More Ebola in Sierra Leone as Dallas probe notes missteps

Ebola burial
Ebola burial

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Sierra Leone officials have reported four new Ebola cases, all tied to a recent case that ended the country's countdown to Ebola-free status more than a week ago, and a review of a Dallas hospital's steps following the country's first Ebola case last fall found preparedness and communication issues both locally and nationally.

In related news, the Philippines announced that monkeys in a research lab have tested positive for a non-outbreak, milder strain of Ebola virus.

Sierra Leone outbreak grows to 5

The four new Sierra Leone cases are in Sella Kaffta, a village in Kambia district in the northwest part of the country on Guinea's border. All the newly reported patients had contact with a 67-year-old woman whose death from Ebola was announced last week, Reuters reported today.

A national health official said that family members cared for the woman themselves instead of reporting her illness to authorities.

"I am expecting more cases," said Alfred Palo Conteh, director of the country's National Ebola Response Centre (NERC). "All those who took part in the washing of the corpse, all those who were helping her when she was having wet symptoms would all become infected."

Conteh also said that one person who had contact with the dead woman is missing. Troops and police are enforcing a quarantine in the village, which has a population of almost 1,000.

The new patients are among 50 people deemed high-risk by health officials, Agence France-Presse (AFP) reported today.

AFP yesterday reported that one of the patients is a niece of the 67-year-old woman. Today the agency, citing the NERC, said that the other three patients are not among the 116 people who received post-exposure VSV-EBOV vaccine in a "ring" strategy to prevent the outbreak from spreading.

Spokesperson Sidi Yahya Tunis noted that all of the latest patients were already being monitored. "The development remains a concern for us," he said, "but since it has taken place within a quarantined home, it can be adequately monitored and further transmission can be contained."

Also, local health officials said the experimental ring vaccine campaign begun in the village by a World Health Organization (WHO) team on Sep 4 was going very well, AFP reported.

The number of confirmed, suspected, and probable Ebola cases in West Africa is at 28,073, including 11,290 deaths, the WHO reported last week. Those numbers don't include these recent cases.

Dallas review finds readiness gaps

Meanwhile, a five-person independent review panel noted a general lack of Ebola preparedness at Texas Health Presbyterian Hospital Dallas, which treated the country's first Ebola patient last fall, as well as patchy coordination with federal and other partners and difficulty following the Centers for Disease Control and Prevention's (CDC's) changing guidance.

Texas Health Resources, the hospital's parent company, announced the experts' findings and recommendations on Sep 4. The hospital treated Thomas Eric Duncan after he arrived via paramedic rescue vehicle on Sep 28, 2014. In mid October, two nurses treating him also contracted Ebola.

On Sep 25, Duncan had visited the hospital's emergency department (ED), where he told a nurse that he had traveled to Dallas from Africa. The information was entered in his electronic health record but not communicated verbally to other members of the treatment team. Duncan also spiked a fever of 103°F while in the ED. He was released with a diagnosis of sinusitis and told to report to a healthcare provider if his symptoms worsened.

Much of the report focuses on Duncan's second visit to Texas Health Presbyterian, during which he was given a diagnosis of presumed Ebola and immediately isolated according to CDC protocol. The experts commend the paramedics for alerting ED staffers about the patient's history of travel to Liberia so that they could prepare. In addition to having a high fever, Duncan at the time of his return visit was also experiencing profuse vomiting and diarrhea.

Duncan died on Oct 8. The nurses were diagnosed as having Ebola on Oct 12 and 15, respectively, and have since recovered.

The panel spelled out three overlapping broad issues regarding the hospital's response:

  • Texas Health Resources had not adequately prepared it employees to diagnose and manage an Ebola case, and the ED lacked awareness of the risk.
  • CDC and other officials were learning alongside the Dallas healthcare team, and Texas Health Resources had not collaborated well beforehand with local, state, and federal officials. This led to unclear roles.
  • The CDC needs to better communicate its advisory role; a lack of clarity led to confusion and distrust.

The report specifies that the CDC focused initially on contact tracing and notification rather than on personal protective equipment (PPE), waste management, and other issues affecting worker safety. This led to confusion about proper protocols.

The experts also noted that evolving CDC guidance on PPE and other health worker precautions magnified the confusion and created distrust among health workers. The report also says, "The first representative of the CDC did not arrive on-site until three days after Mr. Duncan entered the Emergency Department the second time, and only after there was a confirmed positive Ebola Virus Disease test."

Texas Health Resources also relied on individual facilities to implement emergency response guidelines without adequate coordination, the experts note. "The Expert Panel therefore recommends the creation of a robust system of drills that tests each facility’s emergency operations plans for different types of disasters ranging from weather events to a local outbreak of a serious infectious disease such as Middle East Respiratory Syndrome," they wrote.

Recommendations wide-reaching

The experts also issued 10 pages of detailed recommendations that it says can be used in hospitals across the country.

The experts urge, for example, improved communication in the ED, deployment of the Systemic Inflammatory Response Syndrome (SIRS) score—which calculates infection risk—across all Texas Health facilities, and enhanced preparedness using outbreak exercises and other steps.

"We agree with the panel's recommendation that we take a look at the roles the different members of the [ED] team play and how they work," said Texas Health's Chief Clinical Officer Daniel Varga, MD, in a Texas Health Resources news release. "The electronic health record is a wonderful tool, but we need to have a high-reliability system in place that doesn't over-rely on that technology and empowers team members to speak up about the condition of a patient."

Ebola Reston in monkeys

Finally, the Philippines Department of Health (DOH) on Sep 5 confirmed that the Ebola Reston virus, which is not known to cause human cases, has infected monkeys in an unspecified research facility in the country, Xinhua, China's state news agency, reported.

Janette Garin, DOH secretary, said 25 lab personnel are being monitored but none have tested positive. Officials are investigating how the monkeys became infected.

Ebola virus disease was first detected in monkeys from the Philippines that were being analyzed in a Reston, Virginia, lab in early 1990s, the story said. The current Ebola outbreak is caused by the Ebola Zaire virus.

See also:

Sep 8 Reuters report

Sep 8 AFP story

Sep 7 AFP story

Aug 31 CIDRAP News scan on death of 67-year-old

Sep 4 Texas Health Resources press release

Sep 3 expert panel findings

Sep 3 expert panel recommendations

Sep 5 Xinhua article

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