Incorporating health workers' perspectives into a WHO guideline on personal protective equipment developed during an Ebola virus disease outbreak.

Background: Ebola virus disease (EVD) health facility transmission can result in infection and death of health workers. The World Health Organization (WHO) supports countries in preparing for and responding to public health emergencies, which often require developing new guidance in short timelines with scarce evidence. The objective of this study was to understand frontline physicians' and nurses' perspectives about personal protective equipment (PPE) use during the 2014-2016 EVD outbreak in West Africa and to incorporate these findings into the development process of a WHO rapid advice guideline. Methods : We surveyed frontline physicians and nurses deployed to West Africa between March and September of 2014. Results: We developed the protocol, obtained ethics approval, delivered the survey, analysed the data and presented the findings as part of the evidence-to-decision tables at the expert panel meeting where the recommendations were formulated within eight weeks. Forty-four physicians and nurses responded to the survey. They generally felt at low or extremely low risk of virus transmission with all types of PPE used. Eye protection reduced the ability to provide care, mainly due to impaired visibility because of fogging. Heat and dehydration were a major issue for 76% of the participants using goggles and for 64% using a hood. Both gowns and coveralls were associated with significant heat stress and dehydration. Most participants (59%) were very confident that they were using PPE correctly. Conclusion : Our study demonstrated that it was possible to incorporate primary data on end-users' preferences into a rapid advice guideline for a public health emergency in difficult field conditions. Health workers perceived a balance between transmission protection and ability to care for patients effectively while wearing PPE. These findings were used by the guideline development expert panel to formulate WHO recommendations on PPE for frontline providers caring for EVD patients in outbreak conditions.

Evidence-based guidelines for supportive care of patients with Ebola virus disease.

The 2013-16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients' reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70%, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief.

Effectiveness of Personal Protective Equipment for Healthcare Workers Caring for Patients with Filovirus Disease: A Rapid Review.

BACKGROUND: A rapid review, guided by a protocol, was conducted to inform development of the World Health Organization's guideline on personal protective equipment in the context of the ongoing (2013-present) Western African filovirus disease outbreak, with a focus on health care workers directly caring for patients with Ebola or Marburg virus diseases. METHODS: Electronic databases and grey literature sources were searched. Eligibility criteria initially included comparative studies on Ebola and Marburg virus diseases reported in English or French, but criteria were expanded to studies on other viral hemorrhagic fevers and non-comparative designs due to the paucity of studies. After title and abstract screening (two people to exclude), full-text reports of potentially relevant articles were assessed in duplicate. Fifty-seven percent of extraction information was verified. The Grading of Recommendations Assessment, Development and Evaluation framework was used to inform the quality of evidence assessments. RESULTS: Thirty non-comparative studies (8 related to Ebola virus disease) were located, and 27 provided data on viral transmission. Reporting of personal protective equipment components and infection prevention and control protocols was generally poor. CONCLUSIONS: Insufficient evidence exists to draw conclusions regarding the comparative effectiveness of various types of personal protective equipment. Additional research is urgently needed to determine optimal PPE for health care workers caring for patients with filovirus.

Clinical presentation of patients with Ebola virus disease in Conakry, Guinea.

BACKGROUND: In March 2014, the World Health Organization was notified of an outbreak of Zaire ebolavirus in a remote area of Guinea. The outbreak then spread to the capital, Conakry, and to neighboring countries and has subsequently become the largest epidemic of Ebola virus disease (EVD) to date. METHODS: From March 25 to April 26, 2014, we performed a study of all patients with laboratory-confirmed EVD in Conakry. Mortality was the primary outcome. Secondary outcomes included patient characteristics, complications, treatments, and comparisons between survivors and nonsurvivors. RESULTS: Of 80 patients who presented with symptoms, 37 had laboratory-confirmed EVD. Among confirmed cases, the median age was 38 years (interquartile range, 28 to 46), 24 patients (65%) were men, and 14 (38%) were health care workers; among the health care workers, nosocomial transmission was implicated in 12 patients (32%). Patients with confirmed EVD presented to the hospital a median of 5 days (interquartile range, 3 to 7) after the onset of symptoms, most commonly with fever (in 84% of the patients; mean temperature, 38.6°C), fatigue (in 65%), diarrhea (in 62%), and tachycardia (mean heart rate, >93 beats per minute). Of these patients, 28 (76%) were treated with intravenous fluids and 37 (100%) with antibiotics. Sixteen patients (43%) died, with a median time from symptom onset to death of 8 days (interquartile range, 7 to 11). Patients who were 40 years of age or older, as compared with those under the age of 40 years, had a relative risk of death of 3.49 (95% confidence interval, 1.42 to 8.59; P=0.007). CONCLUSIONS: Patients with EVD presented with evidence of dehydration associated with vomiting and severe diarrhea. Despite attempts at volume repletion, antimicrobial therapy, and limited laboratory services, the rate of death was 43%.

