title: Deaths, late deaths, and role of infecting dose in Ebola virus disease in Sierra Leone: retrospective cohort study.
abstract: OBJECTIVE
  To assess the frequency of fatal recrudescence from Ebola virus disease after discharge from treatment centres, and explore the influence of infecting dose on case fatality rates.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Western Area, Sierra Leone.
  
  
  METHODS
  151 survivors treated for Ebola virus disease at the Kerry Town treatment centre and discharged. Survivors were followed up for a vital status check at four to nine months after discharge, and again at six to 13 months after discharge. Verbal autopsies were conducted for four survivors who had died since discharge (that is, late deaths). Survivors still living in Western Area were interviewed together with their household members. Exposure level to Ebola virus disease was ascertained as a proxy of infecting dose, including for those who died.
  
  
  METHODS
  Risks and causes of late death; case fatality rates; odds ratios of death from Ebola virus disease by age, sex, exposure level, date, occupation, and household risk factors.
  
  
  RESULTS
  Follow-up information was obtained on all 151 survivors of Ebola virus disease, a mean of 10 months after discharge. Four deaths occurred after discharge, all within six weeks: two probably due to late complications, one to prior tuberculosis, and only one after apparent full recovery, giving a maximum estimate of recrudescence leading to death of 0.7%. In these households, 395 people were reported to have had Ebola virus disease, of whom 227 died. A further 53 people fulfilled the case definition for probable disease, of whom 11 died. Therefore, the case fatality rate was 57.5% (227/395) for reported Ebola virus disease, or 53.1% (238/448) including probable disease. Case fatality rates were higher in children aged under 2 years and adults older than 30 years, in larger households, and in infections occurring earlier in the epidemic in Sierra Leone. There was no consistent trend of case fatality rate with exposure level, although increasing exposure increased the risk of Ebola virus disease.
  
  
  CONCLUSIONS
  In this study of survivors in Western Area, Sierra Leone, late recrudescence of severe Ebola virus disease appears to be rare. There was no evidence for an effect of infecting dose (as measured by exposure level) on the severity of disease.
authors.affiliation: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Hilary
authors.initials: H
authors.lastname: Bower
authors.affiliation: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Smout
authors.affiliation: Save the Children, Freetown, Sierra Leone.
authors.forename: Mohamed S
authors.initials: MS
authors.lastname: Bangura
authors.affiliation: Save the Children, Freetown, Sierra Leone.
authors.forename: Osman
authors.initials: O
authors.lastname: Kamara
authors.affiliation: Save the Children, Freetown, Sierra Leone.
authors.forename: Cecilia
authors.initials: C
authors.lastname: Turay
authors.affiliation: Save the Children, Freetown, Sierra Leone.
authors.forename: Sembia
authors.initials: S
authors.lastname: Johnson
authors.affiliation: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Shefali
authors.initials: S
authors.lastname: Oza
authors.affiliation: Humanitarian Department, Save the Children, London, UK.
authors.forename: Francesco
authors.initials: F
authors.lastname: Checchi
authors.affiliation: London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK judith.glynn@lshtm.ac.uk.
authors.forename: Judith R
authors.initials: JR
authors.lastname: Glynn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D029043:Ebolavirus / Q000472:pathogenicity*; D005260:Female; D005500:Follow-Up Studies; D019142:Hemorrhagic Fever, Ebola / Q000401:mortality* / Q000821:virology; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012807:Sierra Leone; D017741:Survivors / Q000706:statistics & numerical data*; D013997:Time Factors; D014774:Virulence; D055815:Young Adult