Panafrican Medical Journal

RESEARCH Awareness and utilization of female condoms among street youths in Ibadan, an urban setting in South-West Nigeria Obioma Chukwudi Uchendu et al. Condoms are the only method available technologically that prevents against several STIs including HIV and unwanted pregnancies. It has been found to be very effective compared to other forms of contraception. Female condom awareness and use have been poorly documented in sub-Saharan region especially among street youths. READ MORE Healthcare seeking behaviour for common infectious syndromes among people in three administrative regions of Johannesburg, South Africa, 2015: a cross-sectional study Relebogile Mapuroma et al. In South Africa, tuberculosis, influenza and pneumonia were among the top ten causes of death in all age groups in 2014-2016. In 2016, of 456,612 total deaths reported, tuberculosis was responsible for 29,680 (6.5%), and pneumonia and influenza for 19,634 (4.3%). In children under 15 years of age, intestinal infectious diseases and central nervous system inflammatory diseases were in the top ten causes of deaths in 2016. Hospital-based surveillance programs only capture people presenting to facilities and may underestimate disease burden. READ MORE

IMAGES IN CLINICAL MEDICINE Nodule-forming pseudoangiomatous stromal hyperplasia of the breast: case report Faten Limaiem et al. Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign proliferation of fibrous stroma, containing slitlike pseudovascular spaces lined by myofibroblasts. Less than 200 cases of PASH have been described in the English literature with the largest series including 40 cases.  READ MORE Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign proliferation of fibrous stroma, containing slitlike pseudovascular spaces lined by myofibroblasts. Less than 200 cases of PASH have been described in the English literature with the largest series including 40 cases. A 48-year-old woman with no particular past medical history, presented with a complaint of a slow, progressive, painless left breast mass. The patient underwent mammography which revealed a well delineated left breast nodule with microcalcifications classified BI-RADS 4. An excisional biopsy was performed on the mass to confirm the histological diagnosis. The specimen was a well-circumscribed whitish tumor measuring 3 x 3 cm with several microcysts (A). Histological examination revealed proliferation of fibrous stroma, with spindle cells and a network of slit-like empty clefts within acellular hyalinized stroma (B). The spindle cells were positive for CD34 and smooth muscle actin but were negative for Factor VIII. The final pathological diagnosis was nodular PASH. Postoperative course was uneventful and the patient is still being followed-up. Corresponding author: Faten Limaiem, Department Of Pathology, Mongi Slim Hospital, La Marsa, Tunisia fatenlimaiem@yahoo.fr  ©Faten Limaiem et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Mounier-Kuhn syndrome Badreeddine Alami et al. A 39-year-old man presented with a productive cough, a history of chronic dyspnea and recurrent lower respiratory tract infections. Physical examination and laboratory tests were unremarkable. READ MORE A 39-year-old man presented with a productive cough, a history of chronic dyspnea and recurrent lower respiratory tract infections. Physical examination and laboratory tests were unremarkable. A chest X-ray (A) showed an enlarged tracheal diameter (white arrows), with multiple cysts in the lower lobes (red arrows). A computed tomography scan of the chest (B) showed the dilatation of both the trachea and the two main bronchi (white arrows) with multiple diverticulae (blue arrows). It also revealed bilateral cystic bronchiectasis involving both lower lung zones (red arrows). A possibility of Mounier-Kuhn syndrome (MKS) was considered. MKS is a rare condition characterized by recurrent lower respiratory tract infections and tracheobronchial dilation that is due to atrophy of the muscular and elastic tissues in the trachea and main bronchial wall. The patient underwent bronchoscopy which demonstrated tracheal dilation with diverticulae and enlargement of both main bronchi confirming the diagnosis of MKS. Corresponding author: Badreeddine Alami, Department of Radiology and Clinical Imaging, University Hospital of Fez, Fez, Morocco badr.alami@ymail.com  ©Badreeddine Alami et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

