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BACKGROUND: Between December 2013 and June 2016, West Africa experienced the largest Ebola virus disease (EVD) outbreak in history. Understanding EVD in pregnancy is important for EVD clinical screening and infection prevention and control. METHODS: We conducted a review of medical records and EVD investigation reports from three districts in Sierra Leone. We report the clinical presentations and maternal and fetal outcomes of six pregnant women with atypical EVD, and subsequent transmission events from perinatal care. RESULTS: The six women (ages 18-38) were all in the third trimester. Each presented with signs and symptoms initially attributed to pregnancy. None met EVD case definition; only one was known at presentation to be a contact of an EVD case. Five women died, and all six fetuses/neonates died. These cases resulted in at least 35 additional EVD cases. CONCLUSIONS: These cases add to the sparse literature focusing on pregnant women with EVD, highlighting challenges and implications for outbreak control. Infected newborns may also present atypically and may shed virus while apparently asymptomatic. Pregnant women identified a priori as contacts of EVD cases require special attention and planning for obstetrical care.
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Fiebre Hemorrágica Ebola/diagnóstico , Complicaciones Infecciosas del Embarazo/diagnóstico , Adolescente , Adulto , Brotes de Enfermedades , Femenino , Fiebre Hemorrágica Ebola/epidemiología , Humanos , Recién Nacido , Embarazo , Complicaciones Infecciosas del Embarazo/virología , Salud Pública , Sierra Leona/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Ebola virus disease (EVD) survivors are at risk for uveitis during convalescence. Vision loss has been observed following uveitis due to cataracts. Since Ebola virus (EBOV) may persist in the ocular fluid of EVD survivors for an unknown duration, there are questions about the safety and feasibility of vision restorative cataract surgery in EVD survivors. METHODS: We conducted a cross-sectional study of EVD survivors anticipating cataract surgery and patients with active uveitis to evaluate EBOV RNA persistence in ocular fluid, as well as vision outcomes post cataract surgery. Patients with aqueous humor that tested negative for EBOV RNA were eligible to proceed with manual small incision cataract surgery (MSICS). FINDINGS: We screened 137 EVD survivors from June 2016 - August 2017 for enrolment. We enrolled 50 EVD survivors; 46 with visually significant cataract, 1 with a subluxated lens, 2 with active uveitis and 1 with a blind painful eye due to uveitis. The median age was 24.0years (IQR 17-35) and 35 patients (70%) were female. The median logMAR visual acuity (VA) was 3.0 (Snellen VA Hand motions; Interquartile Range, IQR: 1.2-3.0, Snellen VA 20/320 - Hand motions). All patients tested negative for EBOV RNA by RT-PCR in aqueous humor/vitreous fluid and conjunctiva at a median of 19months (IQR 18-20) from EVD diagnosis in Phase 1 of ocular fluid sampling and 34months (IQR 32-36) from EVD diagnosis in Phase 2 of ocular fluid sampling. Thirty-four patients underwent MSICS, with a preoperative median VA improvement from hand motions to 20/30 at three-month postoperative follow-up (P<0.001). INTERPRETATION: EBOV persistence by RT-PCR was not identified in ocular fluid or conjunctivae of fifty EVD survivors with ocular disease. Cataract surgery can be performed safely with vision restorative outcomes in patients who test negative for EBOV RNA in ocular fluid specimens. These findings impact the thousands of West African EVD survivors at-risk for ocular complications who may also require eye surgery during EVD convalescence.
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Líquidos Corporales/virología , Extracción de Catarata , Ebolavirus/fisiología , Ojo/virología , Fiebre Hemorrágica Ebola/virología , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa/métodos , Sobrevivientes , Adolescente , Adulto , Catarata , Ojo/fisiopatología , Humanos , Sierra Leona , Resultado del Tratamiento , Agudeza Visual , Adulto JovenRESUMEN
The magnitude of violence and human loss in conflict settings often exceeds the caring capacity of traditional support systems for orphans. The aim of this study is to understand the developmental context for children experiencing armed conflict, parental loss, extreme poverty, violence and social exclusion in a setting affected by interethnic violence. This article challenges the received wisdom that community reintegration is always better than institutional provision. Using a case study employing interviews, focus groups, workshops and observations, we examined how children's experiences of armed violence and parental loss affected their mental well-being, and their relationships within their community. Emerging findings such as experienced violence and psychological distress were further investigated using a cross-sectional survey design to explore the generalisability or transferability of theories or conclusions drawn from qualitative data. Findings showed that parental loss had a major impact on children's lives in the context of armed violence. Four main outcomes of orphanhood emerged: (i) facing the situation and evading harm (feelings of rejection and stigmatisation); (ii) trauma exposure and mental health effects (associations of orphanhood with adverse mental health outcomes and the number and type of experienced trauma); (iii) dealing with psychological distress (seeking caring connections and decreased feelings of isolation); and (iv) education and acceptance (increasing knowledge, skills and attitude and being respected in their community). We discuss the role that contexts such as armed violence, parental loss and social exclusion play for children's mental well-being and their implications for psychosocial interventions and orphan care in humanitarian settings. Copyright © 2015 John Wiley & Sons, Ltd.
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Niños Huérfanos/psicología , Etnicidad , Violencia , Adolescente , Niño , Estudios Transversales , Femenino , Necesidades y Demandas de Servicios de Salud , Humanos , Entrevistas como Asunto , Masculino , Investigación Cualitativa , Autoinforme , Aislamiento Social , Sudán del Sur , Guerra , Heridas y LesionesRESUMEN
As of 20 May 2016 there have been 28,646 cases and 11,323 deaths resulting from the West African Ebola virus disease (EVD) outbreak reported to the World Health Organization. There continue to be sporadic flare-ups of EVD cases in West Africa.EVD presentation is nonspecific and characterized initially by onset of fatigue, myalgias, arthralgias, headache, and fever; this is followed several days later by anorexia, nausea, vomiting, diarrhea, and abdominal pain. Anorexia and gastrointestinal losses lead to dehydration, electrolyte abnormalities, and metabolic acidosis, and, in some patients, acute kidney injury. Hypoxia and ventilation failure occurs most often with severe illness and may be exacerbated by substantial fluid requirements for intravascular volume repletion and some degree of systemic capillary leak. Although minor bleeding manifestations are common, hypovolemic and septic shock complicated by multisystem organ dysfunction appear the most frequent causes of death.Males and females have been equally affected, with children (0-14 years of age) accounting for 19 %, young adults (15-44 years) 58 %, and older adults (≥45 years) 23 % of reported cases. While the current case fatality proportion in West Africa is approximately 40 %, it has varied substantially over time (highest near the outbreak onset) according to available resources (40-90 % mortality in West Africa compared to under 20 % in Western Europe and the USA), by age (near universal among neonates and high among older adults), and by Ebola viral load at admission.While there is no Ebola virus-specific therapy proven to be effective in clinical trials, mortality has been dramatically lower among EVD patients managed with supportive intensive care in highly resourced settings, allowing for the avoidance of hypovolemia, correction of electrolyte and metabolic abnormalities, and the provision of oxygen, ventilation, vasopressors, and dialysis when indicated. This experience emphasizes that, in addition to evaluating specific medical treatments, improving the global capacity to provide supportive critical care to patients with EVD may be the greatest opportunity to improve patient outcomes.
