Longitudinal Trends in Patient-Reported Outcomes in the First Year After Lumpectomy Versus Mastectomy.

BACKGROUND: It is unclear how patient-reported outcomes (PROs) change longitudinally after breast cancer surgery. We sought to compare trends in PROs among patients who underwent lumpectomy versus mastectomy over the first year after surgery. PATIENTS AND METHODS: Newly diagnosed stage 0-III female patients with breast cancer who underwent lumpectomy or mastectomy at an academic breast center between June 2019 and March 2023 were invited to participate in a longitudinal PRO study. Enrolled patients received the BREAST-Q™ module, a validated tool measuring domains, such as satisfaction with breasts, psychosocial well-being, physical well-being, and sexual well-being. Scores for each domain were compared between the lumpectomy and mastectomy groups over the first year after surgery. Linear mixed models were used to estimate the change in PRO scores over time. RESULTS: The cohort included 203 who underwent lumpectomy and 144 who underwent mastectomy. Patients who underwent lumpectomy were older, more likely to receive adjuvant radiation and endocrine therapy, and less likely to receive adjuvant chemotherapy. Patients who underwent lumpectomy demonstrated greater increases in scores over time for satisfaction with breasts, psychosocial well-being, and sexual well-being compared with patients who underwent mastectomy, after adjusting for the abovementioned covariates and receipt of reconstruction. The lumpectomy group had a larger decline in physical well-being over time compared with the mastectomy group. CONCLUSIONS: Patients who underwent lumpectomy demonstrated greater satisfaction with their breasts, psychosocial well-being, and sexual well-being but worse physical well-being over the first year after surgery compared with patients who underwent mastectomy. These results may help inform early-stage breast cancer patients making decisions about their surgical care.

Multidimensional Religiousness and Spirituality Are Associated With Lower Interleukin-6 and C-Reactive Protein at Midlife: Findings From the Midlife in the United States Study.

BACKGROUND: Religiousness and spirituality (R/S) are associated with lower morbidity and mortality, yet the physiological mechanisms underlying these associations are under-studied. Chronic inflammation is a plausible biological mechanism linking R/S to downstream health given the sensitivity of the immune system to the social environment and the role of inflammation in many chronic diseases. PURPOSE: The purpose of the present study was to examine associations between multiple R/S dimensions and two markers of chronic inflammation, interleukin-6 (IL-6) and C-reactive protein (CRP). METHODS: In this cross-sectional study, data came from biological subsamples of two cohorts from the Midlife in the United States (MIDUS) Study (combined N = 2,118). Predictors include six R/S measures (service attendance, spirituality, private religious practices, daily spiritual experiences, religious coping, and R/S-based mindfulness). Outcomes include log-transformed IL-6 and CRP. Covariates include age, gender, cohort, race, educational attainment, body mass index (BMI), smoking status, and physical activity. RESULTS: Older adults, women (vs. men), non-White (vs. White) adults, those with higher BMIs, current smokers, and those not meeting physical activity guidelines had significantly higher IL-6 and CRP. In fully adjusted models, greater spirituality, daily spiritual experiences, religious coping, and R/S-based mindfulness were associated with lower IL-6. Higher spirituality was also associated with lower CRP. CONCLUSIONS: Many dimensions of R/S may be health protective for adults given their associations with lower levels of chronic inflammation. Findings underscore the importance of examining multiple dimensions of R/S to understand mechanistic pathways.

People who are religious and spiritual are often healthier and live longer than people who are less religious and spiritual. Researchers are trying to understand why. We know that religiousness and spirituality can help people manage stress and make healthy choices, which might contribute to less chronic inflammation. Chronic inflammation can lead to cardiovascular diseases, diabetes, and other chronic conditions. This study examined data from over 2,000 participants of the Midlife in the United States (MIDUS) Study to determine whether midlife and older adults who are more religious and spiritual have less chronic inflammation. People who reported greater spirituality, more frequent spiritual experiences, use their religious/spiritual beliefs to cope with stressors, and use their religion/spirituality to practice mindfulness had lower inflammation than individuals who had less of these religious/spiritual characteristics. These findings are important because they provide knowledge about which dimensions of religiousness and spirituality are connected to health and present a biological pathway (bodily inflammation) that connects religiousness and spirituality to chronic diseases.

