WHO To Revisit Guidelines On Ebola Survivors’ Care; Study Finds 5-fold Higher Mortality

New data revealing that survivors of Guinea’s 2013-16 Ebola outbreak were five times more likely to die within the first year after recovery, as compared to the general population, suggests a need to revisit WHO guidance on Ebola survivors’ monitoring and care, a top WHO official said on Friday.

The findings were part of a study published in Lancet Infectious Diseases earlier this week. The WHO-led study also found that people hospitalized with the Ebola virus for a longer period had higher overall mortality rates than those with shorter stays. Beyond a year, however, the study of some 1130 survivors found that mortality rates of survivors and the general population evened out. The study also pointed to kidney failure as the most common cause of death.

The findings have many implications for monitoring and treating survivors of the current outbreak in the Democratic Republic of the Congo, said Professor Judith Glynn, a senior author of the study from the London School of Hygiene & Tropical Medicine.

Siah Tamba puts on a light personal protective equipment (PPE). She is an Ebola survivor who now works at the Ebola treatment unit (ETU) in Sinje, Grand Cape Mount, Liberia, after losing her mother, sister, and daughter. The facility is operated by the International Organization for Migration (IOM) in partnership with Liberia's Ministry of Health and Social Welfare (MOHSW) and supported by USAID's Office of U.S Foreign Disaster Assistance. It opened with a capacity of 10 beds, but can rapidly scale to provide care to up to 50 people. The ETU is staffed with 23 medical professionals from Kenya, South Africa, Tanzania, Uganda and Ukraine, as well as 114 Liberians from Grand Cape Mount county, who were recruited and trained to offer clinical and non-clinical care within the facility. The staff received training from the World Health Organisation (WHO) and the MOHSW, and experienced hands-on training at the IOM-managed ETU in Tubmanburg, Bomi County, Liberia.
Ebola survivor dons protective gear to meet and support a patient currently undergoing treatment.

“Our results could help to guide current and future survivors’ programmes and the prioritisation of funds in resource-constrained settings. For example, those hospitalised with Ebola for longer may be at greater risk, and could be specifically targeted,” Glynn said in a statement.

“As the evidence increases on Ebola survivors it might be good to revisit the Ebola CRF,” tweeted Sylvie Briand, director of epidemic and pandemic diseases at WHO, referring to the protocols that guide monitoring, care and treatment.  Currently, interim WHO guidelines on caring for Ebola survivors do not call out kidney failure as a high risk.

While a range of chronic symptoms have been previously reported in Ebola survivors, this was the first study to systematically track and document mortality rates among Ebola patients after they successfully underwent treatment and were discharged.

The study followed up on survivors in Guinea, the first country hit by the 2013-2016 West African Ebola outbreak, for a year and nine months after they were discharged from treatment centers. In the first year (2015), some 55 people died, five times more than the 11 people who might have been expected to die based on mortality rates in the general population. But in the subsequent nine months of 2016, when the study continued, mortality did not differ between Ebola survivors and others.

Because few detailed medical records exist, researchers relied on interviews with family members as the main source of information. Based on reported symptoms, kidney failure was the suspected cause of death in 37 out of 55 cases. Researchers stressed that the lack of documentation available to rule out other causes was a limiting factor in their findings.

“The research suggests that we need to continue supporting those recovering from Ebola and provide health care to them long after they have recovered from Ebola virus disease,” Josie Golding a senior officer at Wellcome Trust told Health Policy Watch.

“And I think that we need to consider other variables that can impact patients recovering from Ebola. As observed in DRC, people affected by Ebola are often stigmatised. We must better understand how this can impact on the health of those survivors in terms of access to healthcare.”

Finally, Golding said, researchers need to explore the long-term impacts of vaccination and treatments that have been become available since the Guinea outbreak. “We need to understand how long people are protected from Ebola, or what the impact vaccination can have in pregnant women.”

Notably Guinea’s Ebola victims did not receive the new WHO-prequalified Ebola treatments that are now being used in the DRC.

Infections Now Top 3000 Since August 2018

As of 4 September another milestone in the DRC epidemic had been passed as WHO reported 3054 Ebola cases  (2945 confirmed and 109 probable) since the outbreak began in August 2018, with 2052 deaths and 914 survivors, for a survival rate of about 30%.

In the latest report posted by WHO Friday evening, 57 new cases had been reported over the past week, slightly less than the average of 77 new cases in the weeks of August. However, while transmission in hotspots such as the Beni Health Zone in the province of North Kivu show signs of easing, “new hotspots are emerging elsewhere,” warned the WHO report. The epicenter of the outbreak has extended across the provinces of North Kivu and Ituri. The areas stretch along DRC’s long and porous border with the neighboring countries of Rwanda, Uganda, Burundi and South Sudan, which have been on high alert for the past few months, with several cases of transmission spilling over into neighboring Uganda.

Funding Shortfalls, Insecurity Continue to Plague Response

Funding shortages continue to plague the response. WHO has asked for an infusion of US$287 million to fund the core public health response to the epidemic between July and December 2019, but so far only about 45 million of those funds have been received and pledges will only fund response until the end of September, said WHO, which has appealed to donors to urgently provide more support.  On Thursday, USAID pledged some US$21 million more to the Ebola effort, bringing the total USAID funding for the DRC outbreak to US$158 million.

In a visit earlier this week to DRC, UN Secretary General Antonio Guterres also appealed to donors to follow through on their commitments urgently; “Ebola cannot wait, if the response is interrupted by one week, we might lose the battle,” he said in an interview broadcast over Twitter.

Guterres also said that more needed to be done to contain the violence that has plagued disease control efforts, due to the activities of armed militias operating in the areas of North Kivu, one of the epicenters of the epidemic.

“Combating Ebola requires freedom of movement, access, security,” the UN leader also observed, during a visit to an Ebola Treatment Center in Mangina, a rural municipality in Beni territory, North-Kivu province, where the first cases of Ebola was been detected over a year ago.

He said that increase cooperation between UN peacekeepers and DRC armed forces was necessary to overcome threats of “terrorist acts”. But efforts should also be intensified to demobilize local armed groups and reintegrate them into the civilian population.

Elaine Ruth Fletcher contributed reporting to this story.

Image Credits: UNMEER/Martine Perret 2015.