Successful Implementation of a Multicountry Clinical Surveillance and Data Collection System for Ebola Virus Disease in West Africa: Findings and Lessons Learned

Reshma Roshania; Michaela Mallow; Nelson Dunbar; David Mansary; Pranav Shetty; Taralyn Lyon; Kacey Pham; Matthew Abad; Erin Shedd; Anh-Minh A Tran; Sarah Cundy; Adam C Levine

doi:10.9745/GHSP-D-16-00186

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Dr. Adam Levine of IMC’s Ebola research team trains staff at the Bong County Ebola treatment unit in Liberia on how to don personal protective equipment.
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Staff at the Lunsar Ebola treatment unit in Sierra Leone transfer patient data from the high‐risk zone to the low‐risk zone.
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FIGURE 1.
Study Flow Diagram, Liberia and Sierra Leone ETUs, September 15, 2014, to September 15, 2015
Abbreviations: EVD, Ebola virus disease; ETU, Ebola treatment unit.
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FIGURE 2.
Patient Admissions by ETU^a and Epidemiological Week, Liberia and Sierra Leone, September 15, 2014, to September 15, 2015 (N=2,351)
Abbreviation: ETU, Ebola treatment unit.
^a ETUs were located in Bong County and Margibi County in Liberia, and in Kambia, Lunsar, and Makeni in Sierra Leone.
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FIGURE 3.
Geographic Distribution of Patients (A) Admitted and (B) Confirmed EVD Positive, Liberia and Sierra Leone, September 15, 2014, to September 15, 2015
Abbreviation: EVD, Ebola virus disease.
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FIGURE 4.
Final Diagnosis and Outcome of Admitted Patients by Epidemiological Week, Liberia and Sierra Leone, September 15, 2014, to September 15, 2015 (N=2,351)
Abbreviation: EVD, Ebola virus disease.
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FIGURE 5.
Final Diagnosis Among Admitted Patients (N=2,351) and Mortality Outcomes Among EVD+ Patients (N=465) by Age and Sex, Liberia and Sierra Leone, September 15, 2014, to September 15, 2015
Abbreviation: EVD, Ebola virus disease.
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An aerial view of the Lunsar Ebola treatment unit in Sierra Leone.

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TABLE 1 Quality of Data Entered From Original Patient Charts Into ETU-Specific Databases: Results of LQAS Audit, Liberia and Sierra Leone, November 2015 (N = 627 Patient Forms)
Patient Form % Data Entered Correctly
Demographic 99.5%
Triage 99.4%
Rounding 98.1%
Treatment 99.1%
Discharge 99.8%
Overall 99.8%
Abbreviations: ETU, Ebola treatment unit; LQAS, lot quality assurance sampling.

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TABLE 2 Outcomes Among All Admitted Patients by EVD Status, Sex, Age, and Location, Liberia and Sierra Leone, September 15, 2014, to September 15, 2015