Breast Cancer Surgery: A Qualitative Exploration of Concerns Over Time.

INTRODUCTION: As outcomes for breast cancer patients improve, addressing the side effects and distress of treatment can optimize survivorship. Although distress in breast cancer is well known in literature, there is a lack of information on how these concerns change through the phases of the cancer care continuum. Therefore, this study investigates the longitudinal trajectory of worry in patients with nonmetastatic breast cancer. METHODS: Female patients with newly diagnosed stage I-III breast cancer comprised a mixed-methods, longitudinal study at a cancer center from June 2019 to June 2023. Patients completed an open-ended survey regarding their top three concerns. Responses were obtained before surgery and two weeks, three, six, nine months, and one year postoperatively. Responses were qualitatively coded and analyzed to determine themes of cancer-related distress. RESULTS: Participants (n = 262) were aged an average 57.53 y (±12.54), 65.8% had stage I disease at diagnosis, and 91.1% were White. Responses revealed that patients' top three sources of concerns varied by treatment phase. Overall, patients were worried about their cancer diagnosis and the risk of recurrence. Preoperatively, patients were worried about treatment timeline, while postoperative concerns transitioned to physical appearance and surgical side effects. CONCLUSIONS: Breast cancer patients consistently reported worries about cancer diagnosis, recurrence, and metastasis as well as the side effects and fear of treatments. However, patient worry appeared to be intrinsically linked with their treatment phase. Therefore, support and interventions should be catered to reflect the changing patterns of patients' sources of distress to optimize breast cancer patients' quality of life.

A Qualitative Analysis of Barriers to Accessing HIV Prevention Services During an HIV Outbreak among Persons who Inject Drugs in West Virginia.

In response to an increase in HIV diagnoses among persons who inject drugs (PWID) in Kanawha County, West Virginia, West Virginia Bureau for Public Health and CDC conducted a qualitative assessment in Kanawha County to inform HIV outbreak response activities. Interviews with 26 PWID and 45 community partners were completed. Transcribed interviews were analyzed to identify barriers to accessing HIV prevention services among PWID using the risk environment framework. Participants identified numerous political, physical, social, and economic community-level barriers that influenced access to HIV prevention services among PWID. Political factors included low community support for syringe services programs (SSPs); physical factors included low SSP coverage, low coverage of HIV testing outreach events, low HIV preexposure prophylaxis availability, and homelessness; social factors included stigma and discrimination; economic factors included community beliefs that SSPs negatively affect economic investments and limited resources for HIV screening in clinical settings. Individual-level barriers included co-occurring acute medical conditions and mental illness. Community-level interventions, such as low-barrier one-stop shop models, are needed to increase access to sterile syringes through comprehensive harm reduction services.

Child maltreatment and peer relationship quality: Types and timing of maltreatment and gender differences.

INTRODUCTION: Research demonstrates that child maltreatment can negatively impact adolescent peer relationships. It is not well understood, however, how the type of maltreatment and its timing (when it occurs) affects the dimensions of peer relationship quality (i.e., companionship, conflict, satisfaction, and intimacy) and differences between genders. This study examines the effects of type and timing of child maltreatment on peer relationship quality, while also exploring the role of gender differences. METHODS: This study involved 851 adolescents (56.1% girls, 56.2% Black, and 26.8% low-income) drawn from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). We used Child Protective Services' information for the type and timing of child maltreatment, along with self-reports of peer relationship quality. Generalized Estimating Equations (GEEs) were conducted. RESULTS: Sexual abuse and neglect during adolescence were associated with less satisfaction and lower levels of companionship, respectively. Physical abuse during middle childhood was associated with lower levels of intimacy. We also found interactions between gender and type and timing of maltreatment. Compared to girls, boys exhibited lower levels of companionship and satisfaction if they experienced sexual abuse during adolescence. CONCLUSION: These findings suggest a need for maltreatment-prevention efforts targeting school-aged children and adolescents, as well as gender-sensitive interventions for high-risk boys with a history of maltreatment.

