Some questions were submitted to the en-net postbag by Jessica Bourdaire at Save the Children. They are posted below with answers provided on consultation with UNICEF and WHO (thanks to their respective HQ, regional and country offices for their valuable and speedy inputs).
Thanks for the document, I have few questions below related to the recommendations (quoted):
1. “Community at large
The key messages are:
3) Only when a trained health worker has determined that a mother meets the criteria of probable, suspected or confirmed Ebola Virus Disease (EVD), breastfeeding should be stopped and available options discussed.
The reference document talks about Suspected: 3a. Case definition to be used by mobile teams or health stations and health centres and Probable 3b. Case definition for exclusive use by hospitals and surveillance teams”
Should we assume both are valid as far as a clinician determines that the mother meets one of the criteria?
Yes, both case definitions are valid, as long as it is determined by someone trained on assessing Ebola (the emphasis is on the training rather than necessarily a clincian). We don’t want untrained workers to take decisions that would affect breastfeeding in the general population.
Should this be done in an Ebola treatment centre?
Identification of suspected cases (see case definition 3a) does not necessarily have to happen in an Ebola treatment centre. Usually there’s a triage room/space within the ETC compound, separate from the place where confirmed and probable patients are.
2. “Breastfeeding mothers with confirmed Ebola; asymptomatic child under 6 months of age
1) Cessation of breastfeeding. Options are:
a. Expressing and heat treating the expressed milk (details to be added)”.
Heating? Are we expecting further advice on it?
In the field would it be difficult to assess heating time/temperature? As far as I know heating should not be less than 30min at quite high temperature or boiling for several minutes? Overheating might also destroy antibodies, enzymes and nutrients so what are the benefits of considering utilization of expressed breast milk "heat treated" against the risk of handling and using breast milk that could still be contaminated?
As you reflect, the most important issue concerning this option is that the breastmilk of an Ebola patient is a contaminated product that needs to be handled with care. The over-riding question then is whether this would be feasible in the concerned setting. Your question prompted a discussion on this issue amongst WHO, UNICEF and members of the IFE Core Group. Given the context in West Africa and the risks of handling a contaminated product, we concluded and advise at this time that heat treatment of breastmilk is not a feasible option. We are updating the guidance note which we’ll post shortly.
“At the moment, insufficient evidence is available about the recommended duration of breastmilk cessation after the mother's recovery from Ebola. It is therefore recommended to not resume breastfeeding unless testing of the milk has confirmed the absence of the virus in the milk”.
Is this test available/systematic for lactating women survivors? Should lactating women be recommended to comeback for the test later on? Are they able to continue breastfeeding?
Testing of breastmilk for lactating women survivors is available where it’s also available for blood testing, but is not done systematically.
If possible, women should be recommended to return for testing. On consultation amongst the group, we suggest it is therefore recommended that mothers return to the health centre to have their breastmilk tested, 4 weeks after recovery. If there is no virus in the milk, mothers can resume breastfeeding. If there is virus in the breastmilk, breastfeeding should not recommence and the mother should be advised to return for repeat testing in 3-4 weeks. Mothers should be supported to re-establish breastfeeding once it is safe to do so, and based on the age of the child.
A return to breastfeeding is in the interests of child survival, once it is safe to do so (as reflected above). Ultimately the decision will need to be taken on a case-by-case basis but generally speaking, mothers should be supported to re-establish breastfeeding once it is safe to do so.
3. Other issues to consider
“3) All patients who recover from Ebola should receive nutritional screening and treated when they are found diagnosed with acute malnutrition. They should receive a discharge package, including nutritional support, upon discharge, and should be followed up”.
When are they considered recovered? Clinically recovered and/or blood tested negative? According to the Daniel G. Bausch and All study, EBOV was found in body fluids while it was cleared up in blood samples.
There’s a difference between ‘recovered’ and ‘discharged’: a patient can only be discharged after recovery and after two consecutive tests are negative on different days. Semen is considered to be infectious for several weeks, and breastmilk. That’s why male patients are asked to use condoms for 7 weeks. Whilst recognising these risks, it is important not to encourage irrational fear of recovered patients.
5) “ The risk of spreading Ebola from the use of anthropometric equipment is considered very low when following WHO's Infection Prevention and Control Guidance”.
Even if the risk is low, crowed places could assemble potential cases increasing this risk. At community and even at health centre level, anthropometric materials will not be properly disinfected between 2 children? Materials are not easy to disinfect: MUAC tapes, wooden height boards and weighing scales pants.
The risks of using length/height boards, weighing scale pants etc. are considered high if the materials are not disinfected after each use. If the frequent disinfection of materials is not feasible, another option would be to employ single use disposable covers (eg plastic) for weight and height measurement (which would then need to be destroyed) – this may only be viable for health centres.
The risk is considered low if a MUAC tape is used but even still, it is recommend that alcohol be used to wipe the upper arm before the measurement and that usual hygiene measures, e.g. washing hands between measuring different children, be followed. Another option is that MUAC tapes are used as single use and destroyed; again, this may only be feasible at health centres and will depend on supplies. A third option is that the mother is supported to conduct the measure if possible.
This question has prompted further discussion in the group. We are now examining this issue of anthropometric assessment in consultation with WHO Ebola ‘super-experts’ engaged in the Ebola response. We’ll post feedback on this as soon as possible.
Amongst all this, it is important to note that non-symptomatic persons are not infectious and to not lose sight of the importance of hand hygiene between patients, which is an important aspect of basic health care that is often forgotten.