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Fiebre Hemorrágica Ebola , Adulto , África Occidental/epidemiología , Anciano , Cuidados Críticos/métodos , Cuidados Críticos/normas , Enfermedad Crítica/mortalidad , Países en Desarrollo , Ebolavirus/patogenicidad , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Limited data are available on the prevalence and predictors of clinical sequelae in survivors of Ebola virus disease (EVD). The EVD Survivor Clinic in Port Loko, Sierra Leone, has provided clinical care for 603 of 661 survivors living in the district. We did a cross-sectional study to describe the prevalence, nature, and predictors of three key EVD sequelae (ocular, auditory, and articular) in this cohort of EVD survivors. METHODS: We reviewed available clinical and laboratory records of consecutive patients assessed in the clinic between March 7, 2015, and April 24, 2015. We used univariate and multiple logistic regression to examine clinical and laboratory features of acute EVD with the following outcomes in convalescence: new ocular symptoms, uveitis, auditory symptoms, and arthralgias. FINDINGS: Among 277 survivors (59% female), median age was 29 years (IQR 20-36) and median time from discharge from an EVD treatment facility to first survivor clinic visit was 121 days (82-151). Clinical sequelae were common, including arthralgias (n=210, 76%), new ocular symptoms (n=167, 60%), uveitis (n=50, 18%), and auditory symptoms (n=67, 24%). Higher Ebola viral load at acute EVD presentation (as shown by lower cycle thresholds on real-time RT-PCR testing) was independently associated with uveitis (adjusted odds ratio [aOR] 3·33, 95% CI 1·87-5·91, for every five-point decrease in cycle threshold) and with new ocular symptoms or ocular diagnoses (aOR 3·04, 95% CI 1·87-4·94). INTERPRETATION: Clinical sequelae during early EVD convalescence are common and sometimes sight threatening. These findings underscore the need for early clinical follow-up of survivors of EVD and urgent provision of ocular care as part of health systems strengthening in EVD-affected west African countries. FUNDING: Canadian Institutes of Health Research.
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Artralgia/etiología , Oftalmopatías/etiología , Pérdida Auditiva/etiología , Fiebre Hemorrágica Ebola/complicaciones , Adolescente , Adulto , Niño , Preescolar , Estudios de Cohortes , Estudios Transversales , Femenino , Fiebre Hemorrágica Ebola/epidemiología , Humanos , Modelos Logísticos , Masculino , Oportunidad Relativa , Factores de Riesgo , Sierra Leona/epidemiología , Carga Viral , Adulto JovenRESUMEN
As the outbreak of Ebola virus disease (EVD) in West Africa continues, clinical preparedness is needed in countries at risk for EVD (e.g., United States) and more fully equipped and supported clinical teams in those countries with epidemic spread of EVD in Africa. Clinical staff must approach the patient with a very deliberate focus on providing effective care while assuring personal safety. To do this, both individual health care providers and health systems must improve EVD care. Although formal guidance toward these goals exists from the World Health Organization, Medecin Sans Frontières, the Centers for Disease Control and Prevention, and other groups, some of the most critical lessons come from personal experience. In this narrative, clinicians deployed by the World Health Organization into a wide range of clinical settings in West Africa distill key, practical considerations for working safely and effectively with patients with EVD.
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Epidemias/prevención & control , Fiebre Hemorrágica Ebola/terapia , África Occidental/epidemiología , Atención a la Salud/organización & administración , Atención a la Salud/normas , Personal de Salud/psicología , Personal de Salud/normas , Fiebre Hemorrágica Ebola/epidemiología , Fiebre Hemorrágica Ebola/prevención & control , Humanos , Seguridad del Paciente , Ropa de ProtecciónRESUMEN
The outbreak of Ebola virus disease (EVD) in West Africa has outstripped available resources. Novel strategies are desperately needed to streamline operations. The present norm of requiring negative results on polymerase chain reaction for EVD convalescent patients to be discharged is not evidence-based and often results in asymptomatic patients competing for beds in dangerously crowded Ebola Treatment Units, posing risks to ward staff and patients and the community if infected persons are turned away. We summarize the relevant data and call for a change in discharge criteria for convalescent patients that can safely help reduce the strain on resources and direct energies where they are most needed. In the longer term, research is needed to assess the true infectivity of EVD convalescent patients to establish evidence-based criteria and guidelines for discharge.