Were Needles Everywhere?: Differing Views on Syringe Waste and Disposal Associated With Needs-Based Syringe Services Programs Among Community Partners and Persons Who Inject Drugs.

BACKGROUND: Community concerns surrounding syringe waste are a common barrier to syringe services program (SSP) implementation. In Kanawha County, West Virginia, community opposition to SSPs resulted in the closure of needs-based SSPs prior to and during an HIV outbreak among persons who inject drugs (PWID). This qualitative analysis examines views of PWID and community partners on syringe waste and disposal associated with needs-based SSPs. METHODS: Qualitative interviews with 26 PWID and 45 community partners (medical and social service providers, law enforcement personnel, policymakers, and religious leaders) were conducted. Interviews were recorded, transcribed, and coded. Code summaries described participants' views on syringe waste and disposal and needs-based SSPs. RESULTS: Community partners and PWID who favored needs-based SSPs reported that needs-based SSPs had not affected or reduced syringe waste. Conversely, community partners who favored one-to-one exchange models and/or barcoded syringes described needs-based SSPs increasing syringe waste. Community partners often cited pervasive community beliefs that SSPs increased syringe waste, risk of needlesticks, drug use, and crime. Community partners were unsure how to address syringe waste concerns and emphasized that contradictory views on syringe waste posed barriers to discussing and implementing SSPs. CONCLUSIONS: Participants' views on whether syringe waste was associated with needs-based SSPs often aligned with their support or opposition for needs-based SSPs. These differing views resulted in challenges finding common ground to discuss SSP operations amid an HIV outbreak among PWID. SSPs might consider addressing syringe waste concerns by expanding syringe disposal efforts and implementing community engagement and stigma reduction activities.

Meaning Salience and Meaning in Life Prospectively Predict Lower Distress During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic is a widespread source of stress with adverse mental health impacts. Meaning in life, both as a trait and as momentary awareness of what is personally meaningful (meaning salience), is associated with positive health outcomes and may buffer against the deleterious effects of stress. PURPOSE: This project examines prospective associations between baseline meaning salience (daily, post-laboratory stressor) and meaning in life with perceived stress during COVID-19. METHODS: A community sample of healthy adults (n = 147) completed a laboratory stress protocol in 2018-2019, where perceived stress, meaning in life, and meaning salience (daily, post-stressor) were assessed. During April and July 2020 (n = 95, and 97, respectively), participants were re-contacted and reported perceived stress. General linear mixed-effects models accounting for repeated measures of stress during COVID-19 were conducted. RESULTS: Partial correlations holding constant baseline perceived stress showed that COVID-19 perceived stress was correlated with daily meaning salience (r = -.28), post-stressor meaning salience (r = -.20), and meaning in life (r = -.22). In mixed-effects models, daily and post-stressor meaning salience and higher meaning in life, respectively, predicted lower perceived stress during COVID-19, controlling for age, gender, and baseline perceived stress. CONCLUSIONS: Individuals more capable of accessing meaning when exposed to laboratory stress reported lower perceived stress during a global health crisis. Despite study limitations concerning generalizability, results support meaning in life and meaning salience as important aspects of psychological functioning that may promote well-being by affecting stress appraisals and available resources for coping.

