Skip to 0 minutes and 13 secondsMATTHIAS BORCHERT: The current treatment of Ebola is supportive because we still haven't got a specific treatment. And the most important element people would agree is the fluid management. So the avoidance and treatment of dehydration is of crucial importance. And oral rehydration goes a long way, particularly if you combine it with symptomatic treatment of diarrhoea and vomiting. But they're still-- there will be some patients who just cannot drink enough. Then, you need to think about ways how to give, for instance, IV fluids or fluids in another than the oral way. There is also subcutaneous infusion and intraosseous infusion. But IV would be the, the second choice. Now, that's sometimes difficult because you need to have enough staff to do that.
Skip to 1 minute and 7 secondsAnd you need to have well-trained staff and the right material. And there have certainly been moments where the providers were simply overwhelmed by the number of patients requiring this kind of care and have then been reluctant to give IV fluids.
Skip to 1 minute and 23 secondsCOLIN BROWN: There are challenges with intravenous hydration. And at the moment, we are looking at the best ways to address those. There are several challenges. One is that in the early stages of disease, there's a feeling that people, if given really good support to drink and if they've got adequate control of symptoms-- so we make sure that any abdominal pain they have is controlled, any nausea they have is controlled. That early intake of appropriate oral rehydration solution, maybe up to two to three litres a day, will be, offer significant benefit and may match the benefit that would be achieved with intravenous hydration. There are challenges with that as we've discussed. It's very time consuming.
Skip to 2 minutes and 3 secondsIt's quite laborious for the medical and nursing staff to spend significant time with people, encouraging them and coaching them to drink. In holding centres, there are problems giving intravenous hydration because there are people with Ebola and there are people without Ebola. And in people who are confused, who are not very mobile, who may be prone to falling off beds and pulling IV lines either unintentionally or intentionally when they're confused, there is serious concerns about staff safety and about the safety of other patients. So people tend to be thrombocytopenic. Their platelets tend to be low. They tend to bleed quite a lot. And it takes a lot of pressure to stop the bleeding.
Skip to 2 minutes and 45 secondsAnd we've seen cases whereby patients have pulled out inadvertently or intentionally intravenous lines and have bled profusely all over the floor. That's got staff safety issues. It's got, because the staff have to clean it up. The staff are potentially able to slip on blood spills. It's got patient cross contamination issues if you've got someone who's likely to have Ebola next to someone who may well not. In terms of how we measure the progression of disease and in terms of measure how we target therapy in West Africa and Sierra Leone compared to what we do in the UK, it's very challenging. There are no routine blood tests available anywhere in Sierra Leone.
Skip to 3 minutes and 24 secondsSo for everyone getting intravenous therapy, we have no idea what electrolyte disturbances they have. People are dying quite regularly and dying quite suddenly. We assume that that's likely from electrolyte disturbance.
Skip to 3 minutes and 35 secondsMATTHIAS BORCHERT: Another challenge is that over the scale of the outbreak, the lessons from earlier outbreaks are not forgotten. Because the isolation unit does not only have to be technically correct, it also has to be acceptable. So that the community come forward with their cases and allow hospitalisation. And there have been at least in the last place where I've been, Monrovia in Liberia, I think several shortcomings in this respect. So there have been several incidences where a patient has been taken away by the ambulance. But the family has not been informed where the patient was hospitalised. So they wouldn't know where he or she's staying. Then, there was no facility for the relatives to visit the patients.
Skip to 4 minutes and 25 secondsIn earlier outbreaks, that was always possible. And that was one of the lessons learned that you need to be transparent in your isolation ward. People need to be able to see that patients are well-cared for, that they receive treatment and food, something to drink. That it is a real hospital. If you don't do that, if it's a closed unit, then people will believe all sorts of rumours, up to the point that people may think patients are actively killed there and not treated. So not providing any possibility to visit patients is certainly not the best way of doing it. What can be done to maintain the contact between the patient, the isolated patient and the family? Several things.
Skip to 5 minutes and 9 secondsI mean, the minimum I think is that you provide a space where at least the patients who can walk can go to in their convalescent phase, and then meet other family members at a distance. So most isolation wards are surrounded by a fence. So the patient would sit comfortably in the shade on one side of the fence. And the family would sit on the other side of the fence. And they can talk to each other. I think that's the minimum. And there's no reason why you would not provide that. It doesn't cost much, easy to organise, safe. It's just a lack of awareness if that is not provided.
Skip to 5 minutes and 53 secondsAnd another thing you can do is to provide mobile phones so that people can telephone their, can make phone calls to the families. That's certainly in an urban setting also easy to organise, not very expensive. No, no reason why not provide that. Slightly more sophisticated is actually allowing the family member into the ward. It has been done successfully in earlier outbreaks. Nothing ever happened. But of course, that requires more human resources. You need to make sure that the family member dresses appropriately. You perhaps also want to supervise a bit of the visit. But that's the only way how really a severely ill Ebola patient can see a family member and be encouraged by the family member.
Skip to 6 minutes and 39 secondsAnd also where the family can see that in this severe situation, the patient receives care. So it's a lot about, maintaining this contact is part of the supportive care for the patient. But it's also transparency and confidence building with the community. That's why it's so important. What matters most for the acceptability of the treatment is that people see the effort. So if they see that drugs are given to the patient, if they see that fluids, IV fluids, IV liquids are given to the patient, that is what they will appreciate. And they see the effort of the health staff towards their loved ones.
Skip to 7 minutes and 25 secondsOf course, if we had a new drug which reduces case fatality really drastically from let's say 70% to 10% so that most of the patients, the vast majority survives, that would change the perception. But a modest decrease of the case fatality and that is perhaps what we are more likely to see, from 70% to 50% will not necessarily change the perception of the isolation ward. There these measures to increase transparency, to be seen to make an effort, that's the more important thing then.
Medical and practical aspects of treatment
The current available treatment for Ebola is supportive. Early oral or intravenous rehydration to rebalance fluid and electrolyte loss are key components. Symptomatic relief should also be provided to all patients, as well as malaria treatment and broad spectrum antimicrobial treatment against secondary bacterial infections. There are several challenges in providing effective supportive care, particularly when treatment facilities are running at maximum capacity. In the video, Dr Matthias Borchert and Dr Colin Brown, speaking from their own experience, discuss some of the practical issues around treatment, including the need to maintain transparency about what is happening in the treatment units for the families of patients.
Currently there is no specific treatment for Ebola. Several therapies are being developed and tested, but their clinical efficacy remains unclear and their availability limited. Hence, treatment relies primarily on supportive care. If care can be provided early in the disease course, it could improve the chances of survival.
The basic principles of supportive care are broadly similar across Ebola treatment facilities. Early rehydration and re-balancing electrolyte loss is the mainstay of supportive care. Oral rehydration should be provided. Drugs are given to treat patients suffering from nausea and vomiting which helps improve oral fluid intake. However, intravenous (IV) fluids and electrolytes are often required for patients who are too ill to drink or those with major fluid loss due to severe diarrhoea and vomiting and/or vascular leakage.
Pain relief is an important component of Ebola care, together with other symptomatic relief such as antacids. Patients should be given anti-malaria treatment; malaria can have similar symptoms to early Ebola, and even after confirmation of Ebola, concomitant malaria infection is possible. Patients also receive treatment for secondary bacterial infections using broad spectrum antibiotics.
There is not enough time for each patient
At the height of the epidemic there were large numbers of patients being looked after, and it is difficult undertaking clinical and nursing duties in full personal protective equipment (PPