Day 43

28.02.2015

The majority of patients in the Ebola holding unit at Connaught hospital now thankfully do not have Ebola.  Any number of other conditions can cause the symptoms of fever, nausea, vomiting, diarrhea, myalgias, headache, fatigue that fit the Ebola case definition.  Our team clinically diagnosed many other conditions – tuberculosis, malaria, tetanus, diabetes ulcers, typhoid, malignancy, meningitis, HIV.  ‘Clinical diagnosis’ is the key phrase, given that the only laboratory testing done on the patients during their typical 24 – 48 hour stay in the holding unit is a blood test for Ebola Zaire Virus and malaria.  Tragically, patients in the holding unit sometimes die of a treatable condition while awaiting their negative Ebola PCR result.

The official reported prevalence of HIV in Sierra Leone is remarkably low compared to many other areas in sub-Saharan Africa – only 1.5% general prevalence, with a slightly higher prevalence of 4% in the capital city, Freetown.  Seeing patients in the general Connaught Hospital wards, where HIV prevalence is more like 50%, has made many of us clinicians suspicious of those low reported numbers.  After several weeks of seeing patients in the Ebola holding unit with AIDS defining illnesses such as advanced Kaposi’s Sarcoma and severe esophageal candidiasis, I began to wonder if we were missing an opportunity to diagnose HIV in our Ebola holding unit patients.  I floated the idea by the King’s leadership team, who enthusiastically supported the idea.   The idea gathered serious momentum after a short, productive meeting with the young and energetic Dr. Zikan Koroma, HIV director at Connaught Hospital, and the HIV counseling and testing national coordinator, Mariama Conteh. I soon developed a deep respect and regard for these two HIV champions.

The time was ripe for such a program.  With fewer Ebola cases in the unit, there is less risk to staff by adding on a lab test that could expose them to a patient’s blood. Clinical efforts are now transitioning from crisis control to system improvement.  Also, new and intriguing information is emerging that patients with Ebola and HIV coinfection might have a different clinical course of Ebola disease, so knowing the HIV status of patients in the Ebola holding unit would have important clinical and public health implications.

So instead of managing loads of patients with Ebola (I had personal contact with only one confirmed case on my Monday call shift), I ran training classes for rapid bedside diagnosis of HIV.  The concept was simple: routine, rapid, opt-out HIV screening would be performed by local nursing staff whenever a patient was admitted to the Ebola holding unit.  The nurse performing the test would obtain informed consent and provide abbreviated pre-test and post-test counseling.  Positive patients would be linked directly to HIV care upon discharge; ambulatory patients would be walked directly from the Ebola decontamination area to the on-site Connaught HIV clinic; patients needing additional inpatient care would be seen the next day on the general ward by the HIV director, Dr. Zikan Koroma. 

Although HIV medications and treatment is free in Sierra Leone, the majority of patients who have been diagnosed with HIV are “defaulters”, the local word used for patients not on treatment.  This is a loaded term, directly placing blame and fault on the patient.  In reality, the reason why a patient “defaults” on her/his HIV medication is multifactorial.  Patient privacy is a loose term here.  Patients coming to the HIV clinic at Connaught Hospital sit together on a bench under an awning; a nurse comes to the door and calls out a patient’s name.  A typical visit to the clinic consists only of a nurse dolling out 30 days of medication.  Transportation to/from HIV clinics can be expensive and difficult.  And although HIV medication is free, many other aspects of care are not.  For example, chest Xrays are not free, despite the fact that about 30% of patients with tuberculosis are co-infected with HIV.  And stigma against HIV-infected persons is rife.

 

'Pharmacy' at the HIV clinic at Connaught Hospital.  Paper records only, no electronic medical records here.

Antiretrovirals available to treat HIV in Sierra Leone.

Nonetheless, many people with HIV in Sierra Leone find a way to overcome these obstacles and get to clinic and take their medications.  Knowledge is power; I am firmly convinced.  We decided the benefits of giving a patient the diagnosis of HIV outweighed the potential harms.

The training was an enormous success.  The unit nursing staff are extremely eager to learn.  Each training session was 4 hours in duration and consisted of a short introductory lecture on HIV/AIDS basics and a lecture on the concepts, strategies, and talking points of informed consent, pre-test and post-test counseling.  Laboratory staff from the HIV clinic came with rapid diagnostic HIV kits and each nurse performed the testing on positive and negative blood samples.  The nurses took notes during the lectures and requested more information about HIV.  Each nurse proudly took home an official, laminated Certificate of Completion of Training in HIV Testing and Counseling in Emergency Settings at Connaught Hospital.

The first day of HIV testing in the unit diagnosed 2 of 5 patients with HIV.  Each of the HIV-infected patients was successfully linked to care at the HIV clinic on discharge.

Ebola holding unit nurses learning how to perform HIV rapid diagnostic testing.

The rapid HIV diagnostic kits that are used to screen for HIV in Sierra Leone; these kits each require a drop of patient's blood, obtained by fingerprick, and can be done at bedside.  Results are obtained in 10-20 minutes.

