Uncrewed #aircraft #systems versus #motorcycles to deliver laboratory #samples in west #Africa: a comparative economic study (Lancet Glob Health, abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

Lancet Glob Health. 2020 Jan;8(1):e143-e151. doi: 10.1016/S2214-109X(19)30464-4.

Uncrewed aircraft systems versus motorcycles to deliver laboratory samples in west Africa: a comparative economic study.

Ochieng WO1, Ye T2, Scheel C2, Lor A2, Saindon J3, Yee SL2, Meltzer MI4, Kapil V2, Karem K2.

Author information: 1 Karna LLC, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA. Electronic address: ocu9@cdc.gov. 2 Office of the Director, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA. 3 Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA. 4 Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.




Transportation of laboratory samples in low-income and middle-income countries is often constrained by poor road conditions, difficult geographical terrain, and insecurity. These constraints can lead to long turnaround times for laboratory diagnostic tests and hamper epidemic control or patient treatment efforts. Although uncrewed aircraft systems (UAS)-ie, drones-can mitigate some of these transportation constraints, their cost-effectiveness compared with land-based transportation systems is unclear.


We did a comparative economic study of the costs and cost-effectiveness of UAS versus motorcycles in Liberia (west Africa) for transportation of laboratory samples under simulated routine conditions and public health emergency conditions (based on the 2013-16 west African Ebola virus disease epidemic). We modelled three UAS with operational ranges of 30 km, 65 km, and 100 km (UAS30, UAS65, and UAS100) and lifespans of 1000 to 10 000 h, and compared the costs and number of samples transported with an established motorcycle transportation programme (most commonly used by the Liberian Ministry of Health and the charity Riders for Health). Data for UAS were obtained from Skyfire (a UAS consultancy), Vayu (a UAS manufacturer), and Sandia National Laboratories (a private company with UAS research experience). Motorcycle operational data were obtained from Riders for Health. In our model, we included costs for personnel, equipment, maintenance, and training, and did univariate and probabilistic sensitivity analyses for UAS lifespans, range, and accident or failures.


Under the routine scenario, the per sample transport costs were US$0·65 (95% CI 0·01-2·85) and $0·82 (0·56-5·05) for motorcycles and UAS65, respectively. Per-sample transport costs under the emergency scenario were $24·06 (95% CI 21·14-28·20) for motorcycles, $27·42 (95% CI 19·25-136·75) for an unadjusted UAS model with insufficient geographical coverage, and $34·09 (95% CI 26·70-127·40) for an adjusted UAS model with complementary motorcycles. Motorcycles were more cost-effective than short-range UAS (ie, UAS30). However, with increasing range and operational lifespans, UAS became increasingly more cost-effective.


Given the current level of technology, purchase prices, equipment lifespans, and operational flying ranges, UAS are not a viable option for routine transport of laboratory samples in west Africa. Field studies are required to generate evidence about UAS lifespan, failure rates, and performance under different weather conditions and payloads.



Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.

PMID: 31839129 DOI: 10.1016/S2214-109X(19)30464-4

Keywords: West Africa; Infectious diseases; Society.


A meta-analysis of #clinical #studies conducted during the West #Africa #Ebola virus disease #outbreak confirms the need for randomized control groups (Sci Transl Med., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

Sci Transl Med. 2019 Nov 27;11(520). pii: eaaw1049. doi: 10.1126/scitranslmed.aaw1049.

A meta-analysis of clinical studies conducted during the West Africa Ebola virus disease outbreak confirms the need for randomized control groups.

Dodd LE1,2, Follmann D3, Proschan M3, Wang J4, Malvy D5,6, van Griensven J7, Ciglenecki I8, Horby PW9, Ansumana R10,11, Jiang JF12, Davey RT13, Lane HC14, Gouel-Cheron A3,15.

Author information: 1 Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA. doddl@mail.nih.gov. 2 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. 3 Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA. 4 Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research Sponsored by the National Cancer Institute, Frederick, MD, USA. 5 Inserm, UMR 1219, Université de Bordeaux, Bordeaux, France. 6 Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. 7 Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium. 8 Operational Centre Geneva, Médecins Sans Frontières, 1211 Geneva, Switzerland. 9 Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK. 10 Mercy Hospital Research Laboratory, Kulanda Town, Bo, Sierra Leone. 11 School of Community Health Sciences, Njala University, Bo, Sierra Leone. 12 Beijing Institute of Microbiology and Epidemiology, Beijing, China. 13 Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA. 14 Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA. 15 Anesthesiology and Intensive Care Department, Hopital Bichat-Claude Bernard, Assistance Publique-Hopitaux de Paris, Paris, France.