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Epidemias/prevención & control , Fiebre Hemorrágica Ebola/terapia , Alta del Paciente , África Occidental/epidemiología , Fiebre Hemorrágica Ebola/diagnóstico , Fiebre Hemorrágica Ebola/epidemiología , Fiebre Hemorrágica Ebola/prevención & control , Fiebre Hemorrágica Ebola/transmisión , Humanos , Reacción en Cadena de la PolimerasaRESUMEN
The study estimated the user cost of Caesarean section (CS), a major component of emergency obstetric care (EmOC), in a post conflict situation in Bunia, DR Congo, 2008. A case control study used a structured questionnaire to compare women who had a CS (cases) with women who had a vaginal delivery (controls). Service information was recorded in 20 facilities providing obstetric care. Maternal and perinatal deaths, including those outside health facilities, were recorded and verified. The user cost of CS was estimated at four hospitals, one of them managed by an international non-governmental organization offering EmOC free of charge, compared to the user cost of women who had a vaginal delivery. Among paying users, the mean healthcare cost was $US68.0 for CS and $US12.1 for vaginal delivery; mean transport cost to and from the hospital was $US11.7 for cases and $US3.2 for controls. The mean monthly family income was $US75.5. The user cost of CS placed an important financial burden on patients and their families. During transition from humanitarian to developmental assistance, donors and the State should shore up the EmOC budget to avoid an increase in maternal and perinatal mortality.
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Cesárea/economía , Financiación Personal/tendencias , Estudios de Casos y Controles , Femenino , Accesibilidad a los Servicios de Salud/economía , Humanos , Entrevistas como Asunto , Embarazo , Investigación Cualitativa , Encuestas y CuestionariosRESUMEN
The largest ever Ebola virus disease outbreak is ravaging West Africa. The constellation of little public health infrastructure, low levels of health literacy, limited acute care and infection prevention and control resources, densely populated areas, and a highly transmissible and lethal viral infection have led to thousands of confirmed, probable, or suspected cases thus far. Ebola virus disease is characterized by a febrile severe illness with profound gastrointestinal manifestations and is complicated by intravascular volume depletion, shock, profound electrolyte abnormalities, and organ dysfunction. Despite no proven Ebola virus-specific medical therapies, the potential effect of supportive care is great for a condition with high baseline mortality and one usually occurring in resource-constrained settings. With more personnel, basic monitoring, and supportive treatment, many of the sickest patients with Ebola virus disease do not need to die. Ebola virus disease represents an illness ready for a paradigm shift in care delivery and outcomes, and the profession of critical care medicine can and should be instrumental in helping this happen.
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Cuidados Críticos/métodos , Fiebre Hemorrágica Ebola/terapia , Atención al Paciente/métodos , África Occidental/epidemiología , Enfermedad Crítica , Brotes de Enfermedades/estadística & datos numéricos , Fiebre Hemorrágica Ebola/epidemiología , Humanos , Cuidados Paliativos/métodosRESUMEN
BACKGROUND: The London School of General Practice Time Out of Programme (OOP) provides general practice (GP) trainees with an opportunity to enhance clinical experience and develop a range of skills and competencies, which are often not achievable in a three-year training programme, that are relevant and transferable to their practice in the UK. The programme offers one-year posts in the developing world to trainees between years ST2/3. AIM: This study builds on the work of the International Health Links Centre and London Deanery report (2011) and is designed to assess the skills and competencies of GP trainees on an OOP scheme. DESIGN: The study evaluated the impact of the OOP scheme on: ⢠GP trainees? clinical skills ⢠GP trainees' decision-making, management and leadership skills ⢠Any other competencies. SETTING: London GP trainees and trainers. METHOD: Data were gathered using structured interview schedules developed for GP trainees and GP trainers and mapped against the RCGP Trainee e-portfolio Competence Areas. RESULTS: Our findings show that trainees and trainers reported an increase in skill levels in the more generic competencies. CONCLUSION: The study shows that the OOP scheme provides GP trainees with an excellent opportunity to develop clinical skills and more generic skills such as leadership, management and decision-making, as well as effective use of resources. However, not all clinical skill improvements were directly transferable to trainees' clinical work on return to the UK.
