Ebola Holding Units at governmenthospitals in Sierra Leone: evidence for aflexible and effective model for safeisolation, early treatment initiation,hospital safety and health systemfunctioning

Oliver Johnson,1 Daniel Youkee,1 Colin S Brown,1,2 Marta Lado,1 Alie Wurie,3

Donald Bash-Taqi,3 Andy Hall,1 Eva Hanciles,4 Isata Kamara,4 Cecilia Kamara,4

Amardeep Kamboz,1 Ahmed Seedat,1 Suzanne Thomas,1 T B Kamara,4,5

Andrew J M Leather,1 Brima Kargbo3

To cite: Johnson O,Youkee D, Brown CS, et al.Ebola Holding Units atgovernment hospitals inSierra Leone: evidence for aflexible and effective modelfor safe isolation, earlytreatment initiation, hospitalsafety and health systemfunctioning. BMJ GlobalHealth 2016;1:e000030.doi:10.1136/bmjgh-2016-000030

▸ Additional material ispublished online only. Toview please visit the journalonline (http://dx.doi.org/10.1136/bmjgh-2016-000030)

Received 12 January 2016Revised 31 March 2016Accepted 27 April 2016

For numbered affiliations seeend of article.

Correspondence toDr Oliver Johnson;oliver.johnson@kcl.ac.uk

ABSTRACTThe 2014-2015 West African outbreak of Ebola VirusDisease (EVD) claimed the lives of more than 11,000people and infected over 27,000 across sevencountries. Traditional approaches to containing EVDproved inadequate and new approaches for controllingthe outbreak were required. The Ministry of Health &Sanitation and King’s Sierra Leone Partnershipdeveloped a model for Ebola Holding Units (EHUs) atGovernment Hospitals in the capital city Freetown. TheEHUs isolated screened or referred suspect patients,provided initial clinical care, undertook laboratorytesting to confirm EVD status, referred onward positivecases to an Ebola Treatment Centre or negative casesto the general wards, and safely stored corpsespending collection by burial teams. Between 29th May2014 and 19th January 2015, our five units hadisolated approximately 37% (1159) of the 3097confirmed cases within Western Urban and Ruraldistrict. Nosocomial transmission of EVD within theunits appears lower than previously documented atother facilities and staff infection rates were also low.We found that EHUs are a flexible and effective modelof rapid diagnosis, safe isolation and early initialtreatment. We also demonstrated that it is possible forinternational partners and government facilities tocollaborate closely during a humanitarian crisis.

INTRODUCTIONThe 2014–2015 West African outbreak ofEbola Virus Disease (EVD) was unprece-dented in modern times, and required newapproaches for containing the outbreak andmanaging the crisis. This article describes theEbola Holding Units (EHU) model devel-oped by the Ministry of Health and Sanitation

and King’s Sierra Leone Partnership inFreetown, Sierra Leone and draws out lessonsthat could be usefully applied for futureEbola outbreaks and health emergencies.

BackgroundThe 2014–2015 West African outbreak ofEVD claimed the lives of more than 11 000people and infected over 27 000 across sevencountries.1 One entry into the human popu-lation is thought responsible for all casesseen.2 Reported case fatality rates rangedfrom 31% to 74% for observed cohorts.3–5

Prior to this outbreak, EVD had infectedunder 2500 people in ∼30 outbreaks since its

Key questions

What is already known about this topic?▸ Ebola Holding Units (EHUs) in government hos-

pitals in Sierra Leone played an important role inbringing the outbreak under control.

What are the new findings?▸ These EHUs were safe for staff and patients, and

enabled patients with Ebola virus disease to beisolated rapidly and start treatment early.

▸ Locating isolation facilities in existing healthcentres allowed non-Ebola emergency healthservices to be maintained, and for new units tobe opened rapidly and with limited resources.

Recommendations for policy▸ Government health services should lead the

response to a health crisis, and effective collab-oration with international partners is possible.

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discovery in 1976.6 Each previous outbreak was rural,limited to <500 cases, and controlled through standardresponse interventions such as contact tracing, rapidcase identification and isolation and infection controlmeasures.7 In West Africa, these traditional approachesto containing EVD proved inadequate due to rapidtransmission across densely populated communities withgood transport infrastructure, and across nationalborders.8 New approaches for controlling the outbreakwere, therefore, required.Many different types of EVD care facilities were estab-

lished in Sierra Leone during the 2014–2015 WestAfrican response to the EVD outbreak, each implemen-ted differently by different partners. In Sierra Leone,facilities could be broadly categorised into three models.Traditional Ebola treatment centres (ETCs) were usuallylarge purpose-built facilities with sizeable medical andnursing teams that undertook long-term EVD care forconfirmed patients with EVD, until death or discharge.These were often operated by international organisa-tions with independent supply chains, and usually had asmaller distinct area for isolation and testing of suspectpatients. EHUs were isolation units established in exist-ing health facilities that undertook screening, testing,and initial treatment; these were largely implementedand staffed by local healthcare workers (HCWs), withvarying amounts of international support. CommunityCare Centres were mainly established in rural areas;these were smaller and usually standalone temporaryunits that also attempted wider community engagementand social mobilisation, again with varying degrees ofinternational assistance. Versions of these models wereused throughout affected countries in West Africaduring the EVD response, but with significant varia-tions. Therefore, when these terms are used in thispaper they refer specifically to the Sierra Leoneancontext. None of these models were intended to workin isolation. Each model was intended to work in col-laboration with the other models, with each having adistinct role.The ideal response to an EVD outbreak with an expo-

nential increase in cases is flexible, readily deployable,and replicable.9 High levels of infection prevention andcontrol practices are needed to ensure patient and staffsafety, to reduce the risk of nosocomial infection, andprevent health facilities acting as amplifiers of the out-break.10 The response should be accessible to patientsand promote effective community engagement neces-sary to overcome stigma and fear. It should act to helpgeneral healthcare services reduce the high levels ofnon-EVD mortality attributed to an outbreak,11 andreduce the high levels of HCW infections.12 It should besustainable and ideally contribute to building moreresilient healthcare and outbreak response systems.Resilience in a health system has been defined as ‘thecapacity of health actors, institutions, and populations toprepare for and effectively respond to crises; maintaincore functions when a crisis hits; and, informed by

lessons learned during the crisis, reorganise if condi-tions require it.’13 Finally, it should limit EVD-associateddeaths and be suited to a low resource environment withlow financial costs for both start-up and maintenance,and with resilience in HCW staffing.This article describes the EHU model developed and

implemented by the Ministry of Health and Sanitation(MOHS) and King’s Sierra Leone Partnership (KSLP)(box 1) in Freetown, Sierra Leone, since March 2014.We discuss the role of EHU within government hospitalsin Sierra Leone in relation to these ideal characteristicsof EVD response, the relevance of EHUs in future EVDoutbreaks, and the role of EHUs within the portfolio ofdelivery platforms that are necessary to respond to EVDoutbreaks.

EHU modelThe MOHS, with the support of KSLP and other inter-national partners, established EHUs at hospitals inFreetown in May 2014, before the country’s first case ofEVD. The original protocols for these units were adaptedfrom pre-existing WHO international guidelines onEVD.15 Initially a two-bed EHU at Connaught Hospitalwas opened. Connaught Hospital played a crucial role intransporting patients before the Western Area EbolaResponse Centre and its ambulance fleet were fully estab-lished. As the outbreak escalated in Freetown in August2014, KSLP and MOHS increased Connaught Hospitalbed capacity to 9, then to 16 beds with two child cots,and later opened four further units in Freetown and sup-ported the construction of two others. Advice and clinicalsupport were also provided to several other centres on anad hoc basis. The EHUs were located within the groundsof government hospitals, either within newly-built adja-cent structures or repurposed existing buildings. All

Box 1 Description of King’s Sierra Leone Partnership(KSLP)

