Nutritional Care for Patients With Ebola Virus Disease

Mija Ververs; Magi Gabra

Disclosures

Emerging Infectious Diseases. 2020;26(1):20-25. 

In This Article

Results

We identified a total of 429 articles (Figure); 268 articles remained after deduplication. We excluded 240 articles after screening for information on nutrition or feeding during care for Ebola patients; content that caused exclusion included animal and bushmeat consumption in relation to Ebola transmission, testing and safety of breast milk in seropositive patients, food availability, malnutrition, agricultural stability before and during Ebola outbreaks, pharmacologic experiments for Ebola treatment, and molecular studies on the pathogenesis of Ebola virus. We completed full-text review on the remaining 28 articles. We excluded 5 non-English articles and added 1 more article identified from gray literature, resulting in review of 24 articles.

Figure.

Flowchart summarizing literature search and selection process for review of nutritional care for patients with Ebola virus disease.

Most of the articles (n = 14) on nutritional support during Ebola treatment were case studies, cohort studies, or management recommendations focused on the clinical features, care provided, and outcomes observed.[2–15] Four articles focused solely on patient care provided in the United States and Europe.[5,6,8,14] Six described patients in West Africa during the 2014 outbreak: 3 in Sierra Leone,[3,4,11] 1 in the Democratic Republic of the Congo,[9] 1 in Liberia,[2] and 1 in both Liberia and Sierra Leone.[15] One particular study was a prospective cohort study on the effects of supplemental vitamin A on disease mortality rate.[15] Two articles were field manuals, one an emergency interim country guidance for clinical management[16] and the other a list of essential medications for Ebola patient care.[17] One article provided evidence-based guidelines for patient care using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.[18] One was a systematic review of current trends of Ebola virus management.[19] Two articles were analyses of policies and programming regarding infant feeding[20] and nutrition.[21] An editorial on nutritional management of patients with Ebola virus disease[22] and a comment published on the overall changes in care for Ebola virus disease[23] were included, as well as a personal report of a nurse's experience in the field while working in an ETU.[24] The final item was a letter from a nutrition advisor during the Ebola outbreak,[25] which we identified from gray literature.

Despite the initially large number of papers with the key search term "nutrition" related to EVD case management, few explicitly described the details of the delivered nutritional support. Most clinical management papers delineated supportive care for dehydration and electrolytes through oral rehydration solutions (ORS) or intravenous fluid administration and did not refer to nutrition. Two studies and a retrospective review concluded that dehydration was associated with worse outcomes and increased mortality rates in patients.[7,9,11] Both Leligdowicz et al.[7] and Smit et al.[11] included electrolyte imbalance as an additional risk factor for poor outcomes. Smit et al. found that poor nutritional status was also associated with increased mortality.[11] The systematic review by Sivanandy et al. noted that nutritional care should include a "good amount of protein supplements" but did not specify a recommended amount or type of protein.[19]

The evidence-based recommendations produced by Lamontagne et al. supported the importance of hydration in supportive care and monitoring serum biochemistry for electrolyte repletion.[23] In creating the recommendations, a multidisciplinary panel met to analyze data on supportive care and voted to create a list of evidence-based guidelines. The panel strongly recommended administering ORS in an adequate amount, rather than using nonstandardized rehydration. The panel also strongly recommended that serum biochemistry (e.g., testing of electrolytes, glucose) should be made available, but the group did not produce any statements on nutrition.[18]

Clinical Cases

Johnson et al.[5] and Uyeki et al.[14] described total parenteral nutrition (TPN) in patient care in the United States and Europe. Patients treated in the biocontainment unit at the University of Nebraska Medical Center had a "moderate state of protein malnutrition" at admission, but protein malnutrition was not defined.[5] A nutritional therapist was consulted for both cases and TPN was started, but further details were not provided. In another case study, a patient treated in Hamburg, Germany, did not tolerate enteral nutrition, and so the treatment team initiated TPN.[6] When the patient showed improvement, enteral nutrition was reinitiated with a low-fiber standard formula; the authors did not provide details of the diet. A physician turned patient hydrated himself with a commercial sports rehydration beverage and a sugary drink mix before seeking treatment at Emory University Hospital in Atlanta, Georgia, USA, where he was given protein drinks and multivitamins. No information on the content of the protein drink or the frequency of use was provided.[8] Similarly, a case study of 581 patients in an ETU in Freetown, Sierra Leone, documented the use of 1 capsule of ImmunoBoost nutrition supplement (Novopharm Formulations, http://www.novopharm1.com per day and ORS and juice drinks consumed freely.[3] However, the authors did not describe treatment rationale or composition.

