Correspondence
Ebola in Africa: beyond epidemics, reproductive health in crisis
Number of patients per quarter
According to WHO, more than 5000 people have died from Ebola, including 240 health workers. 1,2 We are deeply concerned about the devastating effect of Ebola on reproductive health in Guinea, Liberia, and Sierra Leone in the context of continuous deterioration of socioeconomic conditions and general health in affected countries.3 The indirect negative effect of Ebola on reproductive health stems mainly from the desertion of already understaffed health facilities by health-care workers who are fearful of contracting Ebola. This fear is further increased because most reproductive health life-saving interventions include handling blood or bodily fluids from patients whose Ebola status is often unknown and health staff often do not have access to appropriate protection.4 Most referral maternity wards in the three most affected countries (Guinea, Liberia, and Sierra Leone) do not have equipment to do real-time screening for Ebola (eg, PCR), which could lead to the denial of care for women suspected to be pregnant. Additionally, the absence of providers offering relevant services, the inability to differentiate between Ebola and other febrile 1000 Matam maternity hospital 900 760 800 632 700 620 600 500 400 300 200 100 0 January– April– July– March June September
diseases, and the fear of contracting Ebola at a health facility can prevent users seeking reproductive health services. Statistics from Matam maternity hospital in Conakry, Guinea, show a substantial drop in attendance between March, 2014, and September, 2014, compared with 2013 (figure). A decrease in paediatric or maternal admissions because of fear of contracting Ebola has also been reported by Médecins Sans Frontières in Sierra Leone.5 We are concerned that women in need of reproductive health care because of pregnancy, childbirth, and post-partum related complications, including haemorrhage, eclampsia, obstructed labour, and abortion, will not have necessary and even life-saving care and attention. United Nations Population Fund estimates that 15% of the 800 000 women who will give birth in the next 12 months in Guinea, Liberia, and Sierra Leone could die of complications because of inade quate emergency obstetric care,4 and thousands of others could develop devastating pathological conditions, such as obstetric fistula. Increased support to fight Ebola is needed in Guinea, Liberia, and Sierra Leone coupled, with specific attention to reproductive health services. Adequate measures, including health system strengthening and community mobilisation coupled with an enabling environment for 904
569
123
2013
January– March
April– June
July– September
2014 Time period
Figure: Numbers of patients at the Matam maternity Hospital, Conakry, Guinea, in 2013 and 2014
www.thelancet.com Vol 384 December 13, 2014
We declare no competing interests.
*Alexandre Delamou, Rachel M Hammonds, Séverine Caluwaerts, Bettina Utz, Thérèse Delvaux [email protected] Centre de Formation et Recherche en Santé Rurale, Maferinyah, Guinea (AD); Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (AD, RMH, BU, TD); Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (SC); Woman and Child Health Research Centre, Institute of Tropical Medicine, Antwerp, Belgium (AD, SC, BU, TD); and Médecins sans Frontières Operational Centre, Brussels , Belgium (SC) 1
2
3
4
5
WHO. Ebola response roadmap situation report. Oct 29, 2014. http://apps.who.int/iris/ bitstream/10665/137091/1/ roadmapsitrep22Oct2014_eng.pdf?ua=1. (accessed Nov 12, 2014). WHO Ebola Response Team. Ebola virus disease in west Africa—the first 9 months of the epidemic and forward projections. N Engl J Med 2014; 371: 1481–95. Piot P, Muyembe JJ, Edmunds WJ. Ebola in west Africa: from disease outbreak to humanitarian crisis. Lancet Infect Dis 2014; published online Oct 1. http://dx.doi.org/10.1016/S14733099(14)70956-9. UNFPA. Ebola wiping out gains in safe motherhood. Oct 16, 2014. http://www. unfpa.org/public/cache/offonce/home/ news/pid/18486;jsessionid=879EAD984815 2210299DB057BF867F13.jahia01 (accessed Nov 10, 2014). Médecins Sans Frontières. Sierra Leone: MSF suspends emergency pediatric and maternal services in Gondama. Oct 16, 2014. http:// www.doctorswithoutborders.org/article/ sierra-leone-msf-suspends-emergencypediatric-and-maternal-services-gondama (accessed Nov 12, 2014).
Provision of care for Ebola
710
October– December
provision of emergency obstetric care, need to be put in place urgently to avoid devastating short-term and long-term effects for thousands of women.
