According to the Washington Post, NY's Bellevue Hospital plans to discharge Dr. Craig Spencer tomorrow. This is great news. Everyone who has been treated in the US, with the exception of Eric Duncan, has survived Ebola. All those we know about (9 people) were diagnosed and treated early, except Mr. Duncan.
This is an 89% survival rate, for a disease that was thought to have a 10-30% survival rate.
Does that mean Ebola is just another disease, and no match for the US healthcare system? Dream on.
Is early diagnosis and good ICU care all that’s needed to keep someone with Ebola alive? If so, why haven't we been given all the details about how to care for Ebola in America?
I have my doubts things will remain this bright. I have been trying to piece the treatments together from incomplete media reports. As more information accrues, I will report on it.
Here’s what seems to have occurred:
All those who survived got blood products from earlier survivors. Usually this was convalescent serum or plasma. Dr. Brantley donated to at least Dr. Sacra, to nurse Pham and to photojournalist Mukpo. [Why isn’t he (and all the other survivors) on a schedule to donate plasma regularly and freeze it for future cases, instead of calling him up and asking him to give a unit when needed?] Brantley received a transfusion in Africa from a survivor. Nancy Writebol donated blood to Dr. Spencer.
All survivors (and Eric Duncan) received one or more of a variety of experimental drugs or monoclonal antibody products, including TKM-Ebola, ZMapp and brincidofovir. There is no official word whether any of these were felt to be beneficial in their recipients.
At least two people each required renal dialysis for kidney failure and ventilation for respiratory failure. CDC now says that all Ebola patients should be handled in hospitals that can provide continuous renal dialysis.
Many other aspects of the illness caused by Ebola may have had specific treatments, but I have searched and found no information about this. For example:
- Cytokine storm is typical of Ebola, with extremely high levels of certain cytokines, like Interferon alpha. Has this been treated with immune suppressors, plasmapheresis or other modalities?
- Coagulation abnormalities such as disseminated intravascular coagulation, with both bleeding and abnormal clotting, often occurs. How has this been successfully managed?
- Ebola attacks endothelial cells, causing a capillary leak syndrome. Presumably this is managed in the lungs with ventilation. How is it managed in the rest of the body?
- Liver failure is characteristic of Ebola, as the virus has an affinity for liver cells. Liver failure is notoriously difficult to manage. Have any special therapies been used in this regard?
- Pancreatitis and adrenal cortical necrosis often occur. Ebola has tropism for the adrenal cortex. How are these conditions managed? Do patients need steroid replacement?
- Gram-negative sepsis: Meropenem and vancomycin were used for the Hamburg patient. Is this an ideal combination to start with?
I am surprised that the popular medical media have failed to discuss the ins and outs of managing an Ebola patient. Hopefully, America's medical journalists will soon get on this.
UPDATE Nov 13: Just discovered that the NEJM has a trove of free, full text clinical information on Ebola. In one Ebola patient treated in Hamburg, Ebola could be cultured from urine for up to 26 days, 9 days longer than from blood. Culture guarantees (unlike PCR) that the virus is live and infectious. Ebola RNA was present in sweat until at least 40 days after the onset of illness, though it could not be cultured. Sweat may have been contagious to some extent; it is unclear. He survived both gram negative sepsis and encephalopathy with coma.
At the same time, I learned from the Nov. 13 MSF webcast that MSF's clinical experience supported the notion that Ebola patients only became contagious with symptom onset. Never say never, but MSF has the most extensive experience with Ebola of any organization on the planet. CDC said patients may be at low risk of contagion before symptom onset. And the IOM gives 3 citations for information suggesting infection may be transmissible before symptom onset. (See footnote at bottom of this page.)
MSF said they are using more extensive PPE now than they used for an Ebola epidemic in Congo in 2012, without further explanation. Why?)
UPDATE Nov 14: A different patient treated in Germany had a similarly complicated course as the Hamburg patient, with coma, multi-organ failure, including kidney and respiratory failure. He received ventilation and renal dialysis, and a treatment with an experimental hemopurifier to reduce titers of virus and viral byproducts. He also received one (or more) unnamed experimental drug. His medical bill: 2 million euros, or 2.5 million US dollars.
UPDATE Nov 15: Dr. Rick Sacra was cared for by 40 healthcare workers while at University of Nebraska.
UPDATE: (I am finally reading the European press). Here is a quote from The Local:
Infectious diseases chief Bernhard Ruf of the St. Georg clinic in Leipzig, which treated a Sudanese UN official who eventually succumbed to the illness, said that there was “no way” any clinic could treat more than two Ebola cases.
And René Gottschalk, head of the Frankfurt public health service, said that more than 30 specially-trained carers were needed to take care of a single patient each day.
“We were shocked by how much spending and how many man-hours were needed to ensure the care of a single patient,” said Stefan Schmiedel of the Bernhard-Nocht clinic in Hamburg.The University of Nebraska has an informative website about its Ebola activities, as well as CBRN responses. Here is a colorful brochure on Nebraska's bio-containment unit, while below is a brief description:
Our unit is a secure, air-locked facility and operates on an air handling system that’s separate from the rest of the organization. Our highly trained team is perhaps our greatest defense. They have received many hours of highly specialized training and detailed instruction on how to care for these types of seriously ill patients. They would be using special, personal protective gear to control the spread of disease. We are national leaders in this area of response and care and will ensure every safeguard is in place to protect our staff, our other patients and their families.