Monday, December 8, 2014

Ebola in Africa: Describing and Managing the Disease/ NEJM-MSF

The NEJM published a piece written primarily by Medicins Sans Frontieres clinicians who have worked in Liberia, describing the clinical course of Ebola patients, and concluding with the paragraph below, acknowledging the need to provide more comprehensive care than MSF was able to provide earlier in the outbreak.

I believe we are now arriving at a clinical consensus (see the Lancet article I posted on December 5, and the piece I wrote on November 30 seeking the "sweet spot" of doable, comprehensive medical care for Ebola in Africa) regarding what needs to be done, and what can be done, to significantly improve survival in Ebola patients.

Many questions remain,* but the basics of what should be offered by the Ebola treatment facilities that are being built, is crystallizing.  This is very good for Africa and for us, since if the epidemic is not ended in Africa we will be fighting it here.

I still want to push for a wall made from glass in these facilities, separating the "hot" and "cold" zones, so patients can be visually monitored by and converse with clinicians, without clinicians having to don stifling PPE to get a look at a patient.  The dehydrating effect of PPE on caregivers has limited each patient encounter to about one minute, according to these MSF authors. Here is their final paragraph: 
"... The central purpose of Ebola treatment units has historically been to isolate infected persons early in the course of disease — often soon after fever onset — in order to break the chain of disease transmission in the community. However, all efforts must be made to optimize the level of medical care provided within these facilities. Resistance by infected people to voluntary admission will persist unless the treatment facilities 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. Our observations support aggressive use of antiemetics, antidiarrheal medications, and rehydration solution to reduce massive gastrointestinal losses and the consequences of hypovolemic shock. Selective use of intravenous fluid therapy in the population that is most likely to benefit is a rational approach under the current circumstances. When possible, broader use of intravenous fluid therapy and electrolyte replacement, guided by point-of-service laboratory testing, is likely to significantly improve outcomes."
This echoes the storyline in the movie Field of Dreams: "If you build it, they will come."  If you can only provide oral rehydration fluids in a building made of plastic sheeting, they probably won't. And your epidemic will continue to grow.

UPDATE from The Guardian Dec. 20 reiterates this thought:
"Searches are required because people hide their sick relatives partly out of denial and fear of Ebola, but also because they see that they are getting poor care when they are diagnosed, he said. “One of our jobs at the hospital is to demonstrate that local patients will get the best possible care available.”'
*  Questions I have:
  1. Does it make sense to use antimalarials in all patients, particularly given some limited evidence of chloroquine efficacy against Ebola?
  2. What is an optimal empiric antibiotic regimen?
  3. Which lab tests are being used or can be instituted? (In the US, lab tests that have been adapted to use simple equipment so they can be performed at the bedside, without requiring a clinical laboratory, are termed "point of care" tests.  These tests can theoretically be performed right inside a "hot" area of an Ebola treatment unit with immediate results, by someone wearing PPE or by an immune caregiver.)
  4. Has an optimal oral electrolyte solution been established for Ebola?
  5. What is the latest information on rapid diagnostic tests for Ebola, to more quickly determine cases and non-cases?
  6. Are rectal tubes being used to reduce environmental contamination?
  7. Are oxygen concentrators available? Dialysis? Ventilators? Cardiac monitors?
  8. How effective are the available needlestick-protective gloves, for example this one
  9. Are they being used, decontaminated and reused, like rubber boots?
  10. What work is being done to design adequate informed consent processes for Africa?
  11. What level of clinical care is being provided by the newly opened Chinese hospital in Monrovia, which boasts air conditioning and electronic medical records? Why aren't journalists exploring this Ebola treatment unit, which is quite a leg up from what had been planned, so far, by western nations.

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