Field Labs in Action for Ebola Control in Sierra Leone

Infectious Diseases and Translational Medicine

• Letter: Field Laboratory • Field labs in action for Ebola control in Sierra Leone

Infect Dis Transl Med, 2015;1(01):2-5. DOI:10.11979/idtm.201501002

Dear Editor,

To cope with the challenges of newly emerging or re- used to compare the proportion of confirmed EVD cases emerging infectious diseases, timely diagnosis is critical among total cases between Sierra Leone and Liberia. A for triage of suspected patients. The outbreak of Ebola- matched-pairs t-test was used to compare the number virus disease (EVD) in West Africa in late 2013 and the of confirmed EVD cases during the first three weeks of subsequent out-of-control situation compelled the World operation at the five laboratories with the previous three Health Organization (WHO) to declare the epidemic to weeks. The SPSS 18.0 software package for Windows be a Public Health Emergency of International Concern (SPSS, Chicago, IL, USA) was used for statistical analy- (PHEIC)[1]. As of 8 February 2015, a total of 10, 958 ses. confirmed, probable, and suspected EVD cases with 3, LTWG of the Ministry of Health and Sanitation of 344 deaths had been reported by the Ministries of Health Sierra Leone coordinated the Ebola laboratory service and Sanitation of Sierra Leone. Ebola diagnostic labo- response through a special organization, the Director- ratories, supported by international partners, confirmed ates of Hospital and Laboratory Services and Disease 8, 149 cases (74.4%) and 2, 978 deaths (89.1%)[2]. Here Prevention and Control. The goal of the laboratory re- we highlight the critical role played by internationally sponse effort was to ensure a 24-hour turnaround time supported field labs during the Ebola outbreak in Sierra from initial collection of the specimen to result reporting. Leone. The LTWG also collaborated with the WHO and the US Ebola virus spreads primarily by direct contact with Centers for Disease Control and Prevention (CDC) in bodily fluids of patients who are experiencing obvious quality assurance by requesting laboratories to adhere to clinical symptoms, person-to-person transmission can be an external quality assessment (EQA)- proficiency test- prevented effectively by implementation of a combina- ing (PT) scheme that had been validated by the LTWG, tion of early diagnosis to ensure timely patient isolation which developed a manual of laboratory service response and care, contact tracing, infection control measures, and operations to guide specimen collection, packaging, and safe burial[3]. EVD was transmitted into Sierra Leone in dispatch. The manual also includes criteria for laboratory May 2014, at which time only the Kenema Government acceptance or rejection of specimens, as well as for dis- Hospital had research experiences with viral hemorrhag- semination of results. At the end of Jan. 2014, there were ic fever. Therefore, patients whose illness met the criteria 13 international laboratories in Sierra Leone that were defining a suspected Lassa fever case were referred to providing confirmatory diagnostic services for EVD. this hospital for initial diagnosis and clinical care[4]. Due Before 6 Dec. 2014, there were only five laboratories, to the high incidence of nosocomial Ebola virus infec- including the US CDC lab in Bo city, the China CDC lab tion, the Sierra Leone government closed this hospital in Jui Hospital, the National Institute for Communicable in August of 2014[5]. As a result of this closure, the labo- Diseases (NICD) lab of South Africa in Lakka, the Pub- ratory diagnostic capability in Sierra Leone depended lic Health Agency Canada (PHAC) lab in Kailahun, and mainly on international support. the Public Health England (PHE) lab in Kerry Town (Fig. 1). The geographical locations of each of the laboratories Between 6 Dec. 2014 and 15 Jan. 30, 2015, eight other and the status of the sampling teams in Sierra Leone were laboratories were established in support of “Operation obtained from the National Laboratory Technical Work- Western Area Surge” (WAS), the effort initiated to help ing group (LTWG) of the Ministry of Health and Sani- control the epidemic. Of the six existing laboratories tation of Sierra Leone. The weekly statistics regarding in the Western Area, the region with the most affected confirmed EVD cases, total cases, and samples tested, hotspots, three are new, including the European Union- were obtained from the EVD situation report published supported and Nigerian-run lab at Kingtom, the Euro- by the Ministry of Health and Sanitation of Sierra Leone pean Mobile (EM) Lab at the Police Training School in (http://health.gov.sl/?page_id=583). The Directorate of Hastings, and the Italian lab in Goderich, as well as an Disease Prevention and Control of the Ministry of Health additional five new laboratories supported by England, and Sanitation of Sierra Leone provided the situation re- Canada, U.S.A., and Dutch that are located in Port Loko, ports that were missing from the website. These detailed Bombali, Tonkolili, Moyamba and Kono, regions which data are shown in Table 1. The Chi-square method was were expected to become new hotspots.

