Persistence of Ebola virus in semen among Ebola virus disease survivors in Sierra Leone: A cohort study of frequency, duration, and risk factors.

BACKGROUND: Sexual transmission chains of Ebola virus (EBOV) have been verified and linked to EBOV RNA persistence in semen, post-recovery. The rate of semen persistence over time, including the average duration of persistence among Ebola virus disease (EVD) survivors, is not well known. This cohort study aimed to analyze population estimates of EBOV RNA persistence rates in semen over time, and associated risk factors in a population of survivors from Sierra Leone. METHODS AND FINDINGS: In this cohort study from May 2015 to April 2017 in Sierra Leone, recruitment was conducted in 2 phases; the first enrolled 100 male participants from the Western Area District in the capital of Freetown, and the second enrolled 120 men from the Western Area District and from Lungi, Port Loko District. Mean age of participants was 31 years. The men provided semen for testing, analyzed by quantitative reverse transcription PCR (qRT-PCR) for the presence of EBOV RNA. Follow-up occurred every 2 weeks until the endpoint, defined as 2 consecutive negative qRT-PCR results of semen specimen testing for EBOV RNA. Participants were matched with the Sierra Leone EVD case database to retrieve cycle threshold (Ct) values from the qRT-PCR analysis done in blood during acute disease. A purposive sampling strategy was used, and the included sample composition was compared to the national EVD survivor database to understand deviations from the general male survivor population. At 180 days (6 months) after Ebola treatment unit (ETU) discharge, the EBOV RNA semen positive rate was 75.4% (95% CI 66.9%-82.0%). The median persistence duration was 204 days, with 50% of men having cleared their semen of EBOV RNA after this time. At 270 days, persistence was 26.8% (95% CI 20.0%-34.2%), and at 360 days, 6.0% (95% CI 3.1%-10.2%). Longer persistence was significantly associated with severe acute disease, with probability of persistence in this population at 1 year at 10.1% (95% CI 4.6%-19.8%) compared to the probability approaching 0% for those with mild acute disease. Age showed a dose-response pattern, where the youngest men (≤25 years) were 3.17 (95% CI 1.60, 6.29) times more likely to be EBOV RNA negative in semen, and men aged 26-35 years were 1.85 (95% CI 1.04, 3.28) times more likely to be negative, than men aged >35 years. Among participants with both severe acute EVD and a higher age (>35 years), persistence remained above 20% (95% CI 6.0%-50.6%) at 1 year. Uptake of safe sex recommendations 3 months after ETU discharge was low among a third of survivors. The sample was largely representative of male survivors in Sierra Leone. A limitation of this study is the lack of knowledge about infectiousness. CONCLUSIONS: In this study we observed that EBOV RNA persistence in semen was a frequent phenomenon, with high population rates over time. This finding will inform forthcoming updated recommendations on risk reduction strategies relating to sexual transmission of EBOV. Our findings support implementation of a semen testing program as part of epidemic preparedness and response. Further, the results will enable planning of the magnitude of testing and targeted counseling needs over time.

Risk in the "Red Zone": Outcomes for Children Admitted to Ebola Holding Units in Sierra Leone Without Ebola Virus Disease.

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.

Evaluation of convalescent whole blood for treating Ebola Virus Disease in Freetown, Sierra Leone.

BACKGROUND: Convalescent blood therapy has been a promising form of treatment for Ebola Virus Disease (EVD), but less attention has been focused on it for treatment. METHOD: We assessed the effectiveness of convalescent whole blood (CWB) in the treatment of consented EVD patients. We recruited 69 subjects in December 2014 up to April 2015, at the 34 Military Hospital in Wilberforce and the PTS 1 Ebola Treatment Unit in Hastings, Freetown. Forty-four were given CWB, and 25 who consented but preferred to be exempted from the CWB treatment were used to compare clinical outcomes. All were given routine treatment used at the Ebola Treatment Unit. RESULTS: One of 44 subjects treated with CWB dropped out of the study and 31 recovered while 12 succumbed to the disease with a case fatality rate of 27.9%. For the group that was given routine treatment without CWB, 11 died with a case fatality rate of 44%. There was a significant difference between admission viral load and viral load after the first 24 h of treatment with convalescent whole blood (P < 0.01). The odds ratio for survival with CWB was 2.3 (95% CI, 0.8-6.5). CONCLUSION: CWB is promising for treating EVD in resource-poor settings, especially in the early phases of outbreaks when resource-mobilization is done. Even though our sample size was small and the evaluation was not randomised, our results contribute to existing evidence that convalescent whole blood could be considered as a useful candidate for treating EVD. Further studies that are randomised will be required to further assess the efficacy of CWB as treatment option during any EVD outbreak.