Hundreds of UK military and civilian staff will put themselves at some risk of infection when treating patients with Ebola in west Africa over the coming months, raising important questions about how they should best be cared for if they become infected. The cornerstones of treatment for Ebola are volume repletion, including use of intravenous fluids
Published Online December 1, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)62250-9
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2105
Correspondence
as necessary, careful monitoring of fluid and electrolyte balance, and management of complications such as secondary bacterial infection. 1 The UK Ministry of Defence is now running a unit at Kerrytown in Sierra Leone that is equipped and staffed to offer such care. However, this unit does not have facilities for ventilatory or renal support, which have been used in a handful of health-care workers evacuated to Europe or the USA during this outbreak.2 On November 7, 2014, we participated in a meeting of clinical experts in London convened by the Chief Medical Officer, Sally Davis, to review the evidence surrounding critical care in patients with Ebola. We started from the principle that any health-care worker who develops Ebola should be offered the best opportunity to make a full recovery based on available evidence and assessment of their individual circumstances. This assessment also needs to reflect the risks associated with evacuation from west Africa, the risks to carers of any invasive procedures, and the effect of care on wider health services. We concluded that early, aggressive, and well monitored supportive therapy, which the Kerrytown facility is ideally placed to provide, remains the key to successful treatment of patients with Ebola. There is very little available evidence for the use of critical care in the management of Ebola, and no evidence that addition of ventilatory or renal support would result in substantial overall benefit for patients who receive the optimum supportive care. We therefore agreed that we would not expect critical care support to be provided for patients with Ebola, either in-country or for those cases that are repatriated or imported. There might be a few situations in which critical care might offer particular benefit to the individual. Currently, only the Trexler isolators within the high-level isolation unit 2106
at the Royal Free Hospital (London, UK) offer suitable facilities where such treatment can be provided with reasonable safety and without affecting the general services of the National Health Service or requiring much additional training. We remain committed to keeping all aspects of the evidence on treatment of Ebola under regular review and will revise our recommendations as new evidence emerges. We declare no competing interests.
*Michael Jacobs, Mike Beadsworth, Matthias Schmid, Anne Tunbridge [email protected] Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK (MJ); Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK (MB); Infection & Tropical Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MS); and Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK (AT) 1
2
Marshall Lyon G, Mehta A, Varkey J, et al. Clinical care of two patients with Ebola virus disease in the United States. N Engl J Med 2014; published online Nov 12. DOI:10.1056/ NEJMoa1409838. Kreuels B, Wichmann D, Emmerich P, et al. A case of severe Ebola virus Infection complicated by Gram-negative septicemia. N Engl J Med 2014; published online Oct 22. DOI:10.1056/NEJMoa1411677.
Patient safety after partial and total knee replacement
owned by the UK Government. From April, 2014, going forward, industry also made a financial contribution to the NJR in return for postmarket surveillance data. Cobb also states that Justin Hunt and colleagues 2 stop short of commending unicompartmental knee replace ment compared with total knee replacement “to avoid conflict with the stream of registry publications promoting unicompartmental knee replacement over total knee replacement”. This comment also seeks to question the probity of the NJR, suggesting larger scale collusion is occurring. This assertion is also incorrect. Unique among joint registers, the NJR allows independent researchers to use the NJR dataset. The two papers that form the substance of Cobb’s argument 2,3 are exemplars of this process. Investigators of these studies, one of which was internal2 and the other independent, 3 both had access to the NJR dataset. They have contrasting arguments, but use different study designs and analysis methods. We were encouraged that The Lancet published both studies side by side2,3 to stimulate the debate that Cobb suggests the NJR wishes to close down. MP is Medical Director of the NJR and JMW is chair of the research sub-committee of NJR. MP reports fees from Johnson and Johnson.
*Martyn Porter, J Mark Wilkinson In his Comment (Oct 18, p 1405) about the controversies in prosthetic surgery for knee osteoarthritis,1 Justin Cobb makes several statements regarding the utility and focus of joint registries in general and specific allegations regarding the probity of the National Joint Registry for England, Wales, and Northern Ireland (NJR). These comments need redress. Cobb states that the NJR is industry-funded and implies that there is collusion to restrict access to unicompartmental knee replacement. This statement is incorrect. The NJR is funded by the tax-payer and
martynporter@hipkneeclinic Orthopaedic Department, Wrightington Hospital, Wigan WN6 9EP, UK (MP); and Department of Human Metabolism, University of Sheffield, Sheffield, UK (JMW) 1
2
3
Cobb JP. Patient safety after partial and total knee replacement. Lancet 2014; 384: 1405–07. Hunt LP, Ben-Shlomo Y, Clark EM, et al, on behalf of the National Joint Registry for England and Wales. 45-day mortality after 467 779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: an observational study. Lancet 2014; 384: 1429–36. Liddle AD, Judge A, Pandit H, Murray DW. Adverse outcomes after total and unicompartmental knee replacement in 101 330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet 2014; 384: 1437–45.