The COVID-19 pandemic is a widespread source of stress. Having a sense of meaning in life, or that you have goals in life and a sense that the things you do are worthwhile and significant, is an important part of psychological well-being and might help reduce stress. We collected data on 147 healthy adults in 2018­2019 regarding their stress levels, sense of meaning in life, and how often they were aware of their life's meaning on daily basis and after a stress task in the laboratory. We re-contacted these adults in both April and July 2020 to ask about their stress, and 95 adults responded. Adults who had higher meaning in life in 2018­2019 experienced less stress during the early months of the COVID-19 pandemic. Adults who were more aware of their life's meaning each day and immediately after a stress task in the laboratory also experienced less stress during the COVID-19 pandemic. Results from this study provide evidence that having a strong sense of meaning in life overall and being aware of your life's meaning each day and during times of stress, may promote psychological well-being and reduce stress during times when stress is widespread and abundant.

Intimate partner violence, HIV-risk behaviors, and HIV screening among heterosexually active persons at increased risk for infection.

ABSTRACTIntimate partner violence (IPV) can increase a person's risk of HIV and other sexually transmitted infections (STIs), and may affect access to sexual health services. We assessed the prevalence of HIV screening and IPV among heterosexually-active persons using data from the 2016 National HIV Behavioral Surveillance. Participants were eligible if they were 18-60 years old, could complete the interview in English or Spanish, and reported having sex with an opposite sex partner in the previous 12 months. People who reported neither injection drug use within the past 12 months nor prior HIV diagnosis, and persons with valid responses to questions regarding HIV screening and physical/sexual IPV within the past 12 months were included (N = 7,777). Overall, 17% reported IPV in the previous 12 months and 19% had never had HIV screening. Abused persons were more likely to have been screened for HIV and to report high risk behaviors than non-abused persons. There was no difference in the proportion being offered HIV screening by their health care provider in the previous year. Findings suggest an integrated approach to violence prevention and sexual health may help increase awareness about clinical best practices and reduce risk for HIV/STIs among at-risk communities.

Notes from the Field: HIV Outbreak During the COVID-19 Pandemic Among Persons Who Inject Drugs - Kanawha County, West Virginia, 2019-2021.

During October 2019, the West Virginia Bureau for Public Health (WVBPH) noted that an increasing number of persons who inject drugs (PWID) in Kanawha County received a diagnosis of HIV. The number of HIV diagnoses among PWID increased from less than five annually during 2016-2018 to 11 during January-October 2019 (Figure). Kanawha County (with an approximate population of 180,000*) has high rates of opioid use disorder and overdose deaths, which have been increasing since 2016,† and the county is located near Cabell County, which experienced an HIV outbreak among PWID during 2018-2019 (1,2). In response to the increase in HIV diagnoses among PWID in 2019, WVBPH released a Health Advisory§; and WVBPH and Kanawha-Charleston Health Department (KCHD) convened an HIV task force, conducted care coordination meetings, received CDC remote assistance to support response activities, and expanded HIV testing and outreach.

Serious Mental Illness Among Young People Who Inject Drugs: An Assessment of Injection Risks and Healthcare Use.

BACKGROUND: Data on behavioral correlates of mental illness among young people who inject drugs (PWID) are limited. We examine injection risks and healthcare use among young PWID with probable serious mental illness (PSMI). METHODS: People who inject drugs were recruited and interviewed in 20 US cities for 2015 National HIV Behavioral Surveillance. Probable serious mental illness was assessed using the Kessler-6 screening scale. Bivariate analyses using log-linked Poisson regression with generalized estimating equations adjusted for design covariates were conducted to examine associations between PSMI and behaviors among PWID ages 18-29 years. RESULTS: Of 1769 young PWID, 45% had PSMI. Compared to those without PSMI, PWID with PSMI were more likely to report injecting more than once a day, receptive syringe sharing, sharing of other injection equipment, and unmet needs for medical care and substance use disorder (SUD) treatment. Those with PSMI were less likely to use syringe services programs than those without PSMI. CONCLUSIONS: Approximately half of young PWID had PSMI. People who inject drugs with PSMI engaged in high-risk injection behaviors and encountered barriers to healthcare. Human immunodeficiency virus prevention programs such as Syringe Services Programs (SSPs) could benefit from screening for mental illness among young PWID and strong linkage to healthcare, including mental health and SUD treatment.