Nasal carriage of staphylococcus aureus and antibiotic susceptibility pattern among children in Freetown; Sierra Leone

Nasal carriage of Staphylococcus aureus has been demonstrated to be a major risk factor for invasive S. aureus infections in various population including children. The extent of S. aureus carriage in Sierra Leonean children is largely unknown. To determine the prevalence and pattern of antibiotic susceptibility of nasal S. aureus among children in Freetown; Sierra Leone; samples were collected from anterior nares of children less than two years at the Ola During Children's Hospital between October 2008 and April 2009. Of the 116 children screened during the study period; S. aureus isolates were found in the nasal specimens of 40 (34.5) of the children. Antimicrobial susceptibility testing to norfloxacin; gentamycin; erythromycin; trimethoprim-sulfamethazole; doxycycline; tetracycline and amoxycillin-clavulanic acid were observed to be 95; 35; 30; 20; 15; 7.5 and 2.5respectively. All the isolates were susceptible to oxacillin and resistant to chloramphenicol; penicillin G; amoxycillin and ampiclox. Regular monitoring of antimicrobial susceptibility pattern may be useful

Prevalence of Intestinal Helminthes among Children in Selected Communities in Monrovia; Liberia

The present study was carried out among children below 15 years in 10 communities in Monrovia. Out of the 646 children recruited in the study; 216 (33.4) were positive for at least one intestinal helminth parasite. Children between 11 - 15 years had the highest prevalence of intestinal helminthes. Ascaris lumbricoides was the most common intestinal helminth parasite encountered (79.6); followed by Trichuris trichura (19.0). Strongyloides stercoralis and Enterobius vermicularis were the least prevalent helminth parasites encountered among the study population (1each). The population in these communities depended largely on poorly built latrines and buckets for faecal disposal although some (49) used flush toilets despite their being in poor conditions. Only 23.45 of the 646 children surveyed used pipe borne water for drinking and other domestic purposes. The high prevalence rates of helminth infection obtained could be due to persistent infection and re-infection of the study population as a result of the constant seeding of the soil with parasite eggs and larvae in these communities

Knowledge; perception of risk and attitude of Sierra Leone military personnel towards colleagues with HIV/AIDS

The aim of this survey was to gain an insight into the level of knowledge; perception of risk and attitude of Sierra Leone Military personnel towards colleagues with HIV/AIDS. Four hundred and fifty (450) randomly selected male and female military personnel including officers and other ranks from six battalions were surveyed with a standard questionnaire. Results of this survey demonstrated a relatively low level of knowledge of HIV and AIDS amongst the survey population as evidenced by the 40and 52of participants stating that HIV is transmitted by mosquito bites and from public toilets respectively. An equally low perception of risk of the infection was demonstrated from the responses of the participants about attitude towards HIV infected colleagues. Three-fourth of the participants indicated that nobody should be informed if a colleague is HIV positive; with almost all the participants expressing their willingness to take care of an HIV/AIDS person in their household. Varying responses obtained demonstrate the necessity for scaling-up HIV education within the Republic of Sierra Leone Armed Forces. More resources most therefore be made available to the HIV/AIDS office of the Republic of Sierra Leone Armed Forces so that HIV education activities can be extended to all the brigades and battalions

Intestinal protozoa and intestinal helminthic infections in displacement camps in Sierra Leone.