CASE REPORTS Susac syndrome: about two cases Fatoumata Ba et al. Susac's syndrome is an autoimmune endothelopathy affecting precapillary arterioles of the brain, retina and inner ear. This rare microangiopathy affects preferentially young women, 20-40 years old. No risk factor has been described. The picture is manifested by a triad: encephalopathy, occlusions of the branches of the retinal artery and hypoacusis. READ MORE Fatoumata Ba1,&, El Hadji Makhtar Ba2, Modou Mbacké Guèye1, Marième Soda Diop Sène2, Massar Diagne2 1Health Sciences Unit, University Gaston Berger, Saint-Louis, Senegal, 2Neurology Unit, Fann National Teaching Hospital, Saint-Louis, Senegal &Corresponding author Fatoumata Ba, Health Sciences Unit, University Gaston Berger, Saint-Louis, Senegal Abstract Susac syndrome is an autoimmune endothelopathy that affects precapillary arterioles of the brain, retina and inner ear. We report for the first time observations of two patients with Susac syndrome in Senegal. Introduction    Down Susac's syndrome is an autoimmune endothelopathy affecting precapillary arterioles of the brain, retina and inner ear [1]. This rare microangiopathy affects preferentially young women, 20-40 years old [2]. No risk factor has been described. The picture is manifested by a triad: encephalopathy, occlusions of the branches of the retinal artery and hypoacusis. But the triad is often incomplete at first, makes diagnosis difficult. It is a neurological pathology unknown and under diagnosed in our clinical practice. Until now, to our knowledge, no case of Susac syndrome has been published in Senegal. We report two clinical observations of strong suspicion of Susac syndrome. Patient and observation Up    Down Case N°1: a 49-year-old man with a history of recurrent bronchitis and profound deafness occurred at the age of 30, was admitted to the Neurology Unit of the Fann National Teaching Hospital for complex epilepsy drug-resistant. The anamnesis showed that the disorders started from infancy, by frequent crises: 1) sometimes generalized from the outset; 2) sometimes hemi- corporeal at the beginning then secondarily generalized; 3) sometimes complex partial with verbalization; 4) sometimes in the form of dreaming confusion or absences. A therapeutic dose of Phenobarbital, Carbamazepine, Keppra and Depakine, was successively given to the patient. For six months, the intensity, duration and frequency of seizures have worsened. Seizures were associated with temporo-spatial disorientation, attention and memory deficit. The neurological examination concluded to deafness, tremor attitude and bradypsychia. The remainder of the exam was entirely normal, as were the ocular examination, the biological and the hydroelectrolytic balance. The electroencephalography, done twice, at one-year interval, showed a bifronto-temporal irritative focus. Cerebral MRI, also done twice, at one-year interval, did not detect any abnormality. The recording of early auditory evoked potentials showed bilateral cochleo-vestibular neuropathy with severe perception deafness predominant on the right. The objective auditory threshold was 50 decibels (dB) on the left and 55 dB on the right. The audiogram showed a hypoacoustic perception predominant on low frequencies. The evolution has been marked by persistence of drug-resistant seizures, which have become more and more frequent. This required a transfer to Morocco to assess the indication of epilepsy surgery and/or the establishment of a neurostimulator. Case N°2: a 43-year-old woman, sickle cell AS, who had a history of two comitial seizures untreated two years ago, was referred to the neurology unit for complete bilateral perceptual deafness, sudden onset. History has shown that the disorders began a few weeks ago with the brutal onset of complete deafness in conversation. The audiogram performed revealed severe bilateral deafness predominating on the right. The clinical examination of this patient was entirely normal. The fundus oculi were normal, as the biological assessment and hydroelectrolytic balance. Early