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Concept: Kenema


Poor quality housing is an infringement on the rights of all humans to a standard of living adequate for health. Among the many vulnerabilities of those without adequate shelter is the risk of disease spread by rodents and other pests. One such disease is Lassa fever, an acute and sometimes severe viral hemorrhagic illness endemic in West Africa. Lassa virus is maintained in the rodent Mastomys natalensis, commonly known as the “multimammate rat,” which frequently invades the domestic environment, putting humans at risk of Lassa fever. The highest reported incidence of Lassa fever in the world is consistently in the Kenema District of Sierra Leone, a region that was at the center of Sierra Leone’s civil war in which tens of thousands of lives were lost and hundreds of thousands of dwellings destroyed. Despite the end of the war in 2002, most of Kenema’s population still lives in inadequate housing that puts them at risk of rodent invasion and Lassa fever. Furthermore, despite years of health education and village hygiene campaigns, the incidence of Lassa fever in Kenema District appears to be increasing. We focus on Lassa fever as a matter of human rights, proposing a strategy to improve housing quality, and discuss how housing equity has the potential to improve health equity and ultimately economic productivity in Sierra Leone. The manuscript is designed to spur discussion and action towards provision of housing and prevention of disease in one of the world’s most vulnerable populations.

Concepts: Freetown, Epidemiology, Viral hemorrhagic fever, Kenema District, Eastern Province, Sierra Leone, Kenema, Lassa fever, Sierra Leone


To the Editor: Schieffelin et al. (Nov. 27 issue) 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 . . .

Concepts: Ahmad Tejan Kabbah, Western Area Urban District, Viral hemorrhagic fever, Sierra Leone National Premier League, Kenema, Western Area, Freetown, Sierra Leone


 Ebola virus disease (EVD) in health workers (HWs) has been a major challenge during the 2014-15 outbreak. We examined factors associated with Ebola virus exposure and mortality in HWs in Kenema District, Sierra Leone.

Concepts: Viral hemorrhagic fever, Freetown, Malaise, Kenema District, Eastern Province, Sierra Leone, Ebola, Kenema, Sierra Leone


We rapidly assessed the health of Ebola virus disease (EVD) survivors in Kenema, Sierra Leone, by reviewing medical charts of all patients attending the Survivor Clinic of Kenema Government Hospital. Data were abstracted on signs and symptoms at every attendance. As of November 2015, a total of 621 attendances by 115 survivors with laboratory-confirmed EVD were made to the Survivor Clinic. Most (60.9%) survivors were women. Survivors' median age was 28 years (range 0.25-70 years). Survivors attended the clinic a median of 5 times (range 1-21 times) each, and the median time from EVD discharge to attendance was 261 days (range 4-504 days). The most commonly reported signs and symptoms among the 621 attendances were headache (63.1%), fever (61.7%), and myalgia (43.3%). Because health needs of EVD survivors are complex, rapid chart reviews at survivor clinics should be repeated regularly to assess the extent of illness and prioritize service delivery.

Concepts: Ebola, Incubation period, Kenema, Marburg virus, Freetown, Viral hemorrhagic fever, Hospital, Sierra Leone


Contact tracing in an Ebola virus disease (EVD) outbreak is the process of identifying individuals who may have been exposed to infected persons with the virus, followed by monitoring for 21 days (the maximum incubation period) from the date of the most recent exposure. The goal is to achieve early detection and isolation of any new cases in order to prevent further transmission. We performed a retrospective data analysis of 261 probable and confirmed EVD cases in the national EVD database and 2525 contacts in the Contact Line Lists in Kenema district, Sierra Leone between 27 April and 4 September 2014 to assess the performance of contact tracing during the initial stage of the outbreak. The completion rate of the 21-day monitoring period was 89% among the 2525 contacts. However, only 44% of the EVD cases had contacts registered in the Contact Line List and 6% of probable or confirmed cases had previously been identified as contacts. Touching the body fluids of the case and having direct physical contact with the body of the case conferred a 9- and 20-fold increased risk of EVD status, respectively. Our findings indicate that incompleteness of contact tracing led to considerable unmonitored transmission in the early months of the epidemic. To improve the performance of early outbreak contact tracing in resource poor settings, our results suggest the need for prioritized contact tracing after careful risk assessment and better alignment of Contact Line Listing with case ascertainment and investigation.This article is part of the themed issue ‘The 2013-2016 West African Ebola epidemic: data, decision-making and disease control’.

Concepts: Kenema District, Eastern Province, Sierra Leone, Kenema, Risk, Ebola, Incubation period, Sierra Leone, Epidemiology


The recent outbreak of the Ebola virus disease (EVD) in Sierra Leone has been characterized by the World Health Organization as one of the most challenging EVD outbreaks to date. The first confirmed case in Sierra Leone was a young woman who was admitted to a government hospital in Kenema following a miscarriage on 24 May 2014. On 5 January 2015, intensified training for an EVD response project was initiated at the medical university of Sierra Leone in Jui. To understand the knowledge, attitudes, practices, and perceived risk of EVD among the public, especially after this training, a rapid assessment was conducted from 10 to 16 March 2015.