Displacement and refugee camps provide ideal grounds for the transmission of parasites and increase the risk of acute respiratory infections, diarhoea diseases, and intestinal parasitic infection. Cryptosporidium parvum, Giardia lamblia, Entomoeba histolytica, Ascaris lumbricoides, hookworm infection, Schistosoma haematobium, S. mansoni and Strongyloides stercoralis are important cosmopolitan intestinal parasites that are common among children, the immunocompromised and displaced populations. Five hundred and eighty one residents from 5 Internally Displaced Persons (IDPs) Camps voluntarily participated in the study by providing stool and urine samples for analysis. The stool specimens were used for the detection of Cryptosporidium specific and Giardia specific antigens by the DMSO modified Acid-Fast and Trichrome-PLUS stain for C. parvum and G. lamblia and E. histoyltica respectively. Stool specimens for the demonstration of helminth eggs and larvae were prepared by the modified Kato technique. One hundred and seventy eight (31%) of the 581 camp residents that submited samples were children below 10 years of age and were selected because they were screened for various forms of malnutrition. However, the data on C. parvum and G. lamblia were included in the analysis for all parasites. More children were positive for G. lamblia (29%) than for C. parvum (10%) and 5% had double infection with both parasites. The antigen positive rate decreased with age for C. parvum and G. lamblia infections. Adult samples were also examined for the C. parvum, G. lamblia, E. histolytica, A. lumbricoides, hookworms, S. haematobium, S. mansoni and S. stercoralis. The prevalence of hookworm was highest at Parade Ground Camp (50%) and hookworm had the highest pevalence rate of 18% among the 581 IDP residents followed by S. mansoni (16.7%) and A. lumbricoides (15%). The overall prevalence of E. histolytica among the study population was 9.0%. The results of this study indicate that intestinal protozoan and helminth parasites are highly prevalent among camp residents in Sierra Leone with five (5) different helminth parasites demonstrated in the stool specimens of residents in the five IDP camps.

High prevalence of bedbugs Cimex hemipterus and Cimex lectularis in camps for internally displaced persons in Freetown, Sierra Leone: a pilot humanitarian investigation.

The prevalence of bedbugs Cimex hemipera and C. lectularis was investigated in camps for the internally displaced persons (IDPs) in Freetown, Sierra Leone. Two hundred and thirty eight rooms were searched during the day and at night, and 233 (98%) of those rooms in 30 booths were infested with different life cycle stages of bedbugs. There hundred and ninety-eight (68%) of the bedbugs were adults, 145 (24.8%) were nymphs of various instars, and 41 (7%) were clusters of eggs. Significantly (P > 0.05) more bedbugs were recovered during the night inspections 64.6% as compared to 35.4% during the day inspections. In addition, more adult bedbugs were recovered at night than during the day, a manifestation of their peak feeding period. Of the total of 570 adults and nymphs collected and identified, 320 (56.1%) and 250 (43.9%) were Cimex lectularis and Cimex hemipterus respectively. Clinical examination of 221 individuals living in the booths during 3 consecutive weeks of examinations and treatment for conditions suggestive of bedbug infestation (bites and skin reactions as well as treatments for other health and medical conditions) showed that 196 (86%) had wheals as a direct result of bedbug bites. The data of this pilot humanitarian investigation shows a high prevalence of bedbug infestation in these displacement camps. It is recommended that some control measures be instituted, like residual insecticide application along with integrating control methods within the primary health care system, because bedbugs are a source of great irritation and sleepless nights that could lead to stress.

Apparent drug failure following artesunate treatment of Plasmodium falciparum malaria in Freetown, Sierra Leone: four case reports.

Four cases of Plasmodium falciparum malaria who presented in Sierra Leone in November-December 2000 apparently failed to respond to treatment with artesunate. Three (75%) of the cases fulfilled the World Health Organization's criteria for late treatment failure. Although artesunate ranks only sixth as the first-line drug used by clinicians for the treatment of uncomplicated malaria in Sierra Leone, it is widely sold over the counter in pharmacies in the country. The indiscriminate and injudicious use of artesunate among the Sierra Leonean population is likely to increase the level and frequency of resistance among the local strains of P. falciparum. It is recommended that artesunate be reserved for patients who fail to respond to treatment with another of the antimalarial drugs available. Even then, the artesunate should preferably be used in combination with other, longer-acting antimalarial drugs, to slow the development of further resistance.

Sarcoptes scabiei infestation among children in a displacement camp in Sierra Leone.

The prevalence of scabies was investigated among a study population of 125 children between the ages of 1-15 y. Confirmation of scabies was done by clinical examination of each child and by the identification of the mite by microscopically examining the scrapings from the scabies-like lesions. The prevalence was age dependent, with children under five years accounting for 77%, peaking to 86% among the 5 to 9-y-olds, and steadily declining with an increase in age. Lesions were found on almost all parts of the body, but lesions were more commonly located on the fingers, legs, hands, face, stomach, and genitalia. Sarcoptes scabiei var hominis was recovered from 84 (67%) of the 125 skin scrapings examined. The prevalence of scabies is high in children in the displacement camps, suggesting that it may be a serious public health problem not only in these camps, but also in the entire country. This may be due to the fact that certain environmental conditions like civil unrest, overcrowding, poor personal hygiene, poverty, and ignorance, which are conducive to the spread of scabies, is characteristically present among the camp residents. Control programs should be put in place and implemented in an integrated nature, by reducing overcrowding, and by improving health education, personal hygiene, treatment and surveillance among high-risk populations.

