Beyond Ebola treatment units: severe infection temporary treatment units as an essential element of Ebola case management during an outbreak

Abstract

In the course of the Ebola outbreak in West Africa that was witnessed since early 2014, the response mechanisms showed deficits in terms of timeliness, volume and adequacy. The authors were deployed in the Ebola campaign in the West African country Liberia, where by September 2014 the changing epidemiological pattern made reconsiderations of guidelines and adopted procedures necessary. A temporary facility set up as a conventional Ebola Treatment Unit in the Liberian capital Monrovia was re-dedicated into a Severe Infections Temporary Treatment Unit. This facility allowed for stratification based on the nosocomial risk of exposure to Ebola virus for a growing subgroup of admitted patients that in the end would turn out as Ebola negative cases. At the same time, adequate diagnostic measures and treatment for the non-Ebola conditions of these patients could be provided without compromising work safety of the employed staff. The key elements of the new unit comprised a Suspect Cases Area similar to that of conventional Ebola treatment units for newly arriving patients, an Unlikely Cases Area for patients with a first negative Ebola PCR result, and a Confirmed Negative Cases Area for patients in whom Ebola could be ruled out. The authors, comprising representatives of the Liberian Ministry of Health and Social Welfare, as well as infectious disease specialists from the German Ebola Task Force are presenting key features of the adapted concept, and are highlighting its relevance in raising acceptance for outbreak counter-measures within the population at stake.

Keywords: Case management; Ebola; Ebola treatment unit; Epidemiology; Infectious disease unit; Isolation; Liberia; Nosocomial infection; SITTU; Severe infections teamporary treatment unit.

Fig. 1

The concept of an optimized ETU. The Severe Infection Temporary Treatment Unit (SITTU) in Monrovia consisted of a Suspect Cases Area, an Unlikely Cases Area and a Confirmed Negative Cases Area, thereby representing only a part of the idealised facility pictured above (lower half of the image). In the Monrovia scenario the complementary parts (as shown in the upper half of the Fig. 1) were represented by pre-existing conventional ETUs near the SITTU. The two additional areas (Unlikely Cases Area and Confirmed Negative Cases Area, in the lower half of the figure) allow an allocation of patients according to their risk of not being infected by Ebola virus with the aim of reducing the risk of nosocomial Ebola virus infections and facilitating an adapted medical care

Fig. 2

Interior View of the SITTU. The aluminium and sheeting structure is built on sealed concrete foundations. In the cubicles on the left, each compartment is dedicated to one individual patient. Within these cubicles only strictly personalized items such as chairs, drip stands and closets are placed. Individual buckets were provided for personal hygiene and sanitation to avoid mixing of the patients in lavatories or toilets. The patients were requested not to move within the structure

Fig. 3

The German Severe Infections Temporary Treatment Unit. The German Unit at the SKD Football Stadium in Monrovia, Liberia, previously designed as a regular Ebola Treatment Unit, now re-designed into a Severe Infection Temporary Treatment Unit, representing the lower half of Fig. 1. In the course of increasing evidence of non-Ebola virus infection patients are referred between wards from left to right. In case of a positive Ebola virus PCR result patients are referred to a conventional ETU nearby. Please note that the banners at the fence are still presenting an ETU; these banners date back to the start of construction of the facility, when it was still meant to be an ETU. After rededication into a SITTU the banners remained unchanged

Fig. 4

Patient Outcome at the SITTU. Outcome variable for patients is categorized as “died” for all patients that were admitted alive and died within the SITTU, “home” for all patients that could be released into their community, requiring none or minimal further medical care, and “transferred” for all patients that were transferred to other health care facilities for specialized care

Fig. 5

Age Distribution of Admitted SITTU Patients. The histogram with a bin width of 5 years shows the age distribution for each operational calendar month

Fig. 6

Length of Admission over Time at the SITTU. The histogram with a bin width of 2 days shows the patient counts on the y-axis over length of admission time on the x-axis, for each operational calendar month