	EVD+ Recovered	EVD+ Deceased^a	EVD+ Transferred	EVD+ Total	EVD- Discharged	EVD- Deceased	EVD- Total	All Patients
All patients	197 (8.4)	268 (11.4)	5 (0.2)	470 (20.0)	1,725 (73.4)	156 (6.6)	1,881 (80)	2,351 (100)
Sex^b
Men	76 (6.1)	107 (8.5)	3 (0.2)	190 (15.2)	959 (76.6)	97 (7.7)	1,062 (84.8)	1,252 (53.4)
Women	118 (10.8)	159 (14.6)	2 (0.2)	279 (25.6)	754 (69.1)	58 (5.3)	812 (74.4)	1,091 (46.6)
Age, years^b
0 to < 1	1 (1.9)	13 (24.5)	0 (0.0)	14 (26.4)	36 (67.9)	3 (5.7)	39 (73.6)	53 (2.3)
1 to 4	4 (2.4)	28 (16.5)	0 (0.0)	32 (18.8)	127 (74.7)	11 (6.5)	138 (81.2)	170 (7.3)
5 to 14	36 (15.5)	29 (12.4)	1 (0.4)	66 (28.3)	158 (67.8)	9 (3.9)	167 (71.7)	233 (10.0)
15 to 24	44 (10.8)	27 (6.7)	1 (0.2)	72 (17.7)	312 (76.8)	22 (5.4)	334 (82.3)	406 (17.4)
25 to 34	45 (8.1)	42 (7.6)	2 (0.4)	89 (16.1)	434 (78.5)	30 (5.4)	464 (83.9)	553 (23.6)
35 to 44	33 (8.8)	53 (14.2)	1 (0.3)	87 (23.3)	260 (69.5)	27 (7.2)	287 (76.7)	374 (16.0)
45 to 54	17 (5.8)	36 (12.3)	0 (0.0)	53 (18.1)	214 (73.0)	26 (8.9)	240 (81.9)	293 (12.5)
≥ 55	16 (6.2)	40 (15.5)	0 (0.0)	56 (21.7)	175 (67.8)	27 (10.5)	202 (78.3)	258 (11.0)
Country
Sierra Leone	114 (7.5)	173 (11.4)	5 (0.3)	292 (19.2)	1,122 (73.6)	110 (7.2)	1,232 (80.8)	1,524 (64.8)
Liberia	83 (10.0)	95 (11.5)	0 (0.0)	178 (21.5)	603 (72.9)	46 (5.6)	649 (78.5)	827 (35.2)

Abbreviation: EVD, Ebola virus disease.
All data reported as No. (%).
↵a Patients with suspected EVD (n = 14) included in EVD+ deceased.
↵b Missing values not included.

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TABLE 3 Chi-Square Analysis of Symptoms Reported at Triage by Patients With and Without EVD, Liberia and Sierra Leone, September 15, 2014, to September 15, 2014

	EVD+ Patients, No (%)	EVD- Patients, No. (%)	P Value
Clinical symptom
Fever	353 (75.3)	1,481 (78.7)	.11
Asthenia (weakness)	337 (71.9)	1,338 (71.1)	.76
Loss of appetite	321 (68.4)	1,228 (65.3)	.20
Headache	273 (58.2)	1,109 (59.0)	.77
Myalgia or arthralgia (muscle or joint pain)	273 (58.2)	1,093 (58.1)	.97
Nausea or vomiting	225 (58.0)	947 (60.4)	.38
Diarrhea	235 (54.0)	662 (37.4)	< .001
Abdominal pain	204 (43.5)	1,016 (54.0)	< .001
Red eyes^a	129 (27.5)	189 (10.1)	< .001
Sore throat or difficulty swallowing	112 (23.9)	440 (23.4)	.82
Dyspnea (shortness of breath)	110 (23.5)	581 (30.9)	.002
Hiccups	57 (12.2)	246 (13.1)	.59
Jaundice	24 (5.1)	108 (5.7)	.60
Bleeding, non-ocular	26 (5.5)	212 (11.3)	< .001
Epidemiologic variable
Had contact with someone ill	340 (82.1)	367 (21.5)	< .001
Attended funeral	144 (39.7)	146 (8.8)	< .001
Had recent travel outside of home district	18 (11.7)	122 (20.0)	.02
Worked in health sector	9 (4.2)	62 (6.5)	.20
Had contact with bush meat	0 (0.0)	13 (2.5)	.06

Abbreviation: EVD, Ebola virus disease.
↵a Includes red injected eyes, conjunctivitis, and hemorrhagic eyes.