The usefulness of defined clinical features in the diagnosis of HIV/AIDS infection in Sierra Leone.

Sierra Leone ranks at the bottom of the global World Bank Development Index based on multiple health and economic indices and lacks the resources to purchase HIV diagnostic kits. Our study has defined some common clinical features presenting HIV infection that could form clinical algorithms for the diagnosis and recognition of HIV infection by health workers in Sierra Leone. In a private clinic in Freetown, Sierra Leone, West Africa, 106 out of a total of 124 patients presenting with various symptoms and strong clinical suspicion of HIV infection within a two-year period (1999 and 2000), were deemed positive by two different ELISA tests. The prevalence of HIV infection seen in this private clinic in Freetown in 2000 was 14.89% as compared to 9.25% in 1999. The positive predictive value of our clinical diagnosis of HIV/AIDS infection was 85.5%. The male:female ratio of the patients in our series was 1:1.9, with a mean age of 39 years for males and 28 years for females. HIV infection was found in a cross-section of the population that we examined. Heterosexual contact appeared to be the major mode of transmission amongst our patients and there seemed to be a significant epidemiological risk of HIV infection amongst those who traveled to other countries in the West African sub region. Common clinical features in decreasing frequency were fever (92.5%), weight loss (84.1%), lymphadenopathy (78.3%), cough (48.1%), diarrhea (37.7%), candidiasis (32.1%) and body aches (30.1%).

Filariasis in the Kaiyamba Chiefdom, Moyamba District Sierra Leone: an epidemiological and clinical study.

In a cross-sectional epidemiological and clinical study of human filariasis, 630 individuals were examined for Onchocerca volvulus, Wuchereria bancrofti and Mansonella perstans infections in five communities in the Kaiyamba Chiefdom, Moyamba District, Sierra Leone. The overall prevalence of O. volvulus infection in males 144(39.1%) and females 94(35.9%) was not significantly different and the sex prevalence rate between communities was also not significant (G = 3, d.f. = 4, P > 0.05). Prevalence of O. volvulus was significantly lower (G = 42.331, d.f. = 5, P < 0.001) in the 5-9 age group (13.3%) compared to the 40-49 age group (61.9%). Sixty-four (10.2%) and 38(6.0%) of individuals examined were positive for W. bancrofti and M. perstans infections respectively and prevalence of both infections in the five communities was not significant. Mixed infections with the all three filaria parasites were recorded in 10(3.2%) of the individuals. One hundred and sixty-four (71.3%) clinical cases due to W. bancrofti were inflammatory in nature; 36.5% were chronic, of which, 26.6% were hydroceles and 9.4% involved elephantiasis of both the scrotum and the lower legs. All 19(3.0%) of M. perstans-related clinical cases were inflammatory. Ninety-three(63.3%) of O. volvulus positive individuals that presented symptoms were inflammatory in nature, 14(9.5%) had ocular symptoms and 57(38.8%) had subcutaneous nodules. These data indicate that infections due to O. volvulus, W. bancrofti and M. perstans may be of public health importance in Sierra Leone.

Parasitological and clinical studies on Wuchereria bamcrofti infectionin Moyamba District, Sierra Leone.

A total of 302 people were examined in 3 villages in the Moyamba District, Sierra Leone of microfilaria (mf) and clinical signs of Wuchereria bancrofti infection. Mf rates were 34.5% and 31.8% for Bonganema, Old Mosongo and Pelewahun respectively. The average mf rate of those examined was 34.8%. Analysed by age and sex, the highest mf rates were observed in males of age >/=21 years (46 - 56%). The relative risk of infection was significantly lower (P<0.000) for 5-10 year olds than 11+ year old individuals. Clinical studies of 284 individuals of age >/=11 years showed that recurrent fever was the commonest clinical sign observed and the rate was 5.9%. For the ages >/=41 years, the recurrent fever was 10%. The average hydrocele and elephantiasis rates were 2.5% and 1.1% respectively. For the ages >/=41 years, the hydrocele and elephantiasis rates were 4% and 3% respectively, indicating that Filariasis is an important public health problem in the area. Annual mass treatment of the study area residents with ivermectin for onchocerciasis has begun. Ivermectin has been reported to be effective for control of lymphatic Filariasis. The displacement of the population due to the undeclared war in the area will certainly negate the effects of the mass treatment programme.