Distributive Syringe Sharing and Use of Syringe Services Programs (SSPs) Among Persons Who Inject Drugs.

Monitoring distributive syringe sharing (DSS) and syringe services program (SSP) use among persons who inject drugs (PWID) is important for HIV prevention. PWID aged ≥ 18 in 20 US cities were recruited for National HIV Behavioral Surveillance in 2015 using respondent-driven sampling, interviewed and offered HIV testing. Bivariate and multivariable analyses via log-linked Poisson regression with generalized estimating equations were conducted to examine associations between demographic and behavioral variables and DSS. Effect of SSP use on DSS by HIV sero-status was assessed by including an interaction between SSP and sero-status. Analyses were adjusted for sampling design. Among 10,402 PWID, 42% reported DSS. DSS was less likely to be reported among HIV-positive compared to HIV-negative PWID (aPR = 0.51, CI 0.45-0.60), and among those who primarily obtained syringes from SSPs versus those who did not (aPR = 0.82, 95% CI 0.77-0.88). After adjustment, those who primarily used SSPs were less likely to report DSS than those who did not among both HIV-negative PWID (aPR = 0.84, 95% CI 0.78-0.90) and HIV-positive PWID (aPR = 0.54, 95% CI 0.39-0.75). Findings support expansion of SSPs, and referrals to SSPs by providers working with PWID.

Investigating the Degradation Behaviors of a Therapeutic Monoclonal Antibody Associated with pH and Buffer Species.

This study aimed in understanding the degradation behaviors of an IgG 1 subtype therapeutic monoclonal antibody A (mAb-A) associated with pH and buffer species. The information obtained in this study can augment conventional, stability-based screening paradigms by providing the direction necessary for efficient experimental design. Differential scanning calorimetry (DSC) was used for studying conformational stability. Dynamic light scattering (DLS) was utilized to generate B 22*, a modified second virial coefficient for the character of protein-protein interaction. Size-exclusion chromatography (SEC) and hydrophobic interaction chromatography (HIC) were employed to separate degradation products. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) was used for determining the molecular size and liquid chromatography mass spectrometry (LC-MS) were used for identifying the sequence of the separated fragments. The results showed that both pH and buffer species played the roles in controlling the degradation behaviors of mAb-A, but the pH was more significant. In particular, pH 4.5 induced additional thermal transition peaks occurring at a low temperature compared with pH 6.5. A continual temperature-stress study illustrated that the additional thermal transition peaks related to the least stable structure and a greater fragmentation. Although mAb-A showed the comparable conformational structures and an identical amount of aggregates at time zero between the different types of buffer species at pH 6.5, the aggregation formation rate showed a buffer species-dependent discrepancy over a temperature-stress period. It was found that the levels of aggregations associated with the magnitudes of protein-protein interaction forces.

A Fluorescence-Based High-Throughput Coupled Enzymatic Assay for Quantitation of Isoaspartate in Proteins and Peptides.

Formation of isoaspartate (IsoAsp) from spontaneous asparagine (Asn) deamidation or aspartate (Asp) isomerization is one of the most common non-enzymatic pathways of chemical degradation of protein and peptide pharmaceuticals. Rapid quantitation of IsoAsp formation can enable rank-ordering of potential drug candidates, mutants, and formulations as well as support shelf life prediction and stability requirements. A coupled enzymatic fluorescence-based IsoAsp assay (CEFIA) was developed as a high-throughput method for quantitation of IsoAsp in peptides and proteins. In this note, application of this method to two therapeutic candidate proteins with distinct structural scaffolds is described. In addition, the results obtained with this method are compared to those from conventional assays.

Travel-Associated Zika Virus Disease Cases Among U.S. Residents--United States, January 2015-February 2016.

