CORRESPONDENCE

still presents a huge challenge as we move into the second year of the epidemic in West Africa.

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

WHO Ebola Response Team

This letter was published on December 24, 2014, at NEJM.org.

A list of authors (members of the WHO Ebola Response Team who contributed to this letter, in alphabetic order) is available with the full text ofthis letter at NEJM.org.

1. WHO Ebola Response Team. Ebola virus disease in West Africa — the first 9 months of the epidemic and forward projec­ tions. N Engl J Med 2014;371:1481-95. 2. Ebola response roadmap — situation report. Geneva: World Health Organization (http://www.who.int/csr/disease/ebola/ situation-reports/en/). 3. UN Mission for Ebola Emergency Response (UNMEER). Ex­ ternal situation report (http://www.un.org/eboIaresponse/index .shtml#&panell-l).

Supported by the Medical Research Council, the Bill and Me­ linda Gates Foundation, the Models of Infectious Disease Agent Study of the National Institute of General Medical Sciences (National Institutes of Health), the Health Protection Research Units of the National Institute for Health Research, European Union PREDEMICS consortium, Wellcome Trust, Fogarty Inter­ national Center, and World Health Organization.

DOI: 10.1056/NEJMcl414992

Ebola in Freetow n A rea, Sierra Leone — A Case Study o f 581 Patients e d i t o r : Schieffelin et al. (Nov. 27 issue)1 reported on 106 patients with Ebola virus disease who were treated in Kenema, Sierra Leone, in May and June 2014. Here we report similar data on the 631 patients with Ebola virus disease, as confirmed by polymerase-chain-reaction assay, who were admitted to the Ebola treatment center at the Hastings Police Training School near Freetown, Sierra Leone, on or after September 20, 2014 (the date on which the first patients were admitted to that center). The 31% case fatality rate at Hast­ ings is lower than the 74% rate reported by Schieffelin et al. As of December 7, 2014, a total of 50 of the 631 patients with laboratory-confirmed Ebola vi­ rus disease were still inpatients at Hastings, and 581 had either died or been discharged after testing negative for the Ebola virus in follow-up laboratory tests. In total, 183 o f the 581 patients for whom a final disposition is known died, representing a case fatality rate of 31.5%; among the patients who died, 38 were dead on arrival and the other 145 died after admission. We have observed a decreasing case fatality rate among inpatients at Hastings, from 47.7% among the first 151 patients (September 20 to October 13), to 31.7% among the next 126 patients with a final disposition (October 14 to November 4), to 23.4% among the next 304 patients (November 5 to December 7). The most common symptoms reported at ad­ mission were fatigue, anorexia, fever, vomiting and nausea, diarrhea, muscle pain, joint pain, and

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headache. On average, patients were admitted 3 or 4 days after the onset o f symptoms. The inpatients who died usually did so within 3 or 4 days after admission; survivors usually were hospitalized for about 2 weeks. Our current treatment protocol is as follows (for additional details, see Table SI in the Supplemen­ tary Appendix, available with the full text o f this letter at NEJM.org): For 72 hours after admission, all patients receive 1 g of ceftriaxone intravenous­ ly every 12 hours and 500 mg of metronidazole intravenously every 8 hours, as well as 500 ml of Ringer’s lactate every 8 or 12 hours and 500 ml of dextrose saline (5% and 0.9%, respectively) in­ travenously every 8 or 12 hours. All patients also receive 10 mg of vitamin K and 160 mg of artemether intramuscularly immediately on admis­ sion, as well as a 20-mg zinc sulfate tablet daily, a 400-mg ibuprofen tablet every 12 hours, and 10 mg of metoclopramide intravenously as need­ ed for nausea or vomiting. After the first 3 days, continuing therapy includes a 400-mg metroni­ dazole tablet every 8 hours for 7 days, a 500-mg cefuroxime tablet every 12 hours for 5 days, an artesunate-lumefantrine combination-therapy tablet daily for 3 days, a 400-mg ibuprofen tab­ let every 12 hours, and one capsule of ImmunoBoost nutrition supplement (Novopharm Formu­ lations) daily. Oral rehydration solution and juice drinks are given freely. It is unclear why the case fatality rate is decreasing at Hastings. We are unable to assess any individual component of the treatments we used, since we applied a

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package o f interventions. The effectiveness o f this treatment approach will need to be validated with clinical research at other Ebola treatment facilities.

S o ciety, its lic en s ees, a n d its as sig n e e s to use it in t h e jo u r n a l's v a rio u s p r in t a n d e le c tro n ic p u b lic a tio n s a n d in co lle c tio n s , re v is io n s , a n d a n y o th e r fo rm o r m e d iu m .

All data were collected under government mandate as part of an active public health surveillance initiative. The data included in this letter were anonymized before analysis.