Intestinal parasitic infections among rural farming communities in eastern Sierra Leone.

A study carried out in four rural, mainly farming villages in the Gorama Chiefdom, Kono District, Eastern Sierra Leone revealed that intestinal helminth infections are prevalent in this area of Sierra Leone. Out of the 1164 persons of all ages who were examined, 853 (73.5%) proved positive for at least one intestinal helminth infection. Ascaris lumbricoides was the most common helminth encountered (37.5%), followed by hookworms, 12.9%; Trichuris trichiura, 12.6%; Schistosoma mansoni, 5.6%; Strongyloides stercoralis, 3.8%; tapeworms 1.0%, and multiple infections were common. Adults used poorly built pit latrines, while children defecated indiscriminately and unsupervised around houses and in the nearby bush. In addition, in most of the villages, domestic water was obtained from polluted streams and rivers. Only one village had protected pipe borne water supply. The high prevalence of intestinal helminth infections in this area results from constant infection and reinfection caused by poor sewage disposal, poor environmental health, and the low socioeconomic status prevailing in these communities.

White blood cell count in healthy Sierra Leoneans.

The lack of standard local values for use as reference values has been a problem facing our haematological units in Sierra Leone for a long time. As a preliminary step towards the establishment of standard local values, one hundred and sixty apparently healthy Sierra Leoneans between the ages of 10 years to 50 years and above living in Freetown were investigated for the determination of total and differential white blood cells counts. The total white cell count was done by using the neubeur counting chamber whilst the differential white cell count was done from a thin blood smear stained with leishman's stain. A mean white blood cell count of 5.0 x 10(9)/L was obtained for the study group with a range of 2.4-12.0 x 10(9)/L. The study did not show any significant difference in white blood cell count between males and females. A mean differential neutrophil count of 56% was obtained for the study group and a mean differential lymphocyte count of 37% were obtained for the study group. The leucopenia obtained for the study group is thought to be due to the neutropenia and is probably thought to be a genetically determined characteristic of the indigenous Africans.

Transmission of onchocerca volvulus by simulium damnosum S.L. in four villages in the Gorama Chiefdom; Kono district; Sierra Leone

Quantitative studies on the transmission of onchocerca volvulus; including monthly and annual biting densities; age composition; parity rates; infection and infective rates of the similium damnosum s.l. population; were carried out for a year in a tropical rain-forest zone in Sierra Leone. In all 19;432 s. damnosum s.l. female flies were acught and 8;755 dissected; of which 6.307 were parous. The annual biting rate (ABR) varied between 20;787 and 39;188; 5.4 per cent of all flies were infected with O. volvulus; 3.6 per cent carried infective larvae in the head capsule; with mean of 2.5 per fly. The annual transmission potential (ATP) varied between 1;138 and 2;081. The ATPs for Bunabu; Matama; Kangama and Moimandu villages were 2;081; 1;403; 1;138 and 1;498 respectively; with most of the infection occuring during the months of May and August. The prevalences of skin microfilariae (mf) in Bunabu; Matama; Kangama and Moimandu villages were 79.0 per cent; 51.3 per cent; 78.0 per cent and 80.0 per cent respectively

Mermithid (Nematoda: Mermithidae) parasitism of Simulium damnosum s.l. (Diptera: Simuliidae) in Sierra Leone and the need for vector control.

Females of Simulium damnosum Theobald s.l. were systematically collected at four sites in the Gorawa Chiefdom of Sierra Leone, West Africa, over a period of 15 mo from July 1986 to September 1987. The prevalence of mermithids infecting parous females varied from 0 to 7.9%, whereas the prevalence of mermithids in nulliparous females varied from 0 to 42.8%. The peak incidences of mermithid infection in nulliparous females occurred during the rainy season (15.2% in October 1986, 42.8% in August 1987). The high incidence of mermithids was associated with a high monthly biting rate, particularly during the month before the peak mermithid period (5,240 in September 1986, 4,878 in July 1987).