In a recent study, Aluisio et al. assessed oral vitamin A supplementation in 424 patients admitted to ETUs in Sierra Leone and Liberia in 2014–2015.[15] Mortality rate was significantly lower among patients who had received 200,000–400,000 IU of vitamin A in the first 48 hours of admission, compared with those who had not received vitamin A at admission (Relative Risk = 0.77, 95% CI 0.59–0.99; p = 0.041). An editorial published in the Asian Pacific Journal of Tropical Disease provided specific recommendations on the energy, protein, fat, and micronutrient components for the nutritional management of EVD patients.[22] The authors recommended the following: achieving a protein requirement of 1.2 g/kg of ideal bodyweight, 55%–60% of total energy needs via carbohydrates, provision of soft foods to avoid gastrointestinal irritation, and avoidance of trans-fatty acids. It is important to note that there were no references to clinical research or case studies of patients with EVD to support these recommendations.

A nurse's account of her experience working in an ETU in Liberia provided some insight on actual feeding practices.[24] Wilson reported that a locally popular artificial juice powder composed of mostly sugar and vitamin C (Foster Clark, http://fosterclark.com) was occasionally mixed with the ORS to increase palatability. In addition, patients received 3 meals, individually packaged in plastic bags, daily. Patients who were well enough often consumed food purchased or cooked by family or loved ones.

Pediatric Nutrition

Trehan et al. published 2 papers with extensively detailed nutritional care specifically for pediatric patients with Ebola virus disease.[12,13] Recommendations included, though were not limited to, assessing nutritional status using mid-upper arm circumference, providing ample ORS and therapeutic milks (F-75, F-100; Nutriset, https://www.nutriset.fr), and serving ready-to-use therapeutic foods (RUTF) in biscuit and paste form. To improve hydration and intake, flavored ORS solutions were recommended if available, although drinks with added sugar were not recommended because they may exacerbate diarrhea. RUTF pastes and biscuits were 2 examples of energy-dense foods with complete micronutrient and macronutrient composition that retain taste and cleanliness for extended periods and are easily consumed by weak patients. The authors recommended the prioritization of RUTF over local foods in the acute phase of the illness. Instructions were included on how to prepare RUTF to produce a semi-solid porridge for easier consumption and described the minimum quantity of RUTF (for children <15 years varying from 2 to 5 sachets with RUTF paste or 3 to 8 RUTF biscuits). For infants <6 months of age, the authors recommended ready-to-use infant formula. For children >6 months of age who were only able to tolerate liquids, the authors recommended therapeutic milks over dairy milk or commercial infant formulas because of the increased nutritional content. Although it was more nutritionally complete than F-75, F-100 therapeutic milk was not endorsed for all pediatric patients because its higher osmotic load compared with that of F-75 may cause increased diarrhea. The authors recommended that formulas be refrigerated and prepared multiple times a day to avoid spoiling.

A nutrition advisor described infant feeding methods to reduce mother-to-infant transmission.[25] Because feeding utensils and human-to-human contact carried an increased risk for transmission, the author reported the use of a syringe attached to a feeding tube to safely feed infants. Brandt et al. reviewed infant feeding policies and programming during the 2014–2016 Ebola outbreak and highlighted the inconsistencies of the messaging around breastfeeding.[20] They recommended including infant and young child feeding experts in outbreak response and creating consistent, appropriate, and tailored messages regarding breastfeeding and infant nutrition in the early phase of the response.

Perception of Nutrition Response

One descriptive qualitative study of key informants analyzed community perceptions of the nutrition-related response in Guinea.[21] That study had 2 main objectives: the first was to determine how the Ebola outbreak affected infant and child nutrition on a community level, and the second was to gauge stakeholders' perception on the acceptability and effectiveness of the nutrition response, including the WHO/UNICEF/WFP 2014 interim guidelines for nutritional care. A consistent theme across informants was the lack of emphasis on nutrition by health professionals and community members during the Ebola outbreak. Key informants also noted limitations around the use of the WHO/UNICEF/WFP interim guidelines; some informants were unaware of the guidelines or questioned their usefulness, and some reported finding the guidelines useful but difficult to implement. The authors recommended that nutrition be a core component of response and integrated into all aspects of care, treatment, and recovery.

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