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Competencia Clínica , Países en Desarrollo , Medicina General/educación , Misiones Médicas/organización & administración , Toma de Decisiones , Humanos , LondresRESUMEN
Background. Dengue outbreaks are occurring with increasing frequency and intensity. Evidence-based epidemic preparedness and effective response are now a matter of urgency. Therefore, we have analysed national and municipal dengue outbreak response plans. Methods. Thirteen country plans from Asia, Latin America and Australia, and one international plan were obtained from the World Health Organization. The information was transferred to a data analysis matrix where information was extracted according to predefined and emerging themes and analysed for scope, inconsistencies, omissions, and usefulness. Findings. Outbreak response planning currently has a considerable number of flaws. Outbreak governance was weak with a lack of clarity of stakeholder roles. Late timing of responses due to poor surveillance, a lack of combining routine data with additional alerts, and lack of triggers for initiating the response weakened the functionality of plans. Frequently an outbreak was not defined, and early response mechanisms based on alert signals were neglected. There was a distinct lack of consideration of contextual influences which can affect how an outbreak detection and response is managed. Conclusion. A model contingency plan for dengue outbreak prediction, detection, and response may help national disease control authorities to develop their own more detailed and functional context specific plans.
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This paper demonstrates the feasibility of health services research in an unstable environment during the transition from crisis to development and its importance for future planning. Effectiveness and the cost of caesarean sections (CSs) were investigated in Bunia, a town affected by conflict and insecurity, in the Democratic Republic of the Congo (DRC) in 2008. The CS rate was 9.7 per cent of expected deliveries. All CSs in the study sample were emergency procedures. A humanitarian non-governmental organisation (NGO) hospital, offering free services, performed 75 per cent of all CSs. The estimated provider cost for CS in 2008 at this hospital was USD 103,514 (that is, USD 144 per CS). With a cost of between USD 3.8 and 9.2 per year of health adjusted life expectancy (HALE) gained, CSs at the NGO hospital were very cost-effective. The estimates give an indication of funding requirements to maintain adequate access to CS after the departure of the humanitarian organisation.
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Altruismo , Cesárea/economía , Servicio de Urgencia en Hospital/economía , Sistemas de Socorro/economía , Guerra , Adulto , Cesárea/estadística & datos numéricos , Análisis Costo-Beneficio , República Democrática del Congo , Estudios de Factibilidad , Femenino , Investigación sobre Servicios de Salud , Hospitales Privados/economía , Humanos , EmbarazoAsunto(s)
Artemisininas/uso terapéutico , Malaria , Plasmodium falciparum , Viaje , Adulto , Antimaláricos/uso terapéutico , Diagnóstico Diferencial , Manejo de la Enfermedad , Progresión de la Enfermedad , Femenino , Humanos , Malaria/sangre , Malaria/diagnóstico , Malaria/tratamiento farmacológico , Malaria/epidemiología , Malaria/microbiología , Malaria/fisiopatología , Masculino , Plasmodium falciparum/efectos de los fármacos , Plasmodium falciparum/aislamiento & purificación , Plasmodium falciparum/patogenicidad , Índice de Severidad de la Enfermedad , Reino Unido/epidemiologíaRESUMEN
Leeches have been making a remarkable come-back in medical practice in recent years, particularly in reconstructive surgery. This paper opens with a brief review of the historical aspects of the medicinal use of leeches and their recent renaissance in modern medical practice. We then embark on a journey through the murky waters of leech infestation and the potentially life-threatening complications arising from close encounters with these extraordinary creatures. Finally, we get to grips with the tricky issue of safely apprehending and removing uninvited hangers-on.