auditory evoked potentials (PEAP) recording showed severe bilateral axono myelin cochleo-vestibular neuropathy predominantly right-sided with bilateral perceptual deafness predominating in the right side. The objective auditory threshold was 50 dB on the left and 60 dB on the right. Cerebral Magnetic resonance imaging (MRI) found uncollected bilateral oto-mastoiditis without clinical symptoms. The patient was treated with corticosteroid, antibiotic and anti-inflammatory drugs. Despite this treatment, no significant improvement in the clinical picture was observed. However, the oto-rhino-laryngologist considered cochlear implants and the patient was operated with good results. The seizures were not repeated and a control electroencephalogram (EEG) performed was normal. Discussion Up    Down Susac syndrome is an unknown and under diagnosed pathology because of the often-incomplete clinical presentation at the beginning and the lack of specificity of the encephalic involvement. Both patients have neurological signs such as partial or complex convulsive seizures, drug-resistant or spontaneous remission associated with complete hearing loss. Retinopathy was absent in our patients, contrasting with the data in the literature. Ocular involvement was very common. Thus, Dörr et al., in their work, have shown that of the 304 cases published in recent years, 82% had exploitable data and among these 40% had ocular manifestations at the beginning of the disease and 97% during the course of the disease [3]. A complete eye examination should then be performed in the presence of any suspicion of Susac syndrome and repeated if necessary. Finding an occlusion of the branches of the retinal arteries, white retinal ischemia, the presence of soft nodules or cherry red spots were essential for diagnosis. MRI was normal in our patients, and in most cases reported, it was quite evocative with white matter involvement and brain micro-infarction. However, the delay to realize MRI was important, as abnormalities might appear during the course of the disease. Audiogram revealed severe bilateral deafness, according to the literature [4]. Electroencephalogram was often disturbed by Susac syndrome with encephalopathy, revealing diffuse brain suffering [5]. Therefore, the contributory nature of EEG to the diagnosis of Susac syndrome could be discussed. Patients were put on antiepileptic treatment (Case 1) and corticotherapy (Case 2) with antibiotics. This treatment differed from that proposed by Susac et al. [6], which might justify the fact that evolution was not favourable. Susac et al. protocol could be used as a test treatment, even in the absence of confirmation of diagnosis. Our limitation for reported cases was the lack of availability of retinal angiography. Conclusion Up    Down Susac syndrome affects all ethnic groups indiscriminately, although a high prevalence of the disease was noted in Caucasians. Because of the often-incomplete clinical picture, it is necessary to practise systematically a bottom of eye, a retinal angiography, an audiogram and a MRI in front of the slightest sign of appeal. We suggest to conduct other prospective and multi-center studies to determine the prevalence of the disease in Senegal, to give the socio-demographic characteristics of the affected population, the evolutionary modalities and to evaluate the therapeutic possibilities. Competing interests Up    Down The authors declare no competing interests. Authors’ contributions Up    Down Fatoumata Ba collected data and wrote this paper, El Hadji Makhtar, Modou Mbacké collected data, Marième Soda and Massar supervised this work. References Up    Down Pfaffenbach DP, Hollenhorst RW. Microangiopathy of the retinal arterioles. JAMA. 1973;225(5):480-3. PubMed | Google Scholar Garcia Carrosco M, Mendoza-Pinto C, Cervera R. Diagnosis and classification of Susac syndrome. Autoimmunity reviews. 2014;13(4-5):347-350. PubMed | Google Scholar Dorr J, Krautwald S, Wildemann B, Jarius S, Ringelstein M, Duning T et al. Characteristics of Susac syndrome: a review of all reported cases. Nat Rev Neurol. 2013;9 (6):307-316. PubMed | Google Scholar Papo T, Klein I, Sacré K, Doan S, Bodaghi B, Aubart-Cohen F. Syndrome de Susac. Rev Med Interne. 2012;33(2):94-98. Google Scholar Maillart E, Deschamps R, Moulignier A, Vignal-Clermont C, Obadia M, Le Mer Y et al. Syndrome de Susac: étude de cinq cas. Revue Neurologique. 2009; 165(6-7): 575-582. PubMed | Google Scholar Turc G, Monnet D, Rodriguez-Regent C, Touzé E. Le syndrome de Susac. Sang Thrombose Vaisseaux. 2011; 23(9):477-84. Google Scholar Non-traumatic splenic rupture revealed by acute renal failure Yawovi Mawufemo Tsevi et al. Nontraumatic or spontaneous ruptures of the spleen are rare but can be fatal. The diagnosis is often difficult. The delay in treatment and the severity of the underlying pathology explain the high rates of this mortality. Here is a case of rupture of spontaneous subcapsular splenic hematoma caused by toxic product and revealed by acute renal failure with intravascular hemolysis. READ MORE Yawovi Mawufemo Tsevi1,&, Eyram Yoan Makafui Amekoudi1, Kodjo Abossisso Sakiye2, Kwame Doh3, Kossi Akomola Sabi1, Komi Dzidzonu Nemi4, Kodjo Agbeko Djagadou4, Eugène Attisso1, Clement Kan Ackounddou5 1Service de Néphrologie et d'Hémodialyse, Centre Hospitalier Universitaire Sylvanus Olympio de Lomé, Université de Lomé, Togo, 2Service de Chirurgie Viscérale, Centre Hospitalier Universitaire Sylvanus Olympio de Lomé, Université de Lomé, Togo, 3Service d'Anatomo-pathologie, Centre Hospitalier Universitaire Sylvanus Olympio de Lomé, Université de Lomé, Togo, 4Service de Médecine Interne, Centre Hospitalier Universitaire Sylvanus Olympio de Lomé, Université de Lomé, Togo, 5Service de Néphrologie, Hémodialyse et de Transplantation Rénale du CHU de Yopougon, Université Felix Houphouet Boigny, Abidjan, Cote d'Ivoire &Auteur correspondant Yawovi Mawufemo Tsevi, Service de Néphrologie et d'Hémodialyse, Centre Hospitalier Universitaire Sylvanus Olympio de Lomé, Université de Lomé, Togo Résumé Nous rapportons dans ce travail un cas d'hématome sous capsulaire spontané rompu de la rate, induite par un toxique traditionnel, et révélé par une insuffisance rénale aigue avec hémolyse intravasculaire. [+] English abstract Introduction    Les ruptures non traumatiques ou spontanées, de la rate (RNTR) sont rares mais peuvent être mortels [1]. Le diagnostic est souvent difficile. Le retard de la prise en charge thérapeutique, ainsi que la gravité de la pathologie sous-jacente expliquent les taux élevés de cette mortalité [2]. Les RNTR peuvent survenir sur une rate normale ou pathologique. Elles nécessitent dans la majorité des cas une splénectomie [3]. Les causes non traumatiques telles que les maladies infectieuses, les maladies hématologiques et les cancers sont les plus décrites [2,4,5]. Nous rapportons dans ce travail un cas d'hématome sous capsulaire spontané rompu de la rate, induite par un toxique traditionnel, et révélé par une insuffisance rénale aigue avec hémolyse intravasculaire. Patient et observation      Il s'agissait d'une demoiselle âgée de 25 ans, étudiante, qui nous avait été référée du Centre Hospitalier de Kara pour une insuffisance rénale (IR) oligo-anurique avec une créatinémie à 2210µmol/l, urémie à 46 mmol/l et une anémie sévère à 5g/dl. Il faut noter la prise de médicament traditionnel (Figure 1) par voie orale et endovaginale il y a trois jours dans le but de régulariser son cycle menstruel. Elle ne présentait aucun antécédent personnel et il n'y avait pas de commémoratif familial de néphropathie. Elle était nuligeste nullipare et n'avait signalé aucun traumatisme abdominal notable précédant l'hospitalisation. L'examen clinique à l'entrée avait noté une pression artérielle à 120/80 mmHg, un bon état général, un syndrome anémique clinique, un abdomen légèrement augmenté de volume et des lésions ulcéreuses endovaginales. La première biologie a confirmé l'IR majeure avec 2652 µmol/l de créatinine et 50 mmol/l d'urée, l'ionogramme sanguin était normal, et la NFS notait une anémie sévère à 4,5g/dl et une thrombopénie à 88000 /mm3. Devant ce tableau, elle a été hospitalisé dans un service de soins intensifs, et avait été mise en hémodialyse quotidienne avec des séances courtes de 2 heures de temps et avait bénéficié d'une transfusion de 5 poches de culot globulaire. Trois jours après la patiente avait signalé des douleurs abdominales. L'examen de cet abdomen avait montré un abdomen souple, mât, augmenté de volume, sensible dans