King’s Health Partners (KHP) is one of six UK academic healthscience centres. Since January 2013, KSLP has been led by KHPin-country staff, and supported by academic, clinical and adminis-trative staff from across KHP alongside focused short-term tripsby subject experts and international volunteers. KSLP aims tostrengthen the health system across a number of domains: clin-ical services; health professional training and education; andpolicy development that are underpinned by cross-cuttingresearch through its support of Connaught Hospital (the country’sonly adult referral hospital), the Ministry of Health and Sanitation(MOHS), and the College of Medicine and Allied Health Sciences.In March 2014, KSLP was invited by MOHS to contribute to thenational Ebola Case Management Taskforce. The team built onexisting documents to help develop national hospital guidelinesfor triaging patients, and developing safe isolation and testing.14

KSLP helped establish Ebola Holding Units attached to MOHShospitals, advised other facilities on preparedness, trained staffand supported a command and control centre for managing case-load in hospitals across the Western Area of Sierra Leone.

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patients were screened for EVD at the entrance anddirected as appropriate to the general wards, outpatientclinics or the EHU. The EHUs isolated screened orreferred suspect patients, provided initial clinical care,undertook laboratory testing to confirm EVD status,referred onward positive cases to an ETC or negativecases to the general wards, and safely stored corpsespending collection by burial teams (see figure 1).There are four main goals behind the development of

EHUs situated within or adjacent to existing health facil-ities where cases are likely to present. These are:16

1. Reduction of cases in the local community: throughrapid isolation of symptomatic and suspect EVD casesto prevent onward transmission, with prevention ofnosocomial transmission through patient separationand regular decontamination of surfaces and floors.

2. Improved survival of isolated patients: through provi-sion of safe medical care, including antimalarial andantimicrobial treatment, encouragement and assistanceto eat and drink, regular assessment of hydration andclinical status, and symptomatic pain and sickness relief.

3. Maintenance of general non-EVD healthcare:through prompt diagnosis of EVD and onward trans-fer of patients to dedicated ETCs, alongside theexclusion of EVD and triage of negative patients intooutpatient or inpatient facilities for general care. Thisallows for the essential continuation of paediatric vac-cination, maternal and child health, HIV and tubercu-losis programmes and general medical and emergencysurgical care within the hospitals. This is only possiblethrough screening at point of entry into the

healthcare facility to reduce the risk of EVD introduc-tion into the outpatient or ward environment.

4. Reduction in healthcare worker infections: throughstaff training inside the EHU, and infection preven-tion and control strengthening on general wards.This is not only an important goal in its own rightbut is also essential for avoiding closure of facilities,and thereby achieving goal three given above.The MOHS had overall strategic leadership of the

EHUs at all times and took responsibility for: makingbuildings or space available for the facility; posting localhealth workers and cleaning staff; paying hazard pay andstaff salaries; providing personal protective equipmentand medical supplies; and ensuring that support func-tions, including ambulances, laboratory transport andtesting, and burial teams, were available.KSLP (with the support of other organisations, such as

the international non-governmental organisation GOALfor construction) worked with local colleagues to: designand construct the facility; train local staff on safety andpatient care; develop local clinical pathways; oversee clin-ical care and troubleshoot problems or difficult cases;develop administrative systems such as stock systems andpatient records; provide additional manpower (particu-larly at the physician level) and role-modelling; andprovide additional medical supplies, where items werenot available or in short supply through the governmentsupply chain.There were regular assessments of safety, efficiency

and quality of care conducted jointly by the MOHS,KSLP and independent specialist agencies such as the

Figure 1 Simplified patient flow within an Ebola Holding Unit (EHU). DSOs, disease surveillance officers.