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Hirudo medicinalis/fisiología , Aplicación de Sanguijuelas/métodos , Animales , Infestaciones Ectoparasitarias/epidemiología , Hirudo medicinalis/patogenicidad , Historia del Siglo XV , Historia del Siglo XVI , Historia del Siglo XVII , Historia del Siglo XVIII , Historia del Siglo XIX , Historia del Siglo XX , Historia del Siglo XXI , Historia Antigua , Historia Medieval , Humanos , Aplicación de Sanguijuelas/efectos adversos , Aplicación de Sanguijuelas/historia , Procedimientos de Cirugía Plástica/métodosRESUMEN
INTRODUCTION: A rare case of optic disc edema associated with cutaneous larva migrans is presented. To the best of our knowledge, this has not been previously reported in literature. Joint management by ophthalmology and tropical medicine teams proved most beneficial for our patient, facilitating correct diagnosis, appropriate investigations and instigation of suitable treatment. CASE PRESENTATION: A 45-year-old Caucasian man, a naturalist, from the UK developed cutaneous larva migrans while in Kenya and presented to us with visual disturbance secondary to unilateral optic disc edema. This resolved after receiving a single dose of ivermectin and visual acuity reverted to normal. CONCLUSION: To the best of our knowledge, optic disc edema associated with cutaneous larva migrans has not been previously reported. This case highlights the importance of taking relevant history of recent travel to endemic areas affected by the nematodes in patients presenting with optic disc edema, and pertinent questioning regarding non-ocular symptoms, including skin lesions. In this case, a history of recent foreign travel and treatment for skin lesions was crucial.
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BACKGROUND: Malaria is a risk factor for invasive non-typhoidal Salmonella (NTS) infection in children. In the last 10 years, indices of malaria infection in The Gambia have fallen substantially. METHODS: We compared temporal trends of childhood malaria and NTS infection in two Gambian locations. In Fajara, on the coast, the incidence of NTS infection at three time points between 1979 and 2005 was compared to the percentage of malaria positive outpatient thick blood films and the percentage of admissions associated with malaria over time. In Basse, in the eastern part of the country, the incidence of NTS infection at three time points between 1989 and 2008 was compared to the prevalence of malaria parasitaemia at four time points between 1992 and 2008. RESULTS: The estimated incidence of NTS infection in Fajara fell from 60 (1979-1984) to 10 (2003-05) cases per 100,000 person years. The proportion of outpatients in Fajara with suspected malaria who were parasitaemic fell from 33% (1999) to 6% (2007) while the proportion of admissions associated with malaria fell from 14.5% (1999) to 5% (2007). In Basse, the estimated incidence of NTS infection fell from 105 (1989-1991) to 29 (2008) cases per 100,000 person years while the prevalence of malaria parasitaemia fell from 45% (1992) to 10% (2008). The incidence of pneumococcal bacteraemia in Fajara and Basse did not fall over the study period. CONCLUSIONS: These data support an association between malaria and NTS infection. Reductions in malaria infection may be associated with reduced rates of invasive childhood NTS infection.
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Malaria/complicaciones , Malaria/epidemiología , Infecciones por Salmonella/complicaciones , Infecciones por Salmonella/epidemiología , Bacteriemia/complicaciones , Bacteriemia/epidemiología , Niño , Gambia/epidemiología , Humanos , Incidencia , Infecciones Neumocócicas/complicaciones , Infecciones Neumocócicas/epidemiología , Infecciones Neumocócicas/microbiología , Infecciones por Salmonella/microbiología , Factores de Tiempo , Fiebre Tifoidea/complicaciones , Fiebre Tifoidea/epidemiología , Fiebre Tifoidea/microbiologíaRESUMEN
This special issue of Third World Quarterly makes a case for redirecting attention and resources away from the 'war on terror' and focussing as a matter of urgency on the causes and consequences of global climate change. Global climate change must be recognised as an issue of national and international security. Increased competition for scarce resources and migration are key factors in the propagation of many of today's chronic complex humanitarian emergencies. The relentless growth of megacities in natural disaster hotspots places unprecedented numbers of vulnerable people at risk of disease and death. The Earth's fragile ecosystem has reached a critical tipping point. Today's most urgent need is for a collective endeavour on the part of the international community to redirect resources, enterprise and creativity away from the war on terror and to earnestly redeploy these in seeking solutions to the far greater and increasingly imminent threats that confront us as a consequence of global climate change.