Ebola in Freetown Area, Sierra Leone — A Case Study of 581 Patients

To the Editor:

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 Hastings 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 virus 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 of 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 admission were fatigue, anorexia, fever, vomiting and nausea, diarrhea, muscle pain, joint pain, and headache. On average, patients were admitted 3 or 4 days after the onset of 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 S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org): For 72 hours after admission, all patients receive 1 g of ceftriaxone intravenously 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) intravenously every 8 or 12 hours. All patients also receive 10 mg of vitamin K and 160 mg of artemether intramuscularly immediately on admission, 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 needed for nausea or vomiting. After the first 3 days, continuing therapy includes a 400-mg metronidazole 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 tablet every 12 hours, and one capsule of ImmunoBoost nutrition supplement (Novopharm Formulations) 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 package of interventions. The effectiveness of this treatment approach will need to be validated with clinical research at other Ebola treatment facilities.

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]edu

M’baimba Idris, M.B., Ch.B.

Henry Bangura, B.Sc.

Mohamed Boie-Jalloh, M.B., Ch.B.
34 Military Hospital at Wilberforce, Freetown, Sierra Leone

Joseph M. Lamin, M.Sc.
Mercy Hospital Research Laboratory, Bo, Sierra Leonee

Santigie Sesay, M.B., M.P.H.
Ministry of Health and Sanitation, Freetown, Sierra Leone

Foday Sahr, M.B., Ch.B., D.Sc.
34 Military Hospital at Wilberforce, Freetown, Sierra Leone

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