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Post-exposure prophylaxis in Ebola virus disease: don’t
forget the psychological factors
Helene Savini, Cecile Ficko, Fabrice Simon
To cite this version:
Helene Savini, Cecile Ficko, Fabrice Simon. Post-exposure prophylaxis in Ebola virus disease: don’t
forget the psychological factors. The Lancet Infectious Diseases, New York, NY : Elsevier Science ; The
Lancet Pub. Group, 2001-, 2018, 18 (4), pp.378. �10.1016/S1473-3099(18)30131-2�. �hal-01780655�
Correspondence
378 www.thelancet.com/infection Vol 18 April 2018
Third, because of the excess mental burden of occupational exposure to Ebola virus, we can also expect poor tolerance to the post-exposure prophylaxis drugs suggested by Fischer and colleagues. Indeed, this phenomenon is already well known for antiretroviral post-exposure prophylaxis, which is associated with a higher rate of interruption and adverse effects in health-care workers who are occupationally exposed to HIV than in HIV-positive patients on the same regimen.3
Finally, we believe that the psychological burden had been clearly underestimated during the 2014–15 outbreak of Ebola virus disease in west Africa, and that many health-care workers, in fact, faced undermanaged
anxiety. On the basis of this feedback, preparedness for future outbreaks should necessarily include both anticipation and management of the psychological load of occupational exposure to highly contagious and lethal pathogens. This is the best way to support the announced arrival of efficient antiviral products for post-exposure prophylaxis and, simultaneously, to maintain the safety and confidence of teams working in Ebola treatment centres.
We declare no competing interests. *Hélène Savini, Cécile Ficko, Fabrice Simon
helene.savini13@gmail.com
Department of Infectious and Tropical Disease, Military Teaching Hospital of Laveran, Marseille 13013, France (HS, FS); and Department of Infectious and Tropical Disease, Military Teaching Hospital of Begin, Saint Mandé, France (CF)
1 Fischer WA 2nd, Vetter P, Bausch DG, et al. Ebola virus disease: an update on post-exposure prophylaxis. Lancet Infect Dis 2017; published online Nov 15. http://dx.doi.org/10.1016/S1473-3099(17)30677-1.
2 Savini H, Janvier F, Karkowski L, et al. Occupational exposures to Ebola virus in Ebola treatment center, Conakry, Guinea.
Emerg Infect Dis 2017; 23: 1380–83.
3 Quirino T, Niero F, Ricci E, et al. HAART tolerability: post-exposure prophylaxis in healthcare workers versus treatment in HIV-infected patients. Antivir Ther 2000;
5: 195–97.
2 Dara M, Zachariah R. Ending tuberculosis calls for leaving no one behind. Lancet Infect Dis 2018; published online Jan 8. https://doi. org/10.1016/S1473-3099(17)30746-6.
informed by other health workers that several presumptive cases referred to official actors were also declared tuberculosis-negative after similar screening; we are, however, aware of at least two patients who have received treatment, and it is clear to us that whatever pathway exists is erratically followed.
Attempts to get official attention have led to dismissal and, in one disturbing case, without our knowledge a physician in another NGO supplied daily rifampicin and isoniazid for a week and, after a 3-day lapse, another week’s supply. This patient has since fled the island, was held in an Athens jail, and is now back on Lesvos in detention without medical care. Care has been further constrained by the local hospital’s inability to carry out HIV testing because of inadequate supplies. Bacteriology in the local laboratory is limited to the Ziehl-Neelsen stain, which is used only reluctantly and unsystematically.
Refugees from high-incidence countries arrive daily on these islands where they are squeezed into crowded congregate settings, often summer tents on the freezing ground, for months or years with no access to proper tuberculosis diagnosis and treatment. While the patients described in Walker and colleagues’ study are likely to have acquired drug-resistant tuberculosis in their home countries, it is possible that the fragmented care we have witnessed has contributed to the development of resistant strains. We call upon the global tuberculosis community to respond to this critical situation.
We declare no competing interests. Jacob Clary, Richard Dean
jacob.e.clary@gmail.com
Bedford Stuyvesant Volunteer Ambulance Corps, Brooklyn, New York, NY 11221, USA (JC); and the College Yard Surgery, Gloucester, UK (RD) 1 Walker TM, Merker M, Knoblauch AM, et al.
A cluster of multidrug-resistant Mycobacterium
tuberculosis among patients arriving in
Europe from the Horn of Africa: a molecular epidemiological study. Lancet Infect Dis 2018; published online Jan 8. https://doi.org/10.1016/ S1473-3099(18)30004-5.
Post-exposure
prophylaxis in Ebola virus
disease: don’t forget the
psychological factors
In their Article on post-exposure prophylaxis in Ebola virus disease, William Fischer and colleagues1 exhaustively reviewed the medical countermeasures that could be used after accidental exposure, and their indications according to the risk of transmission. On the basis of our experience of 77 accidental exposures in the health-care workers’ treatment centre in Conakry, Guinea,2 we would like to highlight the importance of psychological and psychiatric factors in the management of accidental exposures in Ebola treatment centres.As Fischer and colleagues state, although there is no doubt that post-exposure prophylaxis is indicated in some situations (eg, transcutaneous needle-stick), assessing the risk of transmission often seems to be difficult and varies with individuals. Stress related to the situation might cause difficulties in remembering every detail of what really happened and thus confound the medical decision. In our experience, most health-care workers reporting accidental exposure could not answer with certainty that biological fluids had, in reality, been projected onto their conjunctival mucosa.
Another important point is that some exposed health-care workers could develop strong acute anxiety. This intense reaction is supported by the feeling of considerable injustice at being possibly infected by a deadly pathogen while treating patients. Early detection and psychological management are essential partners to obtain prompt recovery from this occupational risk.