Experts Closest to Ebola Outbreak Testify

Daniel M. Keller, PhD

October 10, 2014

PHILADELPHIA — Excellent supportive care for patients suffering from Ebola can save lives, according to a physician who has spent recent months in the hotspots of the Ebola outbreak in West Africa.

"I think that supportive care is actually very specific care for most of the problems that we get into with Ebola virus," Robert Fowler, MD, from the World Health Organization (WHO) Department of Pandemic and Epidemic Disease, said here at IDWeek 2014.

Rehydration is a real key to management, beginning with oral rehydration, "but there comes a time very quickly, 4 or 5 days in, where people can no longer drink," he explained. At that point, intravenous or intraosseous fluids "have great promise for reducing the mortality of Ebola virus disease generally, even without specific medications."

Bruce Ribner, MD, from the Emory University School of Medicine in Atlanta, who treated the first two Ebola-infected patients brought to the United States from Africa, also emphasized the importance of high-level nursing and supportive care in treating Ebola patients in the United States.

Round the clock one-to-one nursing care allowed rapid responses to changing medical conditions, he said. Patients were also provided nutritional and physical therapy, instructions for self-care, and emotional support.

"At least one of our patients said to us, 'You know, I really thought you guys would bring me back here so that I could die on American soil.' It took a lot of effort to actually convince them 'No, we actually think we can help you survive this episode," Dr Ribner said.

Difficult Conditions in West Africa

The virus at the center of the outbreak in West Africa is Zaire ebolavirus, one of five species of the virus. For all the damage it can do, it contains a genome of only about 19 kilobase pairs containing seven genes.

Dr Fowler listed several clinical challenges in treating the disease in Guinea, Liberia, and Sierra Leone, including poor clinical resources, high mortality, lack of patient isolation, lack of access to family support, and problems mobilizing supportive care. Routine medications and diagnostic testing are not readily available. For example, although polymerase chain reaction testing is available, electrolyte testing is not. Even soap and water or alcohol-based rubs for hand cleansing are not always accessible.

The heat and humidity make wearing personal protective equipment a problem, and the equipment itself makes it cumbersome for healthcare workers to deliver care.

A culture of self-protection among these workers is lacking, and this problem is compounded by community myths and beliefs about transmission risks and ways to overcome them. Even the most basic standard infection prevention and control precautions are inadequate, as is triage, because of a failure to recognize presenting symptoms.

The WHO has published a pocket guide for front-line healthcare workers on the clinical management of patients with viral hemorrhagic fevers, with an interim draft for West Africa.

Another challenge has been getting people into a treatment facility early in the course of the disease. The typical time from initial symptoms to presentation has been 5 days or longer. "It is much better for outcomes to get people to treatment facilities earlier. Time to death is just over a week, and I think we could do much better on that if we had patients come in earlier," said Dr Fowler.

Part of the problem has been a reluctance to seek treatment. "The resistance has been because a lot of people aren't willing to acknowledge that the illness is real," he explained. However, over the past few months, Dr Fowler said he has seen this resistance give way to a realization that the disease is "very real and very deadly."

People who come into facilities often leave with some improvement in their condition, "and most of the population now is, frankly, clamoring to get into facilities," he said. "The challenge that we have is that often we don't have enough facilities to treat people or enough beds in those facilities."

The current mortality rate of about 70% (range, 50% - 90%) is higher than in previous outbreaks, so there might be something different now in terms of viral strain, by response, or by host response. "Maybe there's a lesson to be learned in terms of how we can approach some of the lowest mortality rates from some of the past outbreaks," Dr Fowler speculated.

Mortality risk appears to be age-related, with higher rates in older people. For patients younger than 40 years, mortality 28 days from symptom onset is about 20%, but for patients older than 40 years, it is about 80% (log-rank P = .0023).

Table. Mortality by Age

Age (Years) Number Mortality (%)
<15 218 73.4
15–44 1012 66.1
>44 398 80.4


Although Ebola-specific therapies, such as the monoclonal antibody ZMapp, need to be evaluated, more resources, personnel, and training are sorely needed, said Dr Fowler. Unless the international response improves, he warned, the situation will get worse.

Dr Ribner had just 3 days to prepare Emory staff and the facility for the arrival of two Ebola-infected patients after he got a phone call on July 30 from an air ambulance service. Fortunately, the facility had been practicing for just such an event and was equipped to handle it.

Planning for the event involved every department — emergency medical services, infectious disease, critical care, anesthesiology, other medical subspecialties, nursing, environmental management, security, and media relations.

The patients were isolated in Emory's biocontainment units, although the units were not really necessary because the virus is not spread through the respiratory route, said Dr Ribner.

He explained that the body weights of the patients increased by 15 to 20 kg, yet they were hypovolemic because of third-spacing and had vascular damage and low albumin. They lost 5 to 10 L of fluid a day, which requires "a Herculean effort to keep up with," he said. His patients were more than a week into their illness upon arrival and had hypokalemia, hypocalcemia, hyponatremia, and nutritional deficiency. In underdeveloped countries, the weight gain may not be as much because of an inability to keep up with fluid losses.

Viral RNA was detected on skin and in blood, urine, semen, vomit, stool, and endotracheal suctioning. However, it was not in dialysate, on environmental surfaces in the bathroom, or on high-touch areas on the day of patient discharge.

Protective Measures

Emory personnel followed CDC guidelines and wore gloves, gowns, eye protection, and face masks. Because of the volumes of fluid loss from the patients, staff also used leg and shoe covers.

Although the dedicated staff at Emory had undergone years of training, refresher training was required for all members before the patients arrived.

Lab specimens were packaged in category A containers, which consisted of leak-proof sample vessels, multiwalled packaging (including absorbent material), and rigid outer packaging. Still, commercial couriers refused to transport anything containing the Ebola virus from Emory to the CDC.

Although the CDC has said that sanitary sewers are adequate for the disposal of patient waste, this was not good enough for the county watershed department, which threatened to disconnect Emory if the Ebola virus was discharged into the sewers. Therefore, all liquid wastes were disinfected before flushing.

All regulated medical waste was autoclaved before the contractor picked it up, amounting to 350 bags of material that filled 218 boxes and weighed 3000 lbs.

Emory received extensive coverage in the media while the two patients were being treated. News trucks lined the surrounding streets, and news conferences were regular events. "Fortunately, we have a superb media relations department," Dr Ribner said.

The primary goal was to inform, educate, and allay fears. "Patient confidentiality and respect was paramount," said Dr Ribner.

To keep the hospital staff informed, the communications department organized town hall meetings and emailed updates to all staff. As well, each new inpatient received a letter explaining the situation and the key messages.

Much can be learned from the Emory experience, said Dr Ribner. First, patients with Ebola virus can be cared for safely in developed countries. Although it is not realistic to expect a zero mortality rate, it should be possible to achieve a much better rate than in areas with underdeveloped healthcare systems, he said. Another lesson learned is that internal and external communication is critical.

Dr Ribner said he also learned that patients with Ebola "are incredibly expensive to treat."

Dr Fowler and Dr Ribner have disclosed no relevant financial relationships.

IDWeek 2014. Presented October 8, 2014.


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