www.thelancet.com Vol 384 December 13, 2014
Ebola in Africa: beyond epidemics, reproductive health in crisis
Number of patients per quarter
According to WHO, more than 5000 people have died from Ebola, including 240 health workers. 1,2 We are deeply concerned about the devastating effect of Ebola on reproductive health in Guinea, Liberia, and Sierra Leone in the context of continuous deterioration of socioeconomic conditions and general health in affected countries.3 The indirect negative effect of Ebola on reproductive health stems mainly from the desertion of already understaffed health facilities by health-care workers who are fearful of contracting Ebola. This fear is further increased because most reproductive health life-saving interventions include handling blood or bodily fluids from patients whose Ebola status is often unknown and health staff often do not have access to appropriate protection.4 Most referral maternity wards in the three most affected countries (Guinea, Liberia, and Sierra Leone) do not have equipment to do real-time screening for Ebola (eg, PCR), which could lead to the denial of care for women suspected to be pregnant. Additionally, the absence of providers offering relevant services, the inability to differentiate between Ebola and other febrile 1000 Matam maternity hospital 900 760 800 632 700 620 600 500 400 300 200 100 0 January– April– July– March June September
diseases, and the fear of contracting Ebola at a health facility can prevent users seeking reproductive health services. Statistics from Matam maternity hospital in Conakry, Guinea, show a substantial drop in attendance between March, 2014, and September, 2014, compared with 2013 (figure). A decrease in paediatric or maternal admissions because of fear of contracting Ebola has also been reported by Médecins Sans Frontières in Sierra Leone.5 We are concerned that women in need of reproductive health care because of pregnancy, childbirth, and post-partum related complications, including haemorrhage, eclampsia, obstructed labour, and abortion, will not have necessary and even life-saving care and attention. United Nations Population Fund estimates that 15% of the 800 000 women who will give birth in the next 12 months in Guinea, Liberia, and Sierra Leone could die of complications because of inade quate emergency obstetric care,4 and thousands of others could develop devastating pathological conditions, such as obstetric fistula. Increased support to fight Ebola is needed in Guinea, Liberia, and Sierra Leone coupled, with specific attention to reproductive health services. Adequate measures, including health system strengthening and community mobilisation coupled with an enabling environment for 904
569
123
2013
January– March
April– June
July– September
2014 Time period
Figure: Numbers of patients at the Matam maternity Hospital, Conakry, Guinea, in 2013 and 2014
www.thelancet.com Vol 384 December 13, 2014
We declare no competing interests.
*Alexandre Delamou, Rachel M Hammonds, Séverine Caluwaerts, Bettina Utz, Thérèse Delvaux [email protected] Centre de Formation et Recherche en Santé Rurale, Maferinyah, Guinea (AD); Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium (AD, RMH, BU, TD); Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (SC); Woman and Child Health Research Centre, Institute of Tropical Medicine, Antwerp, Belgium (AD, SC, BU, TD); and Médecins sans Frontières Operational Centre, Brussels , Belgium (SC) 1
2
3
4
5
WHO. Ebola response roadmap situation report. Oct 29, 2014. http://apps.who.int/iris/ bitstream/10665/137091/1/ roadmapsitrep22Oct2014_eng.pdf?ua=1. (accessed Nov 12, 2014). WHO Ebola Response Team. Ebola virus disease in west Africa—the first 9 months of the epidemic and forward projections. N Engl J Med 2014; 371: 1481–95. Piot P, Muyembe JJ, Edmunds WJ. Ebola in west Africa: from disease outbreak to humanitarian crisis. Lancet Infect Dis 2014; published online Oct 1. http://dx.doi.org/10.1016/S14733099(14)70956-9. UNFPA. Ebola wiping out gains in safe motherhood. Oct 16, 2014. http://www. unfpa.org/public/cache/offonce/home/ news/pid/18486;jsessionid=879EAD984815 2210299DB057BF867F13.jahia01 (accessed Nov 10, 2014). Médecins Sans Frontières. Sierra Leone: MSF suspends emergency pediatric and maternal services in Gondama. Oct 16, 2014. http:// www.doctorswithoutborders.org/article/ sierra-leone-msf-suspends-emergencypediatric-and-maternal-services-gondama (accessed Nov 12, 2014).
Provision of care for Ebola
710
October– December
provision of emergency obstetric care, need to be put in place urgently to avoid devastating short-term and long-term effects for thousands of women.