Recent Ebola virus disease outbreaks affirm the dire need for treatments with proven efficacy. Randomized controlled clinical trials remain the gold standard but, during disease outbreaks, may be difficult to conduct due to ethical concerns and challenging field conditions. In the absence of a randomized control group, statistical modeling to create a control group could be a possibility. Such a model-based reference control would only be credible if it had the same mortality risk as that of the experimental group in the absence of treatment. One way to test this counterfactual assumption is to evaluate whether reasonable similarity exists across nonrandomized control groups from different clinical studies, which might suggest that a future control group would be similarly homogeneous. We evaluated similarity across six clinical studies conducted during the 2013-2016 West Africa outbreak of Ebola virus disease. These studies evaluated favipiravir, the biologic ZMapp, the antimalarial drug amodiaquine, or administration of convalescent plasma or convalescent whole blood. We compared the nonrandomized control groups of these six studies comprising 1147 individuals infected with Ebola virus. We found considerable heterogeneity, which did not disappear after statistical modeling to adjust for prognostic variables. Mortality risk varied widely (31 to 66%) across the nonrandomized control arms of these six studies. Models adjusting for baseline covariates (age, sex, and cycle threshold, a proxy for viral load) failed to sufficiently recalibrate these studies and showed that heterogeneity remained. Our findings highlight concerns about making invalid conclusions when comparing nonrandomized control groups to cohorts receiving experimental treatments.

Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.

PMID: 31776287 DOI: 10.1126/scitranslmed.aaw1049

Keywords: Antivirals; Favipiravir; Serotherapy; ZMapp; Monoclonal antibodies; Ebola; West Africa.


Learning from the #Epidemiological #Response to the 2014/15 #Ebola Virus Disease #Outbreak (J Epidemiol Globa Health, abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

J Epidemiol Glob Health. 2019 Sep;9(3):169-175. doi: 10.2991/jegh.k.190808.002.

Learning from the Epidemiological Response to the 2014/15 Ebola Virus Disease Outbreak.

Holding M1,2,3, Ihekweazu C4,5, Stuart JM1,6, Oliver I1,2.

Author information: 1 NIHR Health Protection Research Unit on Evaluation of Interventions, University of Bristol, Bristol, UK. 2 Field Service, National Infection Service, Public Health England, Bristol, UK. 3 NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK. 4 Nigeria Centre for Disease Control, Abuja, Nigeria. 5 ECOWAS Regional Centre for Surveillance and Disease Control, Abuja, Nigeria. 6 School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.



A large international response was needed to bring the 2014/15 West African Ebola virus disease outbreak under control. This study sought to learn lessons from this epidemic to strengthen the response to future outbreaks of international significance by identifying priorities for future epidemiology training and response. Epidemiologists who were deployed to West Africa were recruited through a snowball sampling method and surveyed using an online anonymous questionnaire. Associations between demographics, training, qualifications, and role while in-country were explored alongside respondents’ experience during deployment. Of 128 responses, 105 met the inclusion criteria. Respondents originated from 25 countries worldwide, for many (62%), this was their first deployment abroad. The most common tasks carried out while deployed were surveillance, training, contact tracing, and cluster investigation. Epidemiologists would value more detailed predeployment briefings including organizational aspects of the response. Gaps in technical skills reported were mostly about geographical information systems; however, epidemiologists identified the need for those deployed in future to have greater knowledge about roles and responsibilities of organizations involved in the response, better cultural awareness, and leadership and management skills. Respondents felt that the public health community must improve the timeliness of the response in future outbreaks and strengthen collaboration and coordination between organizations.

© 2019 Atlantis Press International B.V.

KEYWORDS: Ebola virus; West Africa; FETP; epidemiologist; international deployment; outbreak response

PMID: 31529934 DOI: 10.2991/jegh.k.190808.002

Keywords: Ebola; West Africa; Public Health.


Increased #mortality in #survivors of #Ebola virus disease (Lancet Infect Dis., summary)

[Source: The Lancet Infectious Diseases, full page: (LINK). Summary, edited.]