2 Infect Dis Transl Med 2015;1(01):2-5. Field labs in action for Ebola control in Sierra Leone

Table 1 Numbers of confirmed EVD cases, total EVD cases, and samples tested, listed per epidemiological week in Sierra Leone.

Number of confirmed number of total No. of samples Epi week date Week No. cases cases tested

26 May to 01 June 2014 22 18 58 58 02 to 08 June 2014 23 24 55 55 09 to 15 June 2014 24 34 80 80 16 to 22 June 2014 25 29 101 101 23 to 29 June 2014 26 36 89 89 30 June to 06 July 2014 27 63 119 130 07 to 13 July 2014 28 59 92 153 14 to 20 July 2014 29 29 93 122 21 to 27 July 2014 30 57 102 123 28 July to 03 August 2014 31 77 160 251 04 to 10 August 2014 32 95 124 207 11 to 17 August 2014 33 90 122 217 18 to 24 August 2014 34 137 217 293 25 to 31 August 2014 35 171 199 276 01 to 07 September 2014 36 181 210 329 08 to 14 September 2014 37 215 252 414 15 to 21 September 2014 38 254 301 510 22 to 28 September 2014 39 350 408 677 29 September to 05 October 2014 40 315 467 647 06 to 12 October 2014 41 371 468 842 13 to 19 October 2014 42 386 496 987 20 to 26 October 2014 43 399 471 1092 27 October to 02 November 2014 44 435 540 1272 03 to 09 November 2014 45 421 543 1419 10 to 16 November 2014 46 533 705 1912 17 to 23 November 2014 47 385 526 1690 24 to 30 November 2014 48 537 713 2042 1 to 7 December 2014 49 397 585 1870 8 to 14 December 2014 50 327 459 1721 15 to 21 December 2014 51 315 440 1986 22 to 28 December 2014 52 337 442 2159 29 December 2014 to 04 January 2015 53 252 421 2574 05 to 11 January 2015 54 191 294 2131

Field laboratories play a critical role in providing rapid year of field lab operation in multiple countries. Never diagnosis of emerging infections and implementation of before has the role of field labs been so crucial as it has specific control and prevention countermeasures[6-8]. Field been during the EVD responses in Sierra Leone. Figure laboratory scientists have done essential work in de- 2 depicts a timeline of EVD cases and the laboratory di- ployed laboratories, providing crucial help with the con- agnostic services that facilitated timely triage of patients trol efforts in West Africa. However, some governments and hence the implementation of effective EVD control are worried about the possibility of importing EVD cases and prevention countermeasures. by sending scientists to epidemic areas where they risk According to the WHO Ebola situation report of 8 infection. Professor Tim Inglis, a medical microbiolo- February 2015[2], confirmed EVD cases accounted for gist at the University of Western Australia in Nedlands, 74.4% of the total cases in Sierra Leone, a much higher who is experienced in working in the deployable lab, percent than in Liberia (35.9%) (P < 0.001). Since the appealed that, “Developed nations must not fear sending EVD outbreak began in May 2014 in Sierra Leone, a Ebola help”[9]. There has not been an EVD case reported total of 13 laboratories have been involved in EVD di- among field laboratory personnel after more than a half- agnostic testing in this country. The arrival of additional 3 Infectious Diseases and Translational Medicine

Figure 1. Geographical locations of 11 Ebola laboratories in Sierra Leone with capacity to provide laboratory diagnostic services for con- firmation of EVD cases as of 15 Feb., 2015.