Zika virus is an emerging mosquito-borne flavivirus. Recent outbreaks of Zika virus disease in the Pacific Islands and the Region of the Americas have identified new modes of transmission and clinical manifestations, including adverse pregnancy outcomes. However, data on the epidemiology and clinical findings of laboratory-confirmed Zika virus disease remain limited. During January 1, 2015-February 26, 2016, a total of 116 residents of 33 U.S. states and the District of Columbia had laboratory evidence of recent Zika virus infection based on testing performed at CDC. Cases include one congenital infection and 115 persons who reported recent travel to areas with active Zika virus transmission (n = 110) or sexual contact with such a traveler (n = 5). All 115 patients had clinical illness, with the most common signs and symptoms being rash (98%; n = 113), fever (82%; 94), and arthralgia (66%; 76). Health care providers should educate patients, particularly pregnant women, about the risks for, and measures to prevent, infection with Zika virus and other mosquito-borne viruses. Zika virus disease should be considered in patients with acute onset of fever, rash, arthralgia, or conjunctivitis, who traveled to areas with ongoing Zika virus transmission (http://www.cdc.gov/zika/geo/index.html) or who had unprotected sex with a person who traveled to one of those areas and developed compatible symptoms within 2 weeks of returning.

Advanced (stage D) heart failure: a statement from the Heart Failure Society of America Guidelines Committee.

We propose that stage D advanced heart failure be defined as the presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy. Importantly, the progressive decline should be primarily driven by the heart failure syndrome. Formally defining advanced heart failure and specifying when medical and device therapies have failed is challenging, but signs and symptoms, hemodynamics, exercise testing, biomarkers, and risk prediction models are useful in this process. Identification of patients in stage D is a clinically important task because treatments are inherently limited, morbidity is typically progressive, and survival is often short. Age, frailty, and psychosocial issues affect both outcomes and selection of therapy for stage D patients. Heart transplant and mechanical circulatory support devices are potential treatment options in select patients. In addition to considering indications, contraindications, clinical status, and comorbidities, treatment selection for stage D patients involves incorporating the patient's wishes for survival versus quality of life, and palliative and hospice care should be integrated into care plans. More research is needed to determine optimal strategies for patient selection and medical decision making, with the ultimate goal of improving clinical and patient centered outcomes in patients with stage D heart failure.

Sensitive fluorescence-based method for the rapid determination of polysorbate-80 content in therapeutic monoclonal antibody products.

A sensitive and effective method has been developed for the rapid determination of polysorbate-80 content in therapeutic monoclonal antibody (mAb) products. The method is based on the detection of the fluorescence emission of 4,4'-dianilino-1,1'-binaphthyl-5,5'-disulfonic acid dipotassium salt (bis-ANS) enhanced by the presence of polysorbate-80. The developed method includes two approaches. One requires removal of the mAb from solution prior to analysis, while the other requires only simple sample dilution. The limits of detection and quantitation, calculated from the calibration curve generated in the absence of mAb-A, were 1.5 and 4.7 parts per million, respectively. Given the comparable linear range and linearity of the linear line between the solutions, with or without mAb, the limit of detection and quantitation is assumed to be similar. The dilution method is not only fast and simple in terms of sample preparation, but it is also particularly useful for analyzing the level of polysorbate-80 contained in highly concentrated mAb products. However, given that this method does require availability of polysorbate-80-free materials of mAb for preparation of calibration standards, the protein removal method may be useful for the cases where appropriate protein materials for standard preparation are limited or unavailable.

Survival in elderly patients supported with continuous flow left ventricular assist device as bridge to transplantation or destination therapy.

