While an effective, widely available cure for Ebola virus disease (EVD) remains a distant goal, good supportive treatment, especially rehydration, can make a difference, according to reports yesterday from doctors on the front lines of West Africa's epidemic.
On the basis of their experience in treating more than 700 patients in Monrovia, Liberia, a group of physicians wrote, "Given the massive fluid losses observed with EVD, oral antiemetics and antidiarrheal therapy appear to be important early interventions that may limit life threatening dehydration and shock."
They presented their conclusions in a perspective article in the New England Journal of Medicine (NEJM).
Similarly, a large team of doctors who treated Ebola patients in Conakry, Guinea, early in the epidemic said an emphasis on fluid and electrolyte replacement may have accounted for the lower case-fatality rate (43%) in a series of 37 patients than was seen in most other Ebola outbreaks and most other areas of Guinea at the time. They too published their findings in NEJM.
The doctors who worked in Liberia described the manifestations of EVD, beginning with a high fever and related symptoms, and followed by vomiting and diarrhea starting 3 to 5 days later. They reported that repeated vomiting often prevented patients from taking anything by mouth, and bouts of watery diarrhea began suddenly and persisted for up to 7 days.
Most deaths occurred between days 7 and 12 of illness, and symptoms began to improve in about 40% of patients on about the 10th day, the authors said. A few patients who seemed to be recovering died suddenly, possibly because of cardiac arrhythmias. Children under age 5, pregnant women, and elderly people were the most likely to succumb.
The doctors said they found that patients who had a reduced blood volume but were not in shock and could care for themselves had the potential to recover with the help of antiemetic and antidiarrheal treatment and rehydration with oral electrolyte solutions. These measures helped control symptoms, facilitated oral intake, reduced gastrointestinal fluid losses, and helped reduce environmental contamination by body fluids.
In addition, the authors said that patients who had low blood volume and were not in shock but couldn't care for themselves seemed to benefit the most from short-term intravenous (IV) fluid and electrolyte replacement. Routine use of IV fluid therapy, however, was prevented by "massive caseloads" and too small a staff.
The doctors note that Ebola treatment units historically have been used mainly to isolate patients and break transmission chains, but they said maximum efforts must be made to provide the best possible care in such units. Infected people, they write, will resist admission to treatment units unless they are seen as "a place to go for treatment and recovery and not as a place to die isolated from loved ones and the community."
Case series in Conakry
The doctors who worked in Conakry described their observations during the treatment of 37 patients in March and April, shortly after the outbreak was first identified. As reported here yesterday, 62% of the patients had diarrhea, and 84% had fever.
All but one (97%) of the patients received oral rehydration solution, and 28 (76%) received IV fluids, the World Health Organization (WHO) noted today in a statement about the study.
Sixteen of the 37 patients (43%) died. The authors said this fatality rate was lower than rates reported in most studies of previous Ebola outbreaks and rates in most other regions of Guinea at the time.
"Adherence to new guidelines promoting increased medical interventions, particularly related to the use of oral and intravenous fluids and electrolyte replacement, appropriate antibiotics, and targeted clinical laboratory testing, may have contributed to the reduced case fatality rate, as compared with past outbreaks," the authors wrote.
They acknowledge, however, that assessing links between treatments and outcomes in small observational studies is risky. Also, they note that a shortage of staff members resulted in care that was suboptimal.
The WHO commented, "Evidence of substantial fluid loss and profound electrolyte derangement associated with severe diarrhoea appears to increase the risk of a fatal outcome. More aggressive supportive care, especially intravenous rehydration, is thought to improve the prospects of survival."
The WHO statement also noted that (as reported here yesterday) that patients older than 40 were 3.5 times more likely to die than were younger patients.
Nov 5 NEJM perspective article
Nov 5 NEJM study
Nov 6 WHO statement