Concepts: Biological warfare, Ebola, Kenema, Incubation period, Viral hemorrhagic fever, Freetown, Understanding, Sierra Leone


I will always remember 2014 as the year that Ebola virus took over west Africa and thus, much of my time and life. The epicenters of the outbreak in Guinea and Sierra Leone are areas that I have worked in since 1996 on projects to build capacity to combat another viral hemorrhagic disease, Lassa fever, with the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), Tulane University, and others. I spent a lot time and made many friends and colleagues in the Forest Region of Guinea and the Kenema District of Sierra Leone, both at the heart of this Ebola outbreak. I have also responded to quite a few Ebola and Marburg virus outbreaks over the years. Therefore, it was natural that, when Ebola hit west Africa, I would get involved. Indeed, since April of 2014, it has pretty much been all Ebola all of the time, with me cycling constantly between my home in Lima, Peru and west Africa, Geneva, and Washington, consulting primarily with the WHO and the US Government.

Concepts: Kenema, Ghana, Guinea, West Africa, Ebola, Liberia, Viral hemorrhagic fever, Sierra Leone


In July of 2014, I was working as a nurse for a small non-governmental organization in the Sierra Leone capital, Freetown, as the Ebola virus disease (EVD) epidemic grew in the east of the country. The reason that I had decided to study tropical nursing after completing my basic registered nurse training was because I wanted to apply my professional skills where they were most needed. Thus, it was not difficult for me to decide to work in the eastern city of Kenema, which at the time, was at the heart of the epidemic and the site of one of two Ebola treatment units (ETUs) in Sierra Leone. The situation in Kenema was tense; the regular nurses at the ETU were on strike over issues related to pay, but also, understandably, there was a strong undercurrent of fear, because they had already seen quite a few coworkers contract EVD, many fatally. The hospital management and expatriate World Health Organization (WHO) doctors were struggling desperately to keep the staffing up to something close to a safe and effective level.

Concepts: Viral hemorrhagic fever, Ahmad Tejan Kabbah, Western Area, Sierra Leone National Premier League, Kenema, Nursing, Freetown, Sierra Leone


Health care workers (HCWs) are at increased risk for infection in outbreaks of Ebola virus disease (Ebola). To characterize Ebola in HCWs in Sierra Leone and guide prevention efforts, surveillance data from the national Viral Hemorrhagic Fever database were analyzed. In addition, site visits and interviews with HCWs and health facility administrators were conducted. As of October 31, 2014, a total of 199 (5.2%) of the total of 3,854 laboratory-confirmed Ebola cases reported from Sierra Leone were in HCWs, representing a much higher estimated cumulative incidence of confirmed Ebola in HCWs than in non-HCWs, based on national data on the number of HCW. The peak number of confirmed Ebola cases in HCWs was reported in August (65 cases), and the highest number and percentage of confirmed Ebola cases in HCWs was in Kenema District (65 cases, 12.9% of cases in Kenema), mostly from Kenema General Hospital. Confirmed Ebola cases in HCWs continued to be reported through October and were from 12 of 14 districts in Sierra Leone. A broad range of challenges were reported in implementing infection prevention and control measures. In response, the Ministry of Health and Sanitation and partners are developing standard operating procedures for multiple aspects of infection prevention, including patient isolation and safe burials; recruiting and training staff in infection prevention and control; procuring needed commodities and equipment, including personal protective equipment and vehicles for safe transport of Ebola patients and corpses; renovating and constructing Ebola care facilities designed to reduce risk for nosocomial transmission; monitoring and evaluating infection prevention and control practices; and investigating new cases of Ebola in HCWs as sentinel public health events to identify and address ongoing prevention failures.

Concepts: Eastern Province, Sierra Leone, Kenema, Marburg virus, Public health, Health care, Ebola, Sierra Leone, Viral hemorrhagic fever


There is a paucity of data on the etiologies and outcomes of febrile illness in rural Sierra Leone, especially in the Lassa-endemic district of Kenema. We conducted a retrospective study of patients with subjective or documented fever (T ≥ 38.0°C) who were admitted to a rural tertiary care hospital in Kenema between November 1, 2011 and October 31, 2012. Of 854 patients admitted during the study period, 429 (50.2%) patients had fever on admission. The most common diagnoses were malaria (27.3%), pneumonia (5.1%), and Lassa fever (4.9%). However, 53.4% of febrile patients had no diagnosis at discharge. The in-hospital mortality rate was 18.9% and associated with documented temperature ≥ 38.0°C (adjusted odds ratio [AOR] = 2.89, P = 0.001) and lack of diagnosis at discharge (AOR = 2.04, P = 0.03). Failure to diagnose the majority of febrile adults and its association with increased mortality highlight the need for improved diagnostic capacity to improve patient outcomes.

Concepts: Freetown, Yellow fever, Lassa fever, Kenema District, Eastern Province, Sierra Leone, Kenema, Diagnosis, Sierra Leone