Day 34

19.2.2015

Safe burial procedures are crucial to stopping the Ebola epidemic. Corpses are sealed in body bags by workers in full personal protective equipment (PPE) and buried in secure graves. The current official policy from the Sierra Leone Ministry of Health is that every corpse, regardless of cause of death, should be given a safe “medical” burial. Here, the interests of public health, guarding the public against possible Ebola transmission from infected corpses, often collides with that of mourning friends and family, who typically desire a traditional burial in the family plot.

Connaught Hospital, the tertiary referral health center where I’ve been volunteering in Freetown, is positioned next door to the Connaught Mortuary.  I had heard recent rumors that several bodies had been taken out of the Connaught Mortuary by family members to be buried.  It was unclear whether this was being done with the mortuary’s permission or knowledge. I decided to investigate. 

Through a contact who worked with the non-governmental organization Concern, the group responsible for overseeing burials in the greater Freetown area, I linked up with the burial team that was scheduled to come to the Connaught Ebola Holding Unit on Thursday, my day off.  We had two corpses in the unit’s morgue that morning.  The burial team donned full PPE and brought out the two bodies, placing them in the back of an open pick-up truck.  They then decontaminated, put their used PPE in garbage bags, tossed the open bags on top of the bodies and drove around the block to the Connaught Mortuary to see if there were any bodies there to pick up. I followed the truck in a separate car. I couldn’t help but notice that the garbage bags of used PPE were jostling precariously on the rough roads.  Pedestrians weaved in and out of the slow moving traffic, oblivious to the nature of the unsecured cargo.

Following the burial team, in heavy traffic with pedestrians brushing against the vehicles.  Two bodies in body bags lie underneath the open yellow bag of used PPE in the back of the open pick-up truck.

At the mortuary, I introduced myself to the manager, explaining that I was interested to learn more about the burial process during the Ebola outbreak.  I was graciously offered a chair in his cramped office. That’s when things got a bit bizarre.  The manager was in conversation with family representatives of several people who had just died in a motor vehicle accident. The families were petitioning for the bodies to be released for a private funeral.  During the discussion, a woman walked into the office to decant some formaldehyde from a large container in the back of the room.  Possibly seeing my puzzlement, the mortuary director explained it was for ‘body preservation’ happening in the next room.  Odd, given current policy dictates that all bodies be buried immediately. The conversation between the mortuary manager and the family representative dragged on.  Ultimately the family was told that they would need to go the next day to the command center to obtain the results from the oral swab sample for Ebola.  If the result was negative, they would have the option of bringing an official negative Ebola death certificate back to the mortuary in order to collect the body. The unspoken, but clear, implication was that this service would require a hefty fee. 

From this brief exchange, it was made very clear that not all bodies in Freetown are being given safe ‘Ebola burials’.  One might argue that this policy is not necessary – people continue to die from many causes, not just Ebola.  However, it is impossible to know what most people die of – the oral swabs to detect Ebola in corpses are notoriously insensitive and autopsies are strictly forbidden.  The potential public health consequences of a traditional funeral of a person infected with Ebola are enormous: One funeral where traditional burial practices are performed can spread the virus to hundreds.  Each week, the Ebola Situation Report by the World Health Organization reports tens of known unsafe burials in Sierra Leone, a number that is almost certainly a vast underestimate.

The burial team picked up one more body at the mortuary, and then we got back in the trucks for the short drive to cemetery. 

King Tom cemetery is a very old graveyard located in the heart of Freetown, which borders the city dump.  When the Ebola epidemic hit, city officials offered a small area in the cemetery for the Safe Burials.  Soon, the plot was full.  The rational next step was to make more space by plowing into the city dump. 

When we arrived that afternoon an enormous Caterpillar excavator was moving soil to carve out more usable land in the western corner of the cemetery. About 10 bodies in white body bags were already lined up by ready graves, awaiting burial.  The team that I had been following drove down into the area of the open graves. The team again donned full PPE and unloaded the bodies, placing each one by a single grave. 

King Tom cemetery, pushing up against the the rubbish of the city dump.

A small crowd of onlookers had gathered at the mound at the end of the road. I recognized the brother-in-law of one of our patients that had died the evening before, when I was on call.  The oral swab had come back negative for Ebola, which was small comfort to the family. I could hear their wails of grief. 

Each body bag was placed into a single grave that had been draped with a clean white sheet.  The burial team pulled the sheet over the body, placed a number of short sticks in an orderly fashion over it and then began the physical labor of shoveling in the earth.  An imam standing with the family raised his hands, chanting a melodic prayer.

Just beyond the fresh graves, the rubbish heaps of King Tom city dump are visible, pushing against the flimsy barrier between cemetery and landfill.  On this side of the fence, separated by mere inches, the small mounds that mark full graves stretch for hundreds of meters in all directions.

Freshly dug graves, soon to be filled, in King Tom cemetery, Freetown, Sierra Leone