BACKGROUND: Published data on mechanical circulatory support for elderly patients in continuous flow devices are sparse and suggest relatively poor survival. This study investigated whether LVADs can be implanted in selected patients over the age of 65 years with acceptable survival compared with published outcomes. METHODS AND RESULTS: A single-center retrospective analysis was conducted in 64 consecutive patients ≥65 years of age implanted with a continuous-flow left ventricular assist device (CF-LVAD) as either bridge to transplantation or destination therapy from August 2005 to January 2012. Baseline laboratory and hemodynamic characteristics and follow-up data were obtained. Median survival was 1,090 days. Survival was 85%, 74%, 55%, and 45% at 6 months and 1, 2, and 3 years, respectively. Our cohort had a baseline mean Seattle Heart Failure Model (SHFM) score of 2.6 ± 0.9. Observed survival was significantly better than SHFM-predicted medical survival. Stratification by age subsets, renal function, SHFM, implantation intention, or etiology did not reveal significant differences in survival. The most common cause of death was sepsis and nonlethalcomplication was bleeding. CONCLUSIONS: Our experience with patients over the age of 65 receiving CF-LVADs suggests that this group demonstrates excellent survival. Further research is needed to discern the specific criteria for risk stratification for LVAD support in the elderly.

Support services for survivors of ebola virus disease - Sierra Leone, 2014.

As of December 6, 2014, Sierra Leone reported 6,317 laboratory-confirmed cases of Ebola virus disease (Ebola), the highest number of reported cases in the current West Africa epidemic. The Sierra Leone Ministry of Health and Sanitation reported that as of December 6, 2014, there were 1,181 persons who had survived and were discharged. Survivors from previous Ebola outbreaks have reported major barriers to resuming normal lives after release from treatment, such as emotional distress, health issues, loss of possessions, and difficulty regaining their livelihoods. In August 2014, a knowledge, attitude, and practice survey regarding the Ebola outbreak in Sierra Leone, administered by a consortium of partners that included the Ministry of Health and Sanitation, UNICEF, CDC, and a local nongovernmental organization, Focus 1000, found that 96% of the general population respondents reported some discriminatory attitude towards persons with suspected or known Ebola. Access to increased psychosocial support, provision of goods, and family and community reunification programs might reduce these barriers. Survivors also have unique potential to contribute to the Ebola response, particularly because survivors might have some immunity to the same virus strain. In previous outbreaks, survivors served as burial team members, contact tracers, and community educators promoting messages that seeking treatment improves the chances for survival and that persons who survived Ebola can help their communities. As caregivers in Ebola treatment units, survivors have encouraged patients to stay hydrated and eat and inspired them to believe that they, too, can survive. Survivors regaining livelihood through participation in the response might offset the stigma associated with Ebola.

Rapid assessment of Ebola infection prevention and control needs--six districts, Sierra Leone, October 2014.

As of October 31, 2014, the Sierra Leone Ministry of Health and Sanitation had reported 3,854 laboratory-confirmed cases of Ebola virus disease (Ebola) since the outbreak began in May 2014; 199 (5.2%) of these cases were among health care workers. Ebola infection prevention and control (IPC) measures are essential to interrupt Ebola virus transmission and protect the health workforce, a population that is disproportionately affected by Ebola because of its increased risk of exposure yet is essential to patient care required for outbreak control and maintenance of the country's health system at large. To rapidly identify existing IPC resources and high priority outbreak response needs, an assessment by CDC Ebola Response Team members was conducted in six of the 14 districts in Sierra Leone, consisting of health facility observations and structured interviews with key informants in facilities and government district health management offices. Health system gaps were identified in all six districts, including shortages or absence of trained health care staff, personal protective equipment (PPE), safe patient transport, and standardized IPC protocols. Based on rapid assessment findings and key stakeholder input, priority IPC actions were recommended. Progress has since been made in developing standard operating procedures, increasing laboratory and Ebola treatment capacity and training the health workforce. However, further system strengthening is needed. In particular, a successful Ebola outbreak response in Sierra Leone will require an increase in coordinated and comprehensive district-level IPC support to prevent ongoing Ebola virus transmission in household, patient transport, and health facility settings.