Hundreds of UK military and civilian staff will put themselves at some risk of infection when treating patients with Ebola in west Africa over the coming months, raising important questions about how they should best be cared for if they become infected. The cornerstones of treatment for Ebola are volume repletion, including use of intravenous fluids
Published Online December 1, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)62250-9
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2105
Correspondence
as necessary, careful monitoring of fluid and electrolyte balance, and management of complications such as secondary bacterial infection. 1 The UK Ministry of Defence is now running a unit at Kerrytown in Sierra Leone that is equipped and staffed to offer such care. However, this unit does not have facilities for ventilatory or renal support, which have been used in a handful of health-care workers evacuated to Europe or the USA during this outbreak.2 On November 7, 2014, we participated in a meeting of clinical experts in London convened by the Chief Medical Officer, Sally Davis, to review the evidence surrounding critical care in patients with Ebola. We started from the principle that any health-care worker who develops Ebola should be offered the best opportunity to make a full recovery based on available evidence and assessment of their individual circumstances. This assessment also needs to reflect the risks associated with evacuation from west Africa, the risks to carers of any invasive procedures, and the effect of care on wider health services. We concluded that early, aggressive, and well monitored supportive therapy, which the Kerrytown facility is ideally placed to provide, remains the key to successful treatment of patients with Ebola. There is very little available evidence for the use of critical care in the management of Ebola, and no evidence that addition of ventilatory or renal support would result in substantial overall benefit for patients who receive the optimum supportive care. We therefore agreed that we would not expect critical care support to be provided for patients with Ebola, either in-country or for those cases that are repatriated or imported. There might be a few situations in which critical care might offer particular benefit to the individual. Currently, only the Trexler isolators within the high-level isolation unit 2106
at the Royal Free Hospital (London, UK) offer suitable facilities where such treatment can be provided with reasonable safety and without affecting the general services of the National Health Service or requiring much additional training. We remain committed to keeping all aspects of the evidence on treatment of Ebola under regular review and will revise our recommendations as new evidence emerges. We declare no competing interests.
*Michael Jacobs, Mike Beadsworth, Matthias Schmid, Anne Tunbridge [email protected] Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK (MJ); Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK (MB); Infection & Tropical Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK (MS); and Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK (AT) 1
2
Marshall Lyon G, Mehta A, Varkey J, et al. Clinical care of two patients with Ebola virus disease in the United States. N Engl J Med 2014; published online Nov 12. DOI:10.1056/ NEJMoa1409838. Kreuels B, Wichmann D, Emmerich P, et al. A case of severe Ebola virus Infection complicated by Gram-negative septicemia. N Engl J Med 2014; published online Oct 22. DOI:10.1056/NEJMoa1411677.
Patient safety after partial and total knee replacement
owned by the UK Government. From April, 2014, going forward, industry also made a financial contribution to the NJR in return for postmarket surveillance data. Cobb also states that Justin Hunt and colleagues 2 stop short of commending unicompartmental knee replace ment compared with total knee replacement “to avoid conflict with the stream of registry publications promoting unicompartmental knee replacement over total knee replacement”. This comment also seeks to question the probity of the NJR, suggesting larger scale collusion is occurring. This assertion is also incorrect. Unique among joint registers, the NJR allows independent researchers to use the NJR dataset. The two papers that form the substance of Cobb’s argument 2,3 are exemplars of this process. Investigators of these studies, one of which was internal2 and the other independent, 3 both had access to the NJR dataset. They have contrasting arguments, but use different study designs and analysis methods. We were encouraged that The Lancet published both studies side by side2,3 to stimulate the debate that Cobb suggests the NJR wishes to close down. MP is Medical Director of the NJR and JMW is chair of the research sub-committee of NJR. MP reports fees from Johnson and Johnson.
*Martyn Porter, J Mark Wilkinson In his Comment (Oct 18, p 1405) about the controversies in prosthetic surgery for knee osteoarthritis,1 Justin Cobb makes several statements regarding the utility and focus of joint registries in general and specific allegations regarding the probity of the National Joint Registry for England, Wales, and Northern Ireland (NJR). These comments need redress. Cobb states that the NJR is industry-funded and implies that there is collusion to restrict access to unicompartmental knee replacement. This statement is incorrect. The NJR is funded by the tax-payer and
martynporter@hipkneeclinic Orthopaedic Department, Wrightington Hospital, Wigan WN6 9EP, UK (MP); and Department of Human Metabolism, University of Sheffield, Sheffield, UK (JMW) 1
2
3
Cobb JP. Patient safety after partial and total knee replacement. Lancet 2014; 384: 1405–07. Hunt LP, Ben-Shlomo Y, Clark EM, et al, on behalf of the National Joint Registry for England and Wales. 45-day mortality after 467 779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: an observational study. Lancet 2014; 384: 1429–36. Liddle AD, Judge A, Pandit H, Murray DW. Adverse outcomes after total and unicompartmental knee replacement in 101 330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet 2014; 384: 1437–45.
www.thelancet.com Vol 384 December 13, 2014
