit, Public Health England, London, United Kingdom
| | - Judith R. Glynn
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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8
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Shorten RJ, Brown CS, Jacobs M, Rattenbury S, Simpson AJ, Mepham S. Diagnostics in Ebola Virus Disease in Resource-Rich and Resource-Limited Settings. PLoS Negl Trop Dis 2016; 10:e0004948. [PMID: 27788135 PMCID: PMC5082928 DOI: 10.1371/journal.pntd.0004948] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The Ebola virus disease (EVD) outbreak in West Africa was unprecedented in scale and location. Limited access to both diagnostic and supportive pathology assays in both resource-rich and resource-limited settings had a detrimental effect on the identification and isolation of cases as well as individual patient management. Limited access to such assays in resource-rich settings resulted in delays in differentiating EVD from other illnesses in returning travellers, in turn utilising valuable resources until a diagnosis could be made. This had a much greater impact in West Africa, where it contributed to the initial failure to contain the outbreak. This review explores diagnostic assays of use in EVD in both resource-rich and resource-limited settings, including their respective limitations, and some novel assays and approaches that may be of use in future outbreaks.
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Affiliation(s)
- Robert J Shorten
- Public Health Laboratory Manchester, Manchester Royal Infirmary, Manchester, United Kingdom
- University College London, Centre for Clinical Microbiology, Department of Infection, London United Kingdom
| | - Colin S Brown
- Hospital for Tropical Diseases, University College London Hospital, London, United Kingdom
- King’s Sierra Leone Partnership, King’s Centre for Global Health, King’s College London, and King’s Health Partners, London, United Kingdom
| | - Michael Jacobs
- Department of Infection, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Simon Rattenbury
- Department of Infection, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Andrew J. Simpson
- University College London, Centre for Clinical Microbiology, Department of Infection, London United Kingdom
- Rare and Imported Pathogens Laboratory, Public Health England, Salisbury, United Kingdom
| | - Stephen Mepham
- Department of Infection, Royal Free London NHS Foundation Trust, London, United Kingdom
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9
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Abstract
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.
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Affiliation(s)
- Felicity Fitzgerald
- Infection, Immunity, Inflammation and Physiological Medicine, UCL Institute of Child Health, UK; Kerry Town Ebola Treatment Centre, Save the Children International, Sierra Leone.
| | - Waheed Awonuga
- Live Case Management Team, Western Area Emergency Response Centre, Freetown, Sierra Leone.
| | - Tejshri Shah
- Department of Paediatric Infectious Diseases, Imperial College NHS Healthcare Trust, UK.
| | - Daniel Youkee
- Kings Sierra Leone Partnership, Connaught Hospital, Freetown, Sierra Leone.
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10
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Youkee D, Brown CS, Lilburn P, Shetty N, Brooks T, Simpson A, Bentley N, Lado M, Kamara TB, Walker NF, Johnson O. Assessment of Environmental Contamination and Environmental Decontamination Practices within an Ebola Holding Unit, Freetown, Sierra Leone. PLoS One 2015; 10:e0145167. [PMID: 26692018 PMCID: PMC4687095 DOI: 10.1371/journal.pone.0145167] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/30/2015] [Indexed: 12/21/2022] Open
Abstract
Evidence to inform decontamination practices at Ebola holding units (EHUs) and treatment centres is lacking. We conducted an audit of decontamination procedures inside Connaught Hospital EHU in Freetown, Sierra Leone, by assessing environmental swab specimens for evidence of contamination with Ebola virus by RT-PCR. Swabs were collected following discharge of Ebola Virus Disease (EVD) patients before and after routine decontamination. Prior to decontamination, Ebola virus RNA was detected within a limited area at all bedside sites tested, but not at any sites distant to the bedside. Following decontamination, few areas contained detectable Ebola virus RNA. In areas beneath the bed there was evidence of transfer of Ebola virus material during cleaning. Retraining of cleaning staff reduced evidence of environmental contamination after decontamination. Current decontamination procedures appear to be effective in eradicating persistence of viral RNA. This study supports the use of viral swabs to assess Ebola viral contamination within the clinical setting. We recommend that regular refresher training of cleaning staff and audit of environmental contamination become standard practice at all Ebola care facilities during EVD outbreaks.
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Affiliation(s)
- Daniel Youkee
- King’s Sierra Leone Partnership, King's Centre for Global Health, King's College London, and King’s Health Partners, London, United Kingdom
| | - Colin S. Brown
- King’s Sierra Leone Partnership, King's Centre for Global Health, King's College London, and King’s Health Partners, London, United Kingdom
- The Hospital for Tropical Diseases, University College London Hospitals, London, United Kingdom
| | - Paul Lilburn
- King’s Sierra Leone Partnership, King's Centre for Global Health, King's College London, and King’s Health Partners, London, United Kingdom
| | | | - Tim Brooks
- Public Health England, Salisbury, United Kingdom
| | | | - Neil Bentley
- Public Health England, Salisbury, United Kingdom
| | - Marta Lado
- King’s Sierra Leone Partnership, King's Centre for Global Health, King's College London, and King’s Health Partners, London, United Kingdom
| | | | - Naomi F. Walker
- King’s Sierra Leone Partnership, King's Centre for Global Health, King's College London, and King’s Health Partners, London, United Kingdom
- Department of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Oliver Johnson
- King’s Sierra Leone Partnership, King's Centre for Global Health, King's College London, and King’s Health Partners, London, United Kingdom
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