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WHO and US Centres for Disease Prevention andControl (CDC). All sites were regularly assessed by KSLPover three domains: infection prevention and control;clinical care; and operational performance.Integration within the wider Ebola response was essen-

tial and the Government of Sierra Leone, with thesupport of KSLP and other agencies, established aWestern Area Ebola Response Centre on 8 September2014 that, among other activities, directed case manage-ment flow. This coordinated the transfer of suspect casesfrom the community and from facilities already at cap-acity into EHUs, communicated laboratory results withfacilities, synchronised transfers of confirmed patientswith EVD to treatment centres or burial teams, andinformed relevant surveillance networks. It also allowedfor early warning of potential problems at peripheralEHU sites.

OutcomesBetween 29 May 2014 and 19 January 2015, our fiveEHUs had isolated ∼37% (1159) of the 3097 confirmedcases within Western Urban and Rural districts17 beforetransfer to dedicated ETCs for onward management.Figure 2 highlights the construction of these EHUs at atime when cases were exponentially increasing in SierraLeone, particularly in the Western Area, from early July2014; figure 3 shows their physical location. On average,nearly half (45%) of all isolated suspects wereEVD-positive, with limited discriminatory features seenin cases.18 A further 1412 patients were tested, andeither discharged or entered the general medical systemfor onward care. Nosocomial transmission of EVD withinthe EHUs appears to be lower than that previously docu-mented at other facilities during the outbreak,19 with a

positive readmission rate of 1–3% across all units(Ministry of Health and Sanitation and King’s SierraLeone Partnership—unpublished operational data). Alleight staff infections were fully investigated by the CDCHCW infection team—one was attributed to a break inpersonal protective equipment (PPE) on opening amedication vial, one to inadequate decontamination,two due to provision of medical care outside of theEHU, and the others thought to be associated with com-munity transmission outside of their role in the hospital.Total construction costs of all sites was <$50 000 for 79beds. Start-up times were rapid, with average lead timesof 1 week for units to become operational (see table 1).Staffing was in the main performed by local HCWs andcleaners, though Connaught Hospital, the principleadult referral hospital in the country, received moresupport in terms of international staffing and oper-ational input than the other units. These were largelysupervised by one or two international staff who regu-larly visited and maintained telephone communicationwith the site supervisors.15

DISCUSSIONOur experience demonstrated that EHUs can be a safeand effective model of care that has a number of keystrengths. By co-locating EHUs in existing medical facil-ities, these were able to detect new chains of transmis-sion by screening walk-in patients who had anon-specific febrile illness and were seeking generalhealth services. Screening and early isolation of thesepatients protected both HCWs and patients withoutEVD from nosocomial transmission on the generalwards. This enabled the health facilities to remain open

Figure 2 Ebola Holding Unit (EHU) Bed Capacity in the Western Area Urban and Rural Districts (hospital, date opened, total

bed numbers—red line KSLP-supported MOHS sites, blue line—other MOHS and NGO sites) mapped against total number of

suspect cases in Sierra Leone. KSLP, KSLP, King’s Sierra Leone Partnership; MOHS, Ministry of Health and Sanitation.

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for non-EVD emergency care for the duration of theprotracted outbreak, whereas many other health facil-ities without EHUs had to be closed down. For example,before the construction of the EHU at RokupaGovernment Hospital, the hospital had 11 HCW infec-tions in 3 weeks. After construction of the EHU at thishospital, there were none.Suspected patients who tested negative for EVD but

had another serious illness (such as appendicitis or life-threatening complications of HIV) could immediatelyaccess further inpatient or outpatient care within thesame facility. Our experience was that the EHUs weresafe for staff and patients, provided reliable diagnosesand initiated early bundles of care covering a variety oflikely pathologies (P Arkel, D Youkee, CS Brown, et al.Quantifying the risk of nosocomial infection withinEbola Holding Units: a retrospective cohort study ofnegative patients discharged from five Ebola HoldingUnits in Western Area, Sierra Leone. Paper submitted toTropical Medicine & International Health; March 2016).The EHU model has system-wide benefits. Using exist-