Systematic review of economic evaluations of preparedness strategies and interventions against influenza pandemics.

BACKGROUND: Although public health guidelines have implications for resource allocation, these issues were not explicitly considered in previous WHO pandemic preparedness and response guidance. In order to ensure a thorough and informed revision of this guidance following the H1N1 2009 pandemic, a systematic review of published and unpublished economic evaluations of preparedness strategies and interventions against influenza pandemics was conducted. METHODS: The search was performed in September 2011 using 10 electronic databases, 2 internet search engines, reference list screening, cited reference searching, and direct communication with relevant authors. Full and partial economic evaluations considering both costs and outcomes were included. Conversely, reviews, editorials, and studies on economic impact or complications were excluded. Studies were selected by 2 independent reviewers. RESULTS: 44 studies were included. Although most complied with the cost effectiveness guidelines, the quality of evidence was limited. However, the data sources used were of higher quality in economic evaluations conducted after the 2009 H1N1 pandemic. Vaccination and drug regimens were varied. Pharmaceutical plus non-pharmaceutical interventions are relatively cost effective in comparison to vaccines and/or antivirals alone. Pharmaceutical interventions vary from cost saving to high cost effectiveness ratios. According to ceiling thresholds (Gross National Income per capita), the reduction of non-essential contacts and the use of pharmaceutical prophylaxis plus the closure of schools are amongst the cost effective strategies for all countries. However, quarantine for household contacts is not cost effective even for low and middle income countries. CONCLUSION: The available evidence is generally inconclusive regarding the cost effectiveness of preparedness strategies and interventions against influenza pandemics. Studies on their effectiveness and cost effectiveness should be readily implemented in forthcoming events that also involve the developing world. Guidelines for assessing the impact of disease and interventions should be drawn up to facilitate these studies.

Global perspectives in breast milk contamination: infectious and toxic hazards.

Breast milk is the natural and optimal food for infants. In addition to meeting nutritional needs, breast milk provides numerous immunologic, developmental, psychologic, economic, and practical advantages. It is postulated that breast-feeding may also be related to the prevention of some adult health problems such as diabetes and coronary heart disease. Malnutrition among infants and young children, which remains one of the most severe global public health problems, is among the main reasons that the World Health Organization (WHO) so strongly supports breast-feeding. However, WHO recognizes the growing concern expressed by scientists, health professionals, environmentalists, and mothers about the potential risks posed by the presence of toxicants and infectious agents in breast milk. In this paper we review the main infectious hazards (tuberculosis, hepatitis B, and human immunodeficiency virus) and selected chemical hazards (tobacco, persistent contaminants) and the activities undertaken by WHO. We conclude that in cases where there is a high degree of pollution from chemical sources occurring simultaneously in a bacterially contaminated environment, the choice is not simply between polluted breast milk and risk-free substitutes. Rather, informed choice is based on assessing the known and unknown risks of artificial feeding versus the unknown, but potential, risks of chemical contamination of breast milk. Clearly, the possible toxicity of compounds requires further investigation. Of much greater importance, however, are effective measures to protect the environment for the entire population by controlling the use of these toxic products. Current scientific evidence does not support altering WHO's global public health recommendation of exclusive breast-feeding for 6 months followed by safe and appropriate complementary foods, with continued breast-feeding, up to 2 years of age or beyond.

Evaluación de los métodos de diagnóstico bacteriológico de fiebre tifoidea en pediatría / Evaluation of methods of bacteriologic diagnosis in children with typhroid fever

Comparamos la eficacia del cultivo de contenido duodenal (bilicultivo) por la cuerda encapsulada, médula ósea, heces y sangre en 325 pacientes de 2 a 13 años de edad con sospecha de fiebre tifoidea. Ciento cuarenta y cinco tuvieron S. typhi, 25 S. paratyphi A y 155 otros cuadros febriles no tíficos. El bilicultivo tuvo dos variantes: Grupo I: las cuerdas fueron retiradas a 3 horas de ingeridas y no se tomó el pH del extremo; Grupo II; las cuerdas fueron retiradas a las 4 horas, considerándose adecuadas aquellas con pH > - 5. La tolerancia global al procedimiento fue de 53% en los niños de 2 a 6 años y de 89% en niños de 7 a 13 (p < 0.005). La eficacia del mielocultivo (86%) fue mejor que la del coprocultivo (55%), el cultivo de contenido duodenal (54%) y el hemocultivo (42%) (p < 0.005). Los resultados con mielocultivo y coprocultivo fueron similares en los Grupos I y II. El cultivo de contenido duodenal fue más sensible en el Grupo II (66%) que en el primer grupo (42%) (p = 0.056). El mielocultivo es el método más efectivo para aislar S. typhi. El coproductivo parece ser más efectivo en niños que en adultos. El bilicultivo es útil en los niños que toleran el procedimiento (especialmente escolares)