Increased mortality in survivors of Ebola virus disease

Hugues Fausther-Bovendo, Gary Kobinger

Published: September 04, 2019 / DOI: https://doi.org/10.1016/S1473-3099(19)30429-3


Long-term sequelae of Ebola virus disease—including myalgia, arthralgia, ocular diseases, and mental confusion—have come to light in survivors of the 2014–16 Ebola outbreak in west Africa. The frequency and duration of these sequelae, which are collectively referred to as post-Ebola virus disease syndrome, have since been reported. 1 However, information about subsequent mortality in survivors of Ebola is scarce. Anecdotal reports and one previous study 2  have documented the unexpected death of survivors of Ebola virus disease after viral clearance and discharge from Ebola treatment units, suggesting that the acute phase of the disease can lead to protracted death in some survivors, but no systematic investigations of increased mortality in survivors have previously been published.


Keywords: Ebola; West Africa; Ebola-Makona.


#CFR #estimates for the 2013 – 2016 West #African #Ebola #epidemic: application of Boosted Regression Trees for imputation (Clin Infect Dis., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

Clin Infect Dis. 2019 Jul 22. pii: ciz678. doi: 10.1093/cid/ciz678. [Epub ahead of print]

Case fatality ratio estimates for the 2013 – 2016 West African Ebola epidemic: application of Boosted Regression Trees for imputation.

Forna A1, Nouvellet P1,2, Dorigatti I1, Donnelly CA1,3.

Author information: 1 MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom. 2 School of Life Sciences, University of Sussex, Brighton, UK. 3 Department of Statistics, University of Oxford, Oxford, UK.




The 2013-2016 West African Ebola epidemic has been the largest to date with more than 11,000 deaths in the affected countries. The data collected have provided more insight than ever before into the case fatality ratio (CFR) and how it varies with age and other characteristics. However, the accuracy and precision of the naïve CFR remain limited because 44% of survival outcomes were unreported.


Using a Boosted Regression Tree (BRT) model, we imputed survival outcomes (i.e. survival or death) when unreported, corrected for model imperfection to estimate the CFR without imputation, with imputation and adjusted with imputation. The method allowed us to further identify and explore relevant clinical and demographic predictors of the CFR.


The out-of-sample performances of our model were good: sensitivity=69.7% (95% CI 52.5%-75.6%), specificity=69.8% (95% CI 54.1%-75.6%), percentage correctly classified=69.9% (95% CI 53.7%-75.5%) and area under the ROC curve= 76.0% (95% CI 56.8%-82.1%). The adjusted CFR estimates for the 2013-2016 West African epidemic were 82.8% (95% CI 45%.6-85.6%) overall and 89.1% (95% CI 40.8%-91.6%) , 65.6% (95% CI 61.3%-69.6%) and 79.2% (95% CI 45.4-84.1) for Sierra Leone, Guinea and Liberia, respectively. We found that district, hospitalisation status, age, case classification and quarter explained 93.6% of the variance in the naïve CFR.


The adjusted CFR estimates improved the naïve CFR estimates obtained without imputation and were more representative. Used in conjunction with other resources, adjusted estimates will inform public health contingency planning for future Ebola epidemic, and help better allocate resources and evaluate the effectiveness of future inventions.

© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America.

KEYWORDS: Imputation; Infectious Disease Epidemiology; Machine Learning; Survival; Viral Haemorrhagic Disease

PMID: 31328221 DOI: 10.1093/cid/ciz678

Keywords: Ebola; West Africa.


Effect of Mass #Artesunate-Amodiaquine #Distribution on #Mortality of #Patients With #Ebola Virus Disease During West #African #Outbreak (Open Forum Infect Dis., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

Open Forum Infect Dis. 2019 May 24;6(7):ofz250. doi: 10.1093/ofid/ofz250. eCollection 2019 Jul.

Effect of Mass Artesunate-Amodiaquine Distribution on Mortality of Patients With Ebola Virus Disease During West African Outbreak.

Garbern SC1, Yam D2, Aluisio AR1, Cho DK3, Kennedy SB4, Massaquoi M4, Sahr F5, Perera SM6, Levine AC1, Liu T2.

Author information: 1 Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island. 2 Department of Biostatistics, Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island. 3 Brown University, Providence, Rhode Island. 4 Ministry of Health, Monrovia, Liberia. 5 Sierra Leone Ministry of Defense, Freetown, Sierra Leone. 6 International Medical Corps, Washington, DC.




Experiments in vitro have shown that the drug amodiaquine may inhibit Ebola virus activity. During the Ebola virus disease (EVD) epidemic in West Africa in 2014-2016, 2 mass drug administrations (MDAs) of artesunate-amodiaquine (ASAQ) were implemented to decrease the burden of malaria. The objective of this study was to assess the effect of the ASAQ MDAs on the mortality of patients with EVD.