C O R R EC TIO N S A New Era for the Treatm ent o f Hyperkalemia? (January 15, 2015;372:275-7). In the first paragraph (page 275), the first sentence should have given the potassium concentration w ith­ in hum an cells as approximately 140 mmol per liter, rather than 70 mmol per liter. In the reference list (page 277), the authors o f the first article cited should have been Burnell JM, Villamil MF, Uyeno BT, Scribner BH, rather than Burnell JM, Scribner BH, Uyeno BT, Villamil MF. The article is correct at NEJM.org.

Rashid Ansumana, M.Sc. Mercy Hospital Research Laboratory Bo, Sierra Leone

Kathryn H. Jacobsen, Ph.D., M.P.H. George Mason University Fairfax, VA [email protected]

Foday Sahr, M.B., Ch.B., D. Sc.

Interactive Perspective: Drug Development and FDA Approval, 1938-2013 (June 26, 2014;370:e39). The order o f authors was incorrect; Dr. Darrow should have been listed first, and Dr. Kesselheim second. The article is correct at NEJM.org.

34 M ilitary Hospital at Wilberforce Freetown, Sierra Leone

and Others A complete list o f authors is available with the full text o f this letter at NEJM.org. Disclosure forms provided by the authors are available with the full text o f this letter at NEJM.org.

NOTICES

This letterwas published on December 24, 2014, at NEJM.org.

1. Schieffelin JS, Shaffer JG, Goba A, et al. Clinical illness and outcomes in patients with Ebola in Sierra Leone. N Engl J Med 2014;371:2092-100. DOI: 10.1056/NEJMC1413685 Correspondence C opyright © 2014, 2 015 M assachusetts M e d ical Society.

IN S T R U C T IO N S

FO R

LETTER S T O

THE

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E D IT O R

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9 T H W O R L D CONGRESS O N CONTROVERSIES IN N E U R O L O G Y

The congress will be held in Budapest, Hungary, March 26-28. Contact ComtecMed, 53 Rothschild Blvd., P.O. Box 68, Tel Aviv, 6100001, Israel; or call (972) 3 5666166; or fax (972) 3 5666177; or e-mail [email protected]; or see http://www .comtecmed.com/cony.

• L e tte rs n o t re la te d t o a J o u r n a l a rtic le m u s t n o t e x ceed 4 0 0

FIRST IN T E R N A T IO N A L C RITIC AL CARE M E D IC IN E

w o rd s .

CONFERENCE

• A le tte r can h ave no m o re th a n fiv e references an d o n e fig u re o r ta b le . • A le tte r can be sig n e d by n o m o re th a n th r e e a u th o rs . • F in a n c ia l a s s o c ia tio n s o r o th e r p o s s ib le c o n flic ts o f in te re s t m u s t be d is c lo s e d . D is c lo s u re s w ill be p u b lis h e d w ith th e le tte rs . (F o r a u th o rs o f J o u r n a l a rtic le s w h o a re re s p o n d in g t o le tte rs , w e w ill o n ly p u b lis h n e w re le v a n t re la tio n s h ip s th a t h a v e d e v e lo p e d s in c e p u b lic a tio n o f th e artic le .)

The conference will be held in Da Nang, Vietnam, April 13-17. It is presented by the Vietnam Association o f Emergency, Critical Care Medicine and Medical Toxicology. The conference is supported by the Society o f Critical Care Medicine. Contact Dr. Carl Bartecchi, 615 D ittm er Ave., Pueblo, CO 81005 or Dr. Hoang Huu Hieu, Intensive Care Unit, Da Nang Hospital, 50-52 Nguyen Van Linh St., Da Nang, Vietnam; or e-mail [email protected] or drhoanghieu@ gmaiI.com; or call 0120 813 0561; or see http://www.2015ccmc.org.

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IN T E R N A T IO N A L A C A D E M Y OF C A R D IO L O G Y A N N U A L SC IE N TI F IC SESSIONS 2 0 1 5

• A ll le tte rs m u s t b e s u b m itte d a t a u th o rs .N E J M .o rg . Le tte rs th a t d o n o t a d h e re to th e s e in s tru c tio n s w ill n o t be c o n s id e re d . W e w ill n o tify yo u w h e n w e h a v e m a d e a d e c is io n a b o u t p o s s ib le p u b lic a tio n . Le tte rs re g a rd in g a r e c e n tJ o u r n a l a rtic le m a y be s h a re d w ith th e a u th o rs o f th a t a rtic le . W e are u n a b le to p ro v id e p r e p u b lic a tio n p ro o fs . S u b m is s io n o f a le tte r c o n s titu te s p e rm is s io n fo r th e M a s s a c h u s e tts M e d ic a l

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The “20th World Congress on Heart Disease” will be held in Vancouver, BC, Canada, July 25-27. Deadline for subm ission of abstracts is Feb. 10. Contact Dr. Asher Kimchi, International Academy o f Cardi­ ology, P.O. Box 17659, Beverly Hills, CA 90209; or call (310) 657 8777; or fax (310) 659 4781; or e-mail [email protected]; or see http://www.cardiologyonline.com.

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Ebola in Freetown area, Sierra Leone--a case study of 581 patients.

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