The predicament of patients with suspected Ebola
Authors: Felicity Fitzgerald, David E Baion, Kevin Wing, Shunmay Yeung, Foday Sahr
Journal: The Lancet Global Health (2017)

We have concerns about both the accuracy and underlying rationale of Eugene Richardson and colleagues' Comment1Richardson ET Barrie MB Nutt CT et al.The Ebola suspect's dilemma.Lancet Glob Health. 2017; 5: e254-e256Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar about the “Ebola suspect's dilemma”. The authors quote a nosocomial infection rate of “around 25%” for individuals admitted to Ebola treatment facilities without Ebola virus disease. However, two previous papers document rates of 3%2Arkell P Youkee D Brown CS et al.Quantifying the risk of nosocomial infection within Ebola Holding Units: a retrospective cohort study of negative patients discharged from five Ebola Holding Units in Western Area, Sierra Leone.Trop Med Int Health. 2017; 22: 32-40Crossref PubMed Scopus (7) Google Scholar and 7%.3Fitzpatrick G Vogt F Moi Gbabai O et al.Describing readmissions to an Ebola case management centre (CMC), Sierra Leone, 2014.Euro Surveill. 2014; 19: 20924Crossref PubMed Google Scholar In our previous study4Fitzgerald F Wing K Naveed A et al.Risk in the “Red Zone”: outcomes for children admitted to Ebola holding units in Sierra Leone without Ebola virus disease.Clin Infect Dis. 2017; (published online March 20)https://doi.org/10.1093/cid/cix223Crossref Scopus (5) Google Scholar of over 1000 children admitted to Ebola treatment facilities with suspected Ebola virus disease, only three (0·5%) of 630 children who tested negative were subsequently readmitted with a positive test, all of whom had lost a parent to Ebola virus disease before their first admission; therefore, they were more likely to have acquired Ebola virus disease in the community than nosocomially. Furthermore, the case:fatality ratio of children who were admitted to hospital and were Ebola virus disease-negative was 9% (95% CI 8–12; 66 of 697), similar to previous inpatient mortality rates of children who were negative for Ebola virus disease at Ola During Children's Hospital in Freetown from 2013-2014, prior to the Ebola virus disease outbreak.5Ola During Children's Hospital, Data Annual Report 2013 to February 2014. Internal Document, April 2014.Google Scholar By framing the outbreak within the trope of African subjugation or passivity in the face of international colonialists (humanitarian or otherwise), the agency is removed and the sacrifice belittled of the west African health-care workers, such as those who ran the Sierra Leonean Ministry of Health and military facilities in which our study was based.4Fitzgerald F Wing K Naveed A et al.Risk in the “Red Zone”: outcomes for children admitted to Ebola holding units in Sierra Leone without Ebola virus disease.Clin Infect Dis. 2017; (published online March 20)https://doi.org/10.1093/cid/cix223Crossref Scopus (5) Google Scholar For example, far from “offering little in the way of intravenous resuscitation”, the Republic of Sierra Leone Armed Forces provided aggressive parenteral fluid resuscitation from their opening in September, 2014, several months before this protocol was scaled up in internationally run facilities.6Ansumana R Jacobsen KH Sahr F et al.Ebola in Freetown area, Sierra Leone—a case study of 581 patients.N Engl J Med. 2015; 372: 587-588Crossref PubMed Scopus (90) Google Scholar Nosocomial transmission rates and mortality rates for children who were Ebola virus disease-negative appear to have been lower than those estimated by Richardson and colleagues, which is testament to the leadership of these Sierra Leonean health-care workers and their commitment to patient care and infection control. By misrepresenting the outcomes achieved by efforts of these west African health-care workers, Richardson and colleagues seem to only bolster the colonial structural determinants that they denigrate. We declare no competing interests. The Ebola suspect's dilemmaIn 1950, Merrill Flood and Melvin Dresher of the RAND Corporation developed a theoretical model of cooperation and conflict, which was later formalised by Albert W Tucker as the prisoner's dilemma.1 This model represents a situation in which two prisoners each have the option to confess or not, but their sentencing outcomes depend crucially on the simultaneous choice of the other (figure).1 Fittingly, it has become the paradigmatic example of individual versus group rationality and is an often used heuristic when conveying introductory social theory to students. Full-Text PDF Open AccessThe predicament of patients with suspected Ebola – Authors' replyWe thank Thomas Mayrhofer and colleagues for offering their threshold model as an explanation for patients' aversion to accessing Ebola facilities during the recent Ebola outbreak in west Africa. We agree that this threshold model provides a rational and more elegant explanation of patients' avoidance of ill-equipped and poorly sanitised holding centres; however, such an explanation was not the goal of our Comment.1 Instead, we aimed to produce a reductio ad absurdum2 of rationalist approaches to understanding behaviour during the Ebola outbreak. Full-Text PDF Open Access