son ensemble avec un cri de l'ombilic. Le dosage des beta HCG plasmatique était négatif. Deux échographies abdominales réalisées tour à tour avaient montré un liquide anéchogène de grande abondance avec un utérus vide et non gravide. Une ponction exploratrice réalisée avait ramené un liquide hématique non coagulable. Les reins étaient modérément dédifférenciés de taille conservées. On notait ailleurs une hépatomégalie homogène aux pourtours régulier avec un pancréas normal. Une nouvelle biologie réalisée avait permis de noter la persistance de l'anémie malgré les transfusions itératives avec un taux d'hémoglobine à 6,2g/dl sans schizocytes, l'haptoglobine était normale, les LDH à 600 UI/l, une thrombopénie à 45000/mm3, un TP à 31 %, les D-dimères à 800 ng/ml. Il n'y avait pas de troubles phosphocalcique, l'électrophorèse des protides sériques était normale. Une tomodensitométrie abdominale réalisée avait permis d'objectiver un hématome sous capsulaire spontané rompu de la rate (Figure 2). Une prise en charge chirurgicale avec splénectomie totale avait été réalisée après correction des troubles de l'hémostase. L'examen anatomopathologique réalisé confirme qu'il s'agissait bien d'un hématome sous capsulaire avec fracture de la rate sans signe de malignité (Figure 3 et Figure 4). Les suites opératoires avaient été simples. Les séances de dialyse s'étaient poursuivies avec une crise polyurique survenue au cinquième jour post opératoire. Le bilan sanguin réalisé avait montré un taux d'hémoglobine à 10g/dl, les plaquettes à 135000/mm3, Un TP à 65 %, une urémie à 11,6mmol/l et une créatininémie à 530µmol/l. A 4 semaines de l'hospitalisation, elle a présenté une récupération partielle de sa fonction rénale qui s'est stabilisée autour de 265µmol/l de créatinine équivalent à une clairance MDRD calculée à 25,52ml/min/1,73m2. Discussion      À notre connaissance, aucun cas de rupture spontanée de rate secondaire consécutive à une prise de toxique traditionnelle n'a été rapporté. Dans la majorité des cas, une rupture de la rate (RR) est secondaire à un traumatisme abdominal. Les cas de rupture spontanés sont moins fréquents, mais les causes sont nombreuses et parfois iatrogènes (anticoagulant, thrombolytiques, coloscopie, cholangiopancréatographie rétrograde endoscopique) [6]. Dans notre observation, la rupture de rate semble être lié à la CIVD consécutive à la prise de toxique traditionnelle pour plusieurs raisons: l'absence connue de traumatisme abdominal précédent l'hospitalisation, la présence de stigmate de CIVD, et la présentation clinique compatible avec le diagnostic. Le diagnostic de la CIVD a été établi devant une thrombopénie, une élévation du TCA (2,1 fois celui du témoin), ainsi qu'une augmentation des D-dimères. Le dosage du fibrinogène plasmatique n'a pas été réalisé. Diverses étiologies non classiques des CIVD ont été rapportées dont les causes toxiques [7]. Ici, il s'agit de produit toxique traditionnel, qui pourrait entrainer un tableau d'hémolyse intravasculaire. L'association entre la prise de toxique traditionnelle, la CIVD, et l'insuffisance rénale a été rarement rapporté. Bien que certains travaux [8,9] démontrent clairement le rôle de l'hémolyse dans la survenue de l'IRA, ici il parait difficile d'imputer la cause de l'IRA exclusivement au toxique traditionnel. Dans ce contexte, une ponction biopsie rénale transpariétale (PBR) serait le moyen le plus à même de prouver l'imputabilité du toxique. Cet examen n'a pas été réalisé d'une part parce que jugé trop dangereux dans les conditions initiales de l'hospitalisation (présence des troubles de l'hémostase) et d'autres part à cause du refus de consentement de la part de la patiente et des parents. Le toxique retrouvé était fait à base de plantes traditionnelles conditionnées sous forme liquide dans une bouteille (Figure 1). L'analyse toxicologique n'a pas pu être réalisé. Bien que l'intérêt de la pharmacopée traditionnelle soit déjà prouvée dans certaines pathologies, dans nos pays de l'Afrique subsaharienne, il reste un cadre règlementaire basé sur l'analyse toxicologique et pharmacologique à développer. Conclusion      La rupture spontanée de la rate est une pathologie rare dont le diagnostic est très difficile en absence de contexte traumatique. L'échographie