Although the situation in Sierra Leone with respect to Ebola has improved considerably since November, there are still cases in Freetown every day. With Ebola still present, it is important to stay vigilant and have a high index of suspicion. Every single person that enters the hospital compound needs to be screened according to the case definition, and anyone meeting the case definition needs to be isolated and tested. One positive case can infect many people, and that needs to be avoided.

However, it’s a skill to find a balance between isolating the right cases in an attempt to keep Ebola out of the main hospital and stop further transmission, versus not unnecessarily isolating cases in the unit since by doing so you may expose the patient to the virus in the unit. It’s not an easy judgment call and I applaud the clinical staff making these decisions multiple times a day. Unfortunately Ebola presents like a number of other illnesses, some of which are very common in children, like malaria, and so it really is hard to decide which children to isolate. Work is being done to try to refine the case definition for children in order to improve identification of possible Ebola cases.

At times it’s not only the children who are unwell, but also the caregivers, who are then also isolated and tested. Sometimes we have a group of siblings who are all unwell and so they are all isolated and tested. If the results are negative, it’s pretty easy, the patient/siblings/caregiver can either be discharged home or be transferred to the hospital for regular (non-Ebola) care. When the results are positive, it is also pretty easy, although sad, and the patient(s) is transferred to an Ebola treatment centre. The difficulty arises when you have a negative patient who is still highly suspect, or when the results for a group of patients that are related to each other are different.

What do you do when a mother tests positive and her child tests negative?

What do you do when two siblings test positive and one tests negative?

What do you do when a highly suspect child, with a contact history, tests negative and is very sick needing non-Ebola care, but possibly incubating the virus? Can she go to the general ward? Do you keep her in the unit with sub-optimal care and risk of more exposure?

This is when some difficult clinical decisions need to be made and fortunately we make them as a team during our morning briefing after I have shared the laboratory results. At that particular moment you do not know if the negative case is truly virus free, or if they are incubating the virus and may develop symptoms and start shedding the virus at any moment. It’s not until 21 days later that you really know and during that time they interact with many people. Experience during this outbreak has shown that children especially, can go from being well to being very sick in a matter of hours, testing positive for Ebola and posing a high risk to those around them.

I remember a mother who tested positive and her daughter tested negative. The mother died before she could be transferred to a treatment centre leaving the toddler, who was improving, behind in the unit. We knew the child had been highly exposed so we kept her in the unit in order to re-test her. However, by keeping her in the unit for two more days she was potentially exposed even more. It was a dilemma. The child tested negative the second time and was referred to an observational interim care centre (OICC), where they monitor asymptomatic exposed children for 21 days. If they become symptomatic, they are referred back to the unit for testing. If they remain healthy, they are discharged home or referred to an orphanage if the family cannot be located or if no suitable relative caregiver can be found. Fortunately we could discharge her to the OICC where she continued to improve on her antimalarial treatment and did not develop any other symptoms.

Sadly these situations do not only pose clinical challenges, but they also carry with them some severe psychological and emotional trauma. Siblings who have been admitted to the unit have watched their fellow siblings pass away. Some have watched on while their fellow sibling has been taken away to a treatment centre, not knowing what their brother’s or sister’s fate would be, and whether or not they themselves were yet to test positive, and whether or not they would be re-united. Mothers and fathers have watched their children die, either due to Ebola or non-Ebola diseases. And occassionally, children have witnessed their parent dying in the unit and being left alone. Recently I went to the unit and saw a mother with her child. I knew the child was positive. Sadly a sibling, also positive, had died only hours earlier. It was only a matter of minutes before a nurse would come to tell the mom that this child too was positive and would need to be taken away to a treatment centre. Unfortunately these are just some of the many stories.

We are all waiting for Ebola to end, but until that day, or actually until 42 days of consecutively having 0 cases in the country, we need to remain vigilant. All patients and visitors must be screened, patents on the wards must be monitored continuously and staff must use the appropriate protective equipment and exercise good clinical judgement.

Competing interests: None.

Sandra Lako is a doctor from the Netherlands who has worked in Sierra Leone for the past nine years. She spent the first half of her time setting up and managing a paediatric outpatient clinic with an organisation called Mercy Ships. She then joined Welbodi Partnership, a UK based charity supporting the only government run children’s hospital in the country. As country director, Sandra is leading the team to expand their work to the maternity hospital and a community hospital with the aim of improving the accessibility and quality of healthcare for women and children in Sierra Leone.