ing facilities meant that EHUs could be deployed earlyin the outbreak, and rapidly constructed.20 Start-uptimes were rapid due to the benefits of utilising existinglogistics, waste management facilities and staffing sche-dules. It was much less expensive to adapt existing struc-tures than to build new sites. Together these reducedresourcing requirements, such as capital expenditure orinternational or national health workers, which freed upresources to be deployed elsewhere. The use of existing

supply chain and other government systems reduced theneed for parallel structures that were expensive andchallenging to establish, and risked undermining locallong-term systems. Leadership of the EHUs by theMOHS and local HCWs could be maintained, therebybuilding up local institutional capacity and helping toensure local ownership and community acceptance.Integration within the MOHS allows the EHUs to coord-inate effectively with other aspects of outbreak response,thus strengthening the health system alongside the EVDresponse.EHUs also demonstrated flexibility and could be

adapted as the epidemic grew and receded. In EVDendemic countries, such as Uganda and the DemocraticRepublic of the Congo, sporadic re-emergence is anongoing concern. Capacity must remain to isolate, testand treat EVD: this must be responsive, scalable andadaptive to local epidemiology. The EHU model workswell within a resilience framework.13 These can bediverse; in Freetown, they were located at primary andsecondary care facilities as well as specialist centres forobstetrics, paediatrics and psychiatry. They can be multi-functional and adaptive, allowing for the isolation andscreening of other potential outbreaks such as cholera,Marburg or Lassa fever; it might not be feasible tomanage diseases transmitted through the airborneroute, such as Middle East Respiratory syndrome(MERS), as different infection control methods arerequired. They can easily be reactivated to enable EVDcare with trained, on-site staff if and when the need

Figure 3 KSLP-supported MOHS Ebola Holding Units (EHUs). KSLP, King’s Sierra Leone Partnership.

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should arise. The hub and spoke model, usingConnaught as a base, allowed for resilience and staffsupport and training from a central site.Our experience also showed that the EHU model has

important limitations. The EHUs usually only providedisolation, diagnosis, and early treatment but then had torefer confirmed cases to ETUs for further care. Whereno ETU beds were available, patients sometimes had totravel for up to 6 hours by ambulance to remote ETUfacilities, which most likely had a detrimental impact ontheir outcomes. The medical care available to patients,while meeting national and international standards, wasrelatively limited; the EHUs did not have the capacity toprovide all patients with intravenous fluids or haveaccess to novel therapeutics that were being trialled.These challenges were not unique to EHUs, but therewere some factors about this model that made certainprocedures more difficult or risky for staff: utilising exist-ing buildings limited the ability to optimise layout andinfection control processes; and EHUs operated withmuch lower staffing numbers compared to other typesof facility, as well as relying largely on governmenthealth workers who were often less well paid or highlyqualified than international counterparts. Higher staff topatient ratios and more senior supervision for staffwould enable higher standards of care to be provided,and indeed this was achieved at some EHUs later in theoutbreak.The EHUs were most useful in an urban setting,

where there was easy direct patient access to a secondaryor tertiary care facility: they were able to pick up anddetect new cases that presented to hospital in a settingwhere contact tracing was very challenging; they couldutilise existing buildings in areas where there was littleor no open ground for tented facilities; and could beestablished early in an outbreak and be kept open forlong periods with minimal resources, which was import-ant as new chains of transmission can rapidly be broughtinto urban hubs from rural areas with little notice.While EHUs are still relevant for hospitals in rural areas,community-based models of care may have a more sig-nificant role in this context. The function of EHUs waslargely restricted to medical interventions, with limitedinvolvement in community sensitisation or contacttracing. The use of pre-existing infrastructure sometimesmeant that optimal layout was difficult to achieve andcompromise was often necessary, such as having tolocate incinerators or screening points at sites distantfrom the isolation beds. However, sites did often haveappropriate physical locations, for example by beingadjacent to entrances, for ease of entry into the EHUfrom screening areas.The use of existing systems, such as medical supply

chain and risk allowance, had benefits; however, thiscould also add pressure to an overstretched system andcreate challenges. Managing this required effective col-laboration with government partners, flexibility (eg,switching to different types of PPE, when necessary),T

able

1EHU

data

ason19January

2015

Facility

Openingdate

Hospital

bed

capacity

EHU

bed

capacity

Start-up

(days)

