Ebola Mortality Can Be Sharply Reduced NOW, Given Enough Trained Personnel and Generally-Available Equipment
October 18, 2014 • 10:29AM

Dr. Nahid Bhadelia, director of infection control at Boston University’s National Emerging Infectious Diseases Laboratory, returned from fighting Ebola in Sierra Leone to tell a Harvard audience today, that early hydration and basic care are essential, and that many are dying from hypovolemic shock, which is a condition that occurs when too many body fluids are lost. The hospital where Dr. Bhadelia served in Sierra Leone had a 60% survival rate, as contrasted with the general mortality rate now estimated at 70-80% for this epidemic.

(Incidentally, when she was asked in August why she was leaving for Sierra Leone, the Indian-American doctor quoted Rabbi Hillel: “If not me, then who? And if not now, then when?”)

Similarly, six front-line doctors from Doctors Without Borders (MSF) and the World Health Organization contributed a short Sept. 24 article to the New England Journal of Medicine subtitled, Treating Ebola with Current Tools.

They write:

“Ebola evokes fear among both the public and clinicians. It also evokes a sort of therapeutic nihilism--after all, if there is no treatment, what can be done? And without an Ebola-specific antiviral medication, of what use are infectious-disease clinicians? Without oxygen, let alone mechanical ventilators, how can acute and critical care clinicians possibly contribute?

“We have traveled several times to West Africa and done primary patient care in treatment centers and hospitals in Guinea (Conakry and Gu‚ck‚dou), Sierra Leone (Kenema, Bo, and Daru), and Liberia (Monrovia, Bong, and Foya). Before each trip, we, too, felt a certain unease about treating a highly transmissible infection for which there is no vaccine, no specific therapy, and a high mortality rate. Yet we also appreciated that most viral illnesses, and certainly most critical illnesses, have no specific therapy. And after spending much of the past five months treating patients with Ebola virus disease (EVD), we are convinced that it’s possible to save many more patients. Our optimism is fueled by the observation that supportive care is also specific care for EVD--and in all likelihood reduces mortality. Unfortunately, many patients in West Africa continue to die for lack of the opportunity to receive such basic care.

“EVD presents much as many other viral infections do, with nonspecific signs such as fever, asthenia, and body aches. After a few days, however, the predominant clinical syndrome is a severe gastrointestinal illness with vomiting and diarrhea. Volume depletion with a range of metabolic disorders ensues, and hypovolemic shock ultimately occurs.

“A common assumption is that a lack of material resources constitutes the dominant barrier to clinical care. That is not the case. Intravenous catheters, fluids, and electrolyte replacement are readily available, but thus far are being used much too sparingly. When patients can no longer drink, placement of an intravenous catheter and delivery of appropriate replacement solutions are required, but we have seen many critically ill patients die without adequate intravenous fluid resuscitation.... Simple interventions can prevent deaths attributable to hypovolemia and metabolic abnormalities. The high mortality from Ebola continues to reflect the natural history of the illness, not an inability to alter its course.

“We believe we can and must do better in providing supportive care....

“Another common assumption is that a lack of skilled personnel constitutes a barrier to clinical care; this assumption is in fact valid. There is an insufficient number of clinicians to meet the primary and routine care needs of the population. Yet the skills needed to care for patients with Ebola are fundamental acute care skills, not the privileged domain of tropical medicine, infectious disease, or critical care.

“Though we recognize the potential incremental value of new antiviral options, we believe that EVD requires a greater focus on available basic care. We recommend that experimental therapy be introduced on a foundation of very good supportive care...

“With nearly 5000 cases to date, more than half of them in the past month, there is a pressing need to gain control of this epidemic. As we mourn the loss of nearly 3000 victims thus far, there is an urgency to prevent new cases, but also to reduce the case fatality rate.”