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TABLE 4 Average Length of Stay (in Days) in ETU by EVD Status, Outcome, Sex, Age, and Location, Liberia and Sierra Leone, September 15, 2014, to September 15, 2015

	EVD+^a				EVD-				All Patients
	Recovered		Deceased^b		Discharged		Deceased		All Patients
	n	ALOS	n	ALOS	n	ALOS	n	ALOS	n	ALOS
All patients	197	14.7	268	5.6	1,721	3.6	156	2.3	2,346	4.7
Sex^c
Men	77	13.6	109	5.6	963	3.6	98	2.2	1,250	4.2
Women	118	15.4	159	5.6	751	3.7	58	2.4	1,088	5.2
Age, years^c
0 to < 1	1	18.0	13	6.0	36	4.2	3	1.7	53	4.8
1 to 4	4	23.0	28	6.6	127	3.8	11	1.9	170	4.6
5 to 14	36	15.4	29	5.5	158	3.6	9	3.2	233	5.7
15 to 24	44	14.4	27	4.7	311	3.5	22	2.0	405	4.7
25 to 34	44	13.5	42	5.8	433	3.5	30	2.6	551	4.4
35 to 44	33	15.0	53	5.4	260	3.6	27	1.9	374	4.8
45 to 54	17	13.4	36	5.8	213	3.4	26	2.1	292	4.2
≥ 55	16	15.3	40	5.3	174	3.9	27	2.4	257	4.7
Country
Sierra Leone	113	14.6	173	5.6	1,119	4.0	110	2.4	1,520	4.9
Liberia	83	14.9	95	5.7	602	2.9	46	2.0	826	4.3

Abbreviations: ALOS, average length of stay; ETU, Ebola treatment unit; EVD, Ebola virus disease.
↵a EVD+ patients who were transferred (n = 5) not included.
↵b Patients with suspected EVD (n = 14) included in EVD+ deceased.
↵c Missing values not included.

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TABLE 5 Case Fatality Ratios Among Patients With EVD by Gender, Age, and Location, September 15, 2014, to September 15, 2014

	EVD+ Recovered, No. (%)	EVD+ Deceased,^aNo. (%)	Total,^bNo. (%)	EVD Fatality,OR (95% CI)	P Value
All patients	197 (42.4)	268 (57.6)	465 (100)
Sex^c
Men	78 (41.7)	109 (58.3)	187 (40.3)	-	-
Women	118 (42.6)	159 (57.4)	277 (59.7)	1.0 (0.7, 1.4)	.09
Age, years^c
0 to <1	1 (7.1)	13 (92.9)	14 (3.1)	18.3 (3.3, 463.5)	< .001
1 to 4	4 (12.5)	28 (87.5)	32 (7.0)	10.8 (3.7, 40.8)	< .001
5 to 14	36 (55.4)	29 (44.6)	65 (14.0)	1.3 (0.7, 2.6)	.49
15 to 24	44 (62.0)	27 (38.0)	71 (15.3)	-	-
25 to 34	45 (51.7)	42 (48.3)	87 (18.8)	1.5 (0.8, 2.9)	.20
35 to 44	33 (38.4)	53 (61.6)	86 (18.5)	2.6 (1.4, 5.0)	.004
45 to 54	17 (32.1)	36 (67.9)	53 (11.4)	3.4 (1.6, 7.4)	.001
≥ 55	16 (28.6)	40 (71.4)	56 (12.1)	4.0 (1.9, 8.7)	< .001
Country
Sierra Leone	114 (39.7)	173 (60.3)	287 (61.7)	-	-
Liberia	83 (46.6)	95 (53.4)	178 (38.3)	0.8 (0.5, 1.1)	.15

Abbreviations: CI, confidence interval; EVD, Ebola virus disease; OR, odds ratio.
↵a Patients with suspected EVD (n = 14) included in EVD+ deceased.
↵b EVD+ patients who were transferred (n = 5) not included.
↵c Missing values not included.

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GHSP-D-16-00186 Supplementary Material

Levine et al. doi: 10.9745/GHSP-D-16-00186

Supplementary Material - Levine et al. doi: 10.9745/GHSP-D-16-00186
Supplementary Material - Levine et al. doi: 10.9745/GHSP-D-16-00186
Supplementary Material - Levine et al. doi: 10.9745/GHSP-D-16-00186