A retrospective cohort design was used to analyze mortality data for patients with EVD admitted to 5 Ebola treatment units in Liberia and Sierra Leone. Patients admitted to the ETUs during the time period of ASAQ’s therapeutic effect from areas where the MDA was implemented were matched to controls not exposed to ASAQ, using a range of covariates, including malaria co-infection status, and a logistic regression analysis was performed. The primary outcome was Ebola treatment unit mortality.


A total of 424 patients with EVD had sufficient data for analysis. Overall, the mortality of EVD patients was 57.5%. A total of 22 EVD patients were exposed to ASAQ during the MDAs and were found to have decreased risk of death compared with those not exposed in a matched analysis, but this did not reach statistical significance (relative risk, 0.63; 95% confidence interval, 0.37-1.07; P = .086).


There was a non-statistically significantly decreased risk of mortality in EVD patients exposed to ASAQ during the 2 MDAs as compared with EVD patients not exposed to ASAQ. Further prospective trials are needed to determine the direct effect of ASAQ on EVD mortality.

KEYWORDS: Ebola virus disease; amodiaquine; epidemic; mass drug administration; mortality

PMID: 31281856 PMCID: PMC6602760 DOI: 10.1093/ofid/ofz250

Keywords: Ebola; Malaria; West Africa; Artesunate; Amodiquinine.


A systematic #review and meta-analysis of #patient #data from the west #Africa (2013-16) #Ebola virus disease #epidemic (Clin Microbiol Infect., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

Clin Microbiol Infect. 2019 Jul 5. pii: S1198-743X(19)30387-8. doi: 10.1016/j.cmi.2019.06.032. [Epub ahead of print]

A systematic review and meta-analysis of patient data from the west Africa (2013-16) Ebola virus disease epidemic.

Rojek AM1, Salam A2, Ragotte RJ3, Liddiard E3, Elhussain A3, Carlqvist A3, Butler M3, Kayem N3, Castle L3, Odondi L3, Stepniewska K4, Horby PW3.

Author information: 1 Epidemic Diseases Research Group, University of Oxford, Oxford, United Kingdom. Electronic address: amanda.rojek@ndm.ox.ac.uk. 2 Epidemic Diseases Research Group, University of Oxford, Oxford, United Kingdom; United Kingdom Public Health Rapid Support Team. 3 Epidemic Diseases Research Group, University of Oxford, Oxford, United Kingdom. 4 Epidemic Diseases Research Group, University of Oxford, Oxford, United Kingdom; WorldWide Antimalarial Resistance Network, Oxford, United Kingdom.




Over 28,000 patients were infected with Ebola virus disease (EVD) during the west Africa (2013-16) epidemic, yet there has been criticism of the lack of robust clinical descriptions of illness from that outbreak.


To perform a meta-analysis of published data from the epidemic in order to describe the clinical presentation, evolution of disease, and predictors of mortality in patients with EVD. To assess the quality and utility of published data for clinical and public health decision making.


Primary articles available in PubMed and published between January 2014 and May 2017.


Studies that sequentially enrolled patients hospitalised for EVD and that reported acute clinical outcomes.


We performed meta-analyses using random-effect models and assessed heterogeneity using the I2 method. We assessed data representativeness by comparing meta-analysis estimates to World Health Organization aggregate data. We examined data utility by examining the availability and compatibility of data sets.


We screened 3653 articles and included 34 articles, representing 16 independent cohorts of patients (18 overlapping cohorts) and at least 6168 patients. The pooled estimate for case fatality rate was 51% (CI 46% to 56%). However, pooling of estimates for clinical presentation, and predictors of mortality in patients with EVD was hampered by significant heterogeneity, and inadequate data on clinical progression. Our assessment of data quality found that heterogeneity was largely unexplained, and data availability and compatibility were poor.


We have quantified a missed opportunity to generate reliable estimates of the clinical manifestations of EVD during the west Africa epidemic. Clinical data standards and data capture platforms are urgently needed.

Copyright © 2019. Published by Elsevier Ltd.

KEYWORDS: Ebola; Ebola Virus Disease; Emerging infection; Epidemic; Outbreak; Viral Haemorrhagic Fever; Viral hemorrhagic fever

PMID: 31284032 DOI: 10.1016/j.cmi.2019.06.032

Keywords: Ebola; West Africa.