et le scanner permettent d'orienter le diagnostic. En dehors des causes classiques, la prise de toxique pourrait être une des étiologies et l'insuffisance rénale un mode de découverte. Conflits d'intérêts      Les auteurs ne déclarent aucun conflit d'intérêts. Contributions des auteurs      Tous les auteurs ont contribué à la mise en oeuvre de ce travail. Ils déclarent également avoir lu et approuvé la version finale du manuscrit. Figures      Figure 1: toxique traditionnelle conditionnée dans un bidon d'Evian Figure 2: TDM abdominale montrant la rupture splénique Figure 3: fracture de la rate Figure 4: hématome de la rate Références      Abbadi SE, Rhouni FZ, Jroundi L. Rupture spontané de la rate: à propos d'un cas et revue de la littérature. Pan African Medical Journal. 2017; 27:62. PubMed | Google Scholar Schwarz M, Zaidenstein L, Freud E, Neuman M, Ziv N, Kornreich L, Zer M. Spontaneous splenic rupture in infectious mononucleosis: conservative management with gradual percutaneous drainage of a subcapsular hematoma. Pediatr Surg Int.1999;15(2):139-40. PubMed | Google Scholar Farley DR, Zietlow SP, Bannon MP, Farnell MB. Spontaneous rupture of the spleen due to infectious mononucleosis. Mayo Clin Proc. 1992 Sep;67(9):846-53. PubMed | Google Scholar Black SR, Trenholme GM, Racenstelm M, Reich RS. Spontaneous rupture of the malarial spleen. Am J Med. 2001 Sep;111(4):330-1. PubMed | Google Scholar Massarweh S, Dhingra H. Unusual sites of malignancy: case 3, Solitary splenic metastasis in lung cancer with spontaneous rupture. J Clin Oncol. 2001 Mar 1;19(5):1574-5. PubMed | Google Scholar Wisniewski B, Vadrot J, D'Hubert E, Drouhin F, Fischer D, Denis J, Labayle D. Rupture spontanée de rate secondaire à une maladie des embolies de cristaux de cholestérol: à propos d'un cas. Gastroentérologie Clinique et Biologique. oct 2004;28(10):922-24. PubMed | Google Scholar Bollaert J, Annane D, Aube H. Coagulations intravasculaires disséminées (CIVD) en réanimation: définition, classification et traitement (à l'exception des cancers et hémopathies malignes). Réanimation. 2002; 11:567-74. Google Scholar Lacour B, Massy Z. L'insuffisance rénale aiguë. Revue Francophone des Laboratoires. 2013;43(451):55-58. Google Scholar Kissou SA, Cessouma R, Barro M. Insuffisance rénale aiguë et paludisme à Plasmodium falciparum: à propos d'un cas. Archives de pédiatrie. 2012; 19(1): 34-37. PubMed | Google Scholar

CASE SERIES Prevalence of hepatitis B and C in blood transfusion center, Oujda Morocco (2013-2015) Samira Boubker et al.   Hepatitis Virus B (HBV) and C (HCV) Viruses are a major public health problem worldwide. The World Health Organization (WHO) has estimated that 2 billion people have been infected with HBV and that approximately 350-400 million of them are chronic carries of HBV surface antigen (HBs Ag). Viral hepatitis is a serious public health problem. Its epidemiology is not precisely known in north Africa. READ MORE Diagnostic value of dipstick test in adult symptomatic urinary tract infections: results of a cross-sectional Tunisian study Foued Bellazreg et al. Urinary tract infections (UTIs) are common. They occur in 60% of women at least once in their lifetime and account for 23% of hospital-acquired infections. Clinical signs of UTIs lack of sensitivity and specificity and the definitive diagnosis is based on the isolation of a microorganism by urine culture. The diagnosis is confirmed by urine culture which is costly and takes at least 24 hours before results are known.  READ MORE

LATEST SUPPLEMENT WHO Response to Disease Outbreaks in Liberia: Lessons learned from the 2014 - 2015 Ebola Virus Disease Outbreak This special issue of the Pan African Medical Journal documents the successful application of lesson learnt from response to the Ebola virus disease outbreak in Liberia and identifies some best practices that could be applied to other disease prevention, control and elimination programmes with similar success. The papers, written by those who were actively engaged in response to epidemics in Liberia, cover critical topics in from preparedness and response to disease outbreaks, strengthening surveillance systems and integration as well as strengthening health workforce post Ebola virus disease outbreak. READ MORE