Figure 2. Numbers of confirmed EVD cases, total EVD cases, and samples tested, depicted by epidemiological week. Data are according to the Sierra Leone country situation report. The following laboratories are represented: a, Kenema Government Hospital Lab; b, US Centers for Disease Control (CDC) Lab, Kenema; 1, Public Health Agency Canada (PHAC) Lab, Kailahun; 2, US-CDC Lab, Bo City; 3, South African National Institute for Communicable Diseases (NICD) Lab, Lakka; 4, China-CDC Lab, Jui; 5, Public Health England (PHE) Lab, Kerry Town; 6, PHE Lab, Port Loko; 7, PHE Lab, Makeni; 8, Nigerian Lab, Kingtom; 9, Italian Lab, Goderich; 10, PHAC Lab, Maguraka; 11, EM Lab, Hastings; 12, US Lab, Moyamba; 13, Dutch Lab, Kono. The gray arrow represents the date of first testing for two laboratories that are no longer operational. Lab “a” was closed in August of 2014; and “b” was moved to Bo city in October. The green arrow represents 4 the date of first testing for each of the current eleven laboratories. Field labs in action for Ebola control in Sierra Leone internationally supported laboratories: PHAC (Canadian), erra Leone, Freetown, Sierra Leone (Wenyi Zhang, Yong Chen, CDC USA, NICD (South Africa), CDC China, and PHE Zeliang Chen, Guohui Chang, Chao Liu), Ministry of Health and (England) (Fig. 2), enabled a considerable increase in Sanitation, Freetown, Sierra Leone (Abdul Kamara, David Karg- the number of samples tested. The number of confirmed bo, Brima Kargbo), Technical public health laboratory support, EVD cases in the first three weeks of operation of the Ministry of Health and Sanitation, Freetown, Sierra Leone (Isatta five laboratories was significantly higher compared to the Wurie) three weeks preceding their establishment (P = 0.013), with a total increase of 39.0%. There has been a sharp †: These authors contributed equally to this study. increase in the number of samples tested since epidemiological week 40 (29 November to 5 December) because Corresponding to Prof. Chao Liu, China Mobile Laboratory Re- the numbers of surveillance officers and motorcycles sponse Team for Ebola in Sierra Leone, Jui Hospital, Freetown, were increased for strengthening epidemic control. Sierra Leone. Email: [email protected]. All of the field labs in Sierra Leone employ a real- time PCR diagnostic technique. However, lab design and Author contributions equipment differ from lab to lab. Biosafety measures C.L. conceived of this analysis. Data collection was conducted and were implemented similarly at all of the labs, although supervised by W.Z., Y.C., C.L., A.K., D.K., and B.K.; data analy- specific protective measures vary slightly. Future field ses were performed by Y.C. and W.Z.; and the manuscript was labs should utilize simpler on-site detection techniques, written by C. L., W. Z., and Y. C. such as point-of-care testing (POCT)[10], biosensor[11, 12], and portable PCR machines[13]. Field labs can play a Competing interests statement: more effective role in responses to newly emerging and The authors declare that they have no competing financial inter- re-emerging infectious diseases by working in close col- ests. laboration with disease surveillance and control teams[9]. Open Access Copyright © The Author(s) 2015. This article is distributed under ACKNOWLEDGEMENTS the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which per- The Ebola control contributions of all of the Sierra Leone mits unrestricted use, distribution, and reproduction in any medi- field labs are highly appreciated. um, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, † † † Wenyi Zhang , Yong Chen , Abdul Kamara , Zeliang and indicate if changes were made. The Creative Commons Public Chen, Guohui Chang, Isatta Wurie, David Kargbo, Bri- Domain Dedication waiver (http://creativecommons.org/public- ma Kargbo, Chao Liu domain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. From China Mobile Laboratory Response Team for Ebola in Si-

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