Francesco Grandesso, MSF Patient characteristics and risk of mortality in the Médecins Sans Frontières Ebola Management Centres (EMCs) during the West African Ebola outbreak - Preliminary Analysis Francesco Grandesso, MSF

Objectives Provide an overall description of Ebola virus confirmed patients admitted in MSF main EMCs: age, sex, time to admission, case fatality rate (CFR) Provide a preliminary analysis of the risk factors for death among confirmed and admitted patients

Freetown/Kissy 08-01-15 to 07-03-15 Conakry/Donka 25-03-14 to 12-04-15 Magburaka 15-12-14 to 28-03-15 Freetown/Pow 10-12-14 to 20-02-15 Guéckédou 21-03-14 to 09-02-15 Kailahun 26-06-14 to 22-02-15 Freetown/Kissy 08-01-15 to 07-03-15 Foya 26-06-14 to 13-02-15 Monrovia/Elwa 3 16-08-14 to 24-03-15 Bo 19-09-14 to 16-03-15

Patients admitted to MSF EMCs Patients (up to 12th of April 2015) Country Centre Admitted Confirmed % Guinea Gueckedou 1635 1074 65.7 Donka 1940 779 40.2 Sierra Leone Kailahun 1219 857 70.3 Bo 483 443 91.7 Freetown 401 170 42.4 Magburaka 136 46 33.8 Kissy 102 24 23.5 Liberia Foya 695 384 55.3 Monrovia-ELWA3 1909 1241 65.0 All centres 8520 5018 58.9

Methodology Pooling of 9 MSF EMC line-lists: 5 in Sierra Leone, 2 in Liberia and 2 in Guinea Descriptive analysis of main patient characteristics at admission Incidence rate ratios (IRR) from univariate and multivariate poisson regression analyses adjusted for intra and inter-variation among EMC to explore factors associated with risk of dying: age groups, sex, month of admission, time to admission, and cycle threshold at admission as proxy of viral load

Overall patient characteristics Age (years) n % <5 279 5.6 5-14 693 14.0 15-54 3549 71.6 55+ 437 8.8 Sex Female 2543 50.7 Male 2472 49.3 Time to admission (days) n % 0-3 1645 35.3 4-7 2130 45.7 8-13 675 14.5 14+ 212 4.5

Case fatality by centre EMC Cases Deaths CFR % Risk ratio [95% CI] Gueckedou 1069 618 57.8 1.00 – Donka 723 342 47.3 0.81 [0.74-0.89] Kailahun 853 390 45.7 0.79 [0.72-0.86] Bo 441 171 38.8 0.67 [0.59-0.76] Freetown 166 83 50.0 0.85 [0.72-1.00] Magburaka 44 21 47.7 [0.59-1.11] Kissy 22 14 63.6 1.01 [0.72-1.43] Foya 381 228 59.8 1.04 [0.94-1.14] Monrovia-ELWA3 1204 690 57.3 0.97 [0.90-1.04] All centres 4903 2557 52.2

Changes in case fatality over time

Case fatality according to patients’ age

Factors associated with death (all centres)   Univariate analysis Multivariate analysis Admitted Died % IRR [95% CI] Month of admission – 0.96 [0.94–0.99] Age (years) <5 264 180 68.2 2.00 [1.65–2.41] 2.11 [1.73–2.58] 5-14 677 281 41.5 1.00 15-54 3348 1705 50.9 1.38 [1.22–1.57] 1.35 [1.19–1.55] 55+ 399 273 68.4 2.22 [1.87–2.62] 2.21 [1.85–2.63] Time to admission (days) 0-3 1529 835 54.6 4-7 2053 1051 51.2 1.01 [0.92–1.11] 1.02 [0.93–1.12] 8-13 655 313 47.8 1.03 [0.90–1.17] [0.88–1.15] 14+ 212 98 46.2 1.10 [0.89–1.35] 1.08 [0.87–1.34] Sex Female 2396 1210 50.5 Male 2344 1265 54.0 1.11 [1.02–1.20] [1.02–1.21]

Cycle threshold associated with death

Factors associated with death   Univariate analysis Multivariate analysis Admitted Died % IRR [95% CI] Month of admission – 0.93 [0.90–0.96] Age (years) <5 176 120 68.2 1.96 [1.57–2.45] 1.82 [1.43–2.30] 5-14 520 215 41.3 1.00 15-54 2471 1259 51.0 1.37 [1.19–1.59] [1.18–1.59] 55+ 287 204 71.1 2.30 [1.89–2.78] 2.06 [1.69–2.51] Time to admission (days) 0-3 1131 634 56.1 4-7 1557 803 51.6 0.98 [0.89–1.09] 1.04 [0.94–1.16] 8-13 473 225 47.6 0.96 [0.83–1.13] 1.14 [0.97–1.33] 14+ 152 66 43.4 [0.74–1.24] 1.20 [0.93–1.55] Cycle threshold <18 517 474 91.7 7.29 [6.28–8.46] 7.28 [6.24–8.50] 18-22 1009 642 63.6 2.40 [2.14–2.69] 2.47 [2.19–2.79] 22+ 1969 711 36.1 Sex Female 1789 918 51.3 Male 1703 906 53.2 1.05 [0.96–1.15] 1.06 [0.96–1.17]

Limitations Limited factors explored (i.e. clinical symptoms at admission and exposure/epidemiological link analysis not incorporated) Limited to patients admitted (community deaths and deaths on arrival not included) Time to admission questioned Pooling of data from various contexts Different laboratories and assays for Ebola PCR (and possibly used/reported antigens)

Discussion-Conclusion Cycle threshold at admission the main predictor of death Higher risk of death in relation to younger and older age Death incidence rate decreases with time passing independently from the factors analysed Symptoms at admission, treatment provided during the course of hospitalisation, workload in the EMC, distance to EMC, as well as factors associated with higher viral load should be further investigated

Acknowledgments All MSF volunteers and local staff who work and have been working in the field All epidemiologists and medical referents in the field and in MSF headquarters