Experts call for increased focus on Ebola patients’ clinical care
In two recently published commentaries, health care experts argued that a renewed focus on clinical care could greatly reduce mortality in Ebola virus patients.
“It is often stated that there are no proven therapies for Ebola virus disease but that potential treatments, including blood products, immune therapies and antiviral drugs, are being evaluated. This view is inaccurate,” Ian Roberts, MB, BCh, FRCP, of the London School of Hygiene and Tropical Medicine, United Kingdom, and Anders Perner, MD, PhD, of the University of Copenhagen, Denmark, wrote in The Lancet. “Dehydration and electrolyte abnormalities are important causes of death for which there are proven treatments.”
Despite Ebola patients losing 5 L to 10 L of gastrointestinal fluid daily, the experts wrote that not all treatment centers administer proper IV rehydration or electrolyte substitution. This, they said, could contribute to the disease’s high mortality rate.
“Barriers to the more widespread use of parenteral fluids include time constraints on personnel, in particular shortages of nursing staff at night, and heat stress from wearing personal protective equipment in a hot climate,” Roberts and Perner wrote. “Overcoming these barriers and implementing practical protocols for managing fluids and electrolytes have not been given sufficient priority.”
Their sentiment is shared by Eskild Petersen, MD, of Aarhus University Hospital, Denmark, and Boubacar Maiga, MD, PhD, of the University of Sciences, Techniques and Technology of Bamako, Mali. In an editorial published in the International Journal of Infectious Diseases, they cited varying mortality and care reports from countries at the heart of the outbreak in their argument for more concrete treatment guidelines.
“If the difference in mortality between the report from Sierra Leone (72%) and Guinea (43%) are due to the use of intravenous fluid … it seems that intravenous fluid replacement may significantly reduce mortality in the treatment centers, perhaps by as much as 50%,” Petersen and Maiga wrote. “This can be done in the conditions prevailing in West Africa using pulse, blood pressure, body weight and urine output as guidance and using simple point-of-care tests for measuring electrolytes.”
These measures could be difficult to implement, Petersen told Infectious Disease News, due to the large number of physicians from nongovernment organizations that are not familiar with patients experiencing septic shock. As a result, he said, many inexperienced physicians and local health care workers are hesitant to provide necessary infusions due to the risk for infection.
“It’s mostly a lack of training,” Maiga said in an interview. “The local staff is not familiar with Ebola and is not well prepared to face so many severely ill patients at the same time.”
This challenge is exacerbated by the limited information available to aid workers. Despite the large number of Ebola cases being treated in West Africa, very little treatment data are being documented for study. According to the experts, this is a missed opportunity.
“There should be no objection to [randomized controlled trials] to resolve therapeutic uncertainties about fluid and electrolyte management,” Roberts and Perner wrote. “Pragmatic clinical trials in critically ill patients are routinely done in high-income, middle-income and low-income settings and have led to major therapeutic advances. With a resolute focus on improving patient outcomes, patient involvement and full transparency, there is no reason why trials should undermine trust in health care workers or public authorities.”
Both pairs of researchers also argued for the establishment of well-defined protocols, with Petersen and Maiga calling on WHO to develop detailed diagnosis, IV fluid replacement, electrolyte management, comorbidity screening and data reporting guidelines. Such measures could reasonably be implemented under West African field conditions and, according to Roberts and Perner, would “substantially reduce case fatality.”
“Ebola treatment centers must be more than a setting for quarantine,” Roberts and Perner wrote. “Patients will be reluctant to attend treatment centers unless the care they receive from them is superior to the care provided by family members. Treatment centers must be a setting where the best information is applied in the interest of improving patient outcomes, and where valid information is generated in the interests of future patients.” – by David Muoio
Roberts I. Lancet. 2014;384:2001-2002.
Petersen E. Int J Infect Dis. 2014;doi:10.1016/j.ijid.2014.12.002.
Disclosure: Maiga, Perner, Petersen and Roberts report no relevant financial disclosures.