First use of intravenous artesunate in Liberia and effect on patient mortality relative to artemeter and quinine: a cross-sectional study

Background: Intravenous artesunate reduces mortality by 35% relative to intravenous quinine. In 2010, WHO changed guidelines favouring intravenous artesunate, yet wide-scale adoption lags. In April, 2012, the Clinton Foundation with the Liberian Health Ministry brought intravenous artesunate into Liberia's busiest paediatric centres, Redemption and JDJ. The Foundation reached out to the International Rescue Committee, a non-governmental organisation that supported the hospitals, to implement the change. Methods: We created a JDJ decision support instrument to guide and document proper intravenous artesunate administration. 4 months later, in July–October, 2012, we determined the proportion of children aged 1–16 years who were admitted for malaria with a positive rapid diagnostic test or malaria smear, the proportion who received intravenous artesunate, and the proportion who died. We compared these findings with the same period 1 year earlier when artesunate was not available. Findings: From July to October, 2011, 707 patients were admitted to JDJ for malaria with 67 deaths, giving a mortality rate of 0·0950. 1 year later, 811 patients were admitted with 48 deaths, giving a mortality rate of 0·059—a decrease risk of 0·6455 (95% CI 0·4514–0·9231, p=0·0155). In 2011, no patients received intravenous artesunate, 650 (92%) intramuscular artemether, and 21 (3%) intavenous quinine. 1 year later, 632 (78%) of malaria patients received intravenous artesunate and 178 (22%) intramuscular artemether. Interpretation: We show how malaria treatment can be changed quickly and effectively towards contemporary care standards. Our findings support the probable benefit of intravenous artesunate in Liberia and the need for the Ministry of Health to ensure artesunate supply and provider friendly treatment guidelines. Funding: None

Ebola virus disease contact tracing activities, lessons learned and best practices during the Duport Road outbreak in Monrovia, Liberia, November 2015

<div><p>Background</p><p>Contact tracing is one of the key response activities necessary for halting Ebola Virus Disease (EVD) transmission. Key elements of contact tracing include identification of persons who have been in contact with confirmed EVD cases and careful monitoring for EVD symptoms, but the details of implementation likely influence their effectiveness. In November 2015, several months after a major Ebola outbreak was controlled in Liberia, three members of a family were confirmed positive for EVD in the Duport Road area of Monrovia. The cluster provided an opportunity to implement and evaluate modified approaches to contact tracing.</p><p>Methods</p><p>The approaches employed for improved contact tracing included classification and risk-based management of identified contacts (including facility based isolation of some high risk contacts, provision of support to persons being monitored, and school-based surveillance for some persons with potential exposure but not listed as contacts), use of phone records to help locate missing contacts, and modifications to data management tools. We recorded details about the implementation of these approaches, report the overall outcomes of the contact tracing efforts and the challenges encountered, and provide recommendations for management of future outbreaks.</p><p>Results</p><p>165 contacts were identified (with over 150 identified within 48 hours of confirmation of the EVD cases) and all initially missing contacts were located. Contacts were closely monitored and promptly tested if symptomatic; no contacts developed disease. Encountered challenges related to knowledge gaps among contact tracing staff, data management, and coordination of contact tracing activities with efforts to offer Ebola vaccine.</p><p>Conclusions</p><p>The Duport Road EVD cluster was promptly controlled. Missing contacts were effectively identified, and identified contacts were effectively monitored and rapidly tested. There is a persistent risk of EVD reemergence in Liberia; the experience controlling each cluster can help inform future Ebola control efforts in Liberia and elsewhere.</p></div

Contact tracing components, challenges, and solutions from the Duport Road EVD outbreak, November–December, 2015.

<p>Contact tracing components, challenges, and solutions from the Duport Road EVD outbreak, November–December, 2015.</p

Contacts by risk status, Duport Road EVD outbreak, Montserrado County, November–December 2015.

<p>*Includes two pediatric patient contacts who died during the monitoring period due to underlying illnesses.</p

Contact tracing results from the Duport Road EVD outbreak, November–December, 2015.

<p>This table displays the summary information for the 168 contacts monitored in response to the Duport Road EVD outbreak.</p

Contact status by day of monitoring, Duport Road EVD outbreak, Montserrado County, November–December 2015.

<p>Contact status by day of monitoring, Duport Road EVD outbreak, Montserrado County, November–December 2015.</p

Montserrado County EVD contact tracing structure and information flow for Duport Road outbreak, November–December, 2015.

<p>Montserrado County EVD contact tracing structure and information flow for Duport Road outbreak, November–December, 2015.</p

Key recommendations from the contact tracing activities of the Duport Road EVD outbreak, Montserrado County, November–December 2015.

<p>Key recommendations from the contact tracing activities of the Duport Road EVD outbreak, Montserrado County, November–December 2015.</p

Sample contact tracing dashboard (de-identified) used in the Duport Road EVD outbreak, Montserrado County, November–December 2015.

<p>Sample contact tracing dashboard (de-identified) used in the Duport Road EVD outbreak, Montserrado County, November–December 2015.</p