Construction

costs

Total

suspects

isolated

Positivecases

and%

positivity

Average

staffing

International

staff

EHU

staff

infections*

Connaught

29May2014†

279

17

2$3674

1125

578(51)

60

85

MacauleySt15September2014

36

12

6$9642

243

108(44)

55

0.5

1

Newton

19September2014

24

15

7$9243

397

174(44)

40

0.5

2

Lumley

31October2014

32

12

8$19868

242

94(39)

35

0.5

0

Rokupa

1October2014

56

23

‡$7112

564

205(36)

72

10

Total

–427

79

–$49539

2571

1159(45)

262

10.5

8

*From

date

ofKSLPinvolvementwithsite.

†KSLPofficially

startingclinicalsupervisionin

theunitfrom

15August2014.

‡Siteinheritedfrom

otherpartner.

EHU,Ebola

HoldingUnits;KSLP,King’s

SierraLeonePartnership.

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and proactive troubleshooting when problems arose.Ultimately this worked well but we were unable to elim-inate the need for parallel systems completely; forexample, we needed a supplementary supply chain forsome items, and there were still challenges. Theseincluded staff strikes due to lack of hazard pay. Similarly,the partnership approach involved more stakeholders(local hospital, supporting partner, MOHS, donor) andthis could make decision-making slower and more chal-lenging. Managing this required trust, good communica-tion, mutual empathy and strong, and sustainedleadership from all sides.Overall we believe the EHU model achieved the four

goals set out in the introduction above, although giventhe chaotic, multidimensional and rapidly evolvingnature of the outbreak and the lack of good data it is dif-ficult to prove this or unequivocally show a causal rela-tionship. The EHUs will have significantly reduced thenumber of cases in the community, given that 1159 EVDcases were isolated in EHUs from the community in theWestern Area at a time when no other isolation bedswere available.21 The nosocomial transmission rates inEHUs have been shown to be extremely low and werecertainly lower than would have been achieved in ageneral hospital setting. We believe that EHUs in SierraLeone made an important contribution to reducingEVD transmission. There is no data on survival rates ofpatients with EVD who were isolated in EHUs comparedto those remaining in the community or presenting toother forms of facility; however, since all suspectedpatients were immediately started on treatments (such asoral rehydration and antibiotics) that are known toreduce EVD mortality, and since these were largelyunavailable in the community and there were no avail-able beds elsewhere, we can infer that EHUs reducedmortality for patients with EVD. Some, but not all,general health services were maintained in hospitalswith EHUs; the Connaught Hospital EmergencyDepartment remained open and general medicinewards remained largely at capacity during the outbreak,although other services were significantly reduced, suchas elective surgeries which were reduced by 97%. Theextent to which general health services were maintainedvaried between departments and across different hospi-tals, and varied over time. However, hospitals with EHUswere more likely to remain open. For instance, the Oladuring Children’s Hospital (the equivalent paediatrichospital to Connaught Hospital in Freetown) closedcompletely for 2 months from September to November2014 until an EHU was established and the hospital wasreopened. There were similar closures of hospitals inMonrovia, Liberia. The reduction of health worker mor-tality is a complex issue: many hospitals without aneffective EHU saw high levels of health worker infectionsand these infections reduced significantly when an EHUwas opened (as demonstrated above at RokupaHospital). However, the health worker infection rate wasnot eliminated completely in hospitals with an EHU;

since it is likely that the hospitals would have closedwithout an EHU and staff would have remained athome, it could be argued that EHUs kept staff at risk.However, many health worker infections occurred whenhealth workers provided informal care in the community(which would likely have increased if hospitals hadclosed) and without EHUs, the overall scale of the out-break would likely have been greater (putting everyonein the community, including health workers, atincreased risk). We believe that our data supports theclaim that EHUs largely achieved their goals.We learned a number of important lessons from our

involvement in the response to the Ebola outbreak inSierra Leone. An effective and resilient health system isthe cornerstone of any response to a health crisis and itis essential to invest in getting the basics right whentimes are good, before the emergency. We were too slowto challenge some of the conventional wisdom from pre-vious outbreaks, particularly the belief that EVD wouldnot cause major urban outbreaks. The Government ofSierra Leone and its partners ultimately did shift intoemergency mode, but we could have moved from a‘development’ mindset to a ‘humanitarian’ one morequickly, spending greater resources more rapidly, redu-cing bureaucracy, suspending non-critical activities andadopting a different relationship and form of communi-cation with partners. We demonstrated that governmentservices, including the public health system, are not onlycapable of playing a safe and central role in a healthcrisis and humanitarian emergency but are the fastestand most efficient way of doing so. We believe that sup-porting government health facilities as the primaryresponders to a crisis should be the starting place of anyinternational relief efforts through close collaboration.Crises often become protracted and are likely to recurin future. However, funding for any response soon startsto dry up once the height of the emergency is over; it is,therefore, advisable to plan for the long term even fromthe beginning, such as building permanent facilities ortraining local health workers. Finally, good commandand control can enable a far more effective use of exist-ing resources. For example, maximising the use of exist-ing bed capacity is more effective than building morebeds, but this requires up-to-date operational data andclear protocols for decision-making.

CONCLUSIONWe found that in Sierra Leone, EHUs were a flexibleand effective model of care to achieve rapid diagnosis,safe isolation, and early initial treatment before referralof confirmed patients with EVD to ETCs. We alsodemonstrated that it is possible for international part-ners and government facilities to collaborate closelyduring a humanitarian crisis. We believe our experienceis a successful example of how outbreak response can beintegrated into pre-existing health systems, and how thegovernment and international partners can collaboratein an integrated fashion. This approach had the

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advantages of being quick to establish, of providing long-term resilience for managing future outbreaks, and forbuilding broader capacity in the health sector.

Author affiliations1King’s Sierra Leone Partnership, King’s Centre for Global Health, King’sCollege London & King’s Health Partners, London, UK2Hospital for Tropical Diseases, University College London Hospitals, London,UK3Ministry of Health & Sanitation, Freetown, Sierra Leone4Connaught Hospital, Freetown, Sierra Leone5Department of Surgery, College of Medicine and Allied Health Sciences,University of Sierra Leone, Sierra Leone

Acknowledgements The authors dedicate this article to the memory of DrModupeh Cole, Dr Martin Salia, Sister Hajara Serry and Mr Abdulai Sesaywho were working in Connaught Hospital and died along with so many othersin the service of treating their fellow man.

Contributors OJ, DY, CSB, ML, AW, DB-T, AH, EH, IK, CK, AK, AS, ST, TBK,AL and BK contributed to the development and implementation of this modelof Ebola Holding Unit. OJ, DY, CSB and AJML wrote the manuscript. Allauthors have seen and approved the final manuscript.

Funding The UK Department for International Development funded the King’sSierra Leone Partnership for their activities in establishing the Ebola HoldingUnits and paid the open-access fees for publication.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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8 Johnson O, et al. BMJ Glob Health 2016;1:e000030. doi:10.1136/bmjgh-2016-000030

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health system functioningtreatment initiation, hospital safety and effective model for safe isolation, earlyin Sierra Leone: evidence for a flexible and Ebola Holding Units at government hospitals

Kamara, Andrew J M Leather and Brima KargboKamara, Amardeep Kamboz, Ahmed Seedat, Suzanne Thomas, T BDonald Bash-Taqi, Andy Hall, Eva Hanciles, Isata Kamara, Cecilia Oliver Johnson, Daniel Youkee, Colin S Brown, Marta Lado, Alie Wurie,

doi: 10.1136/bmjgh-2016-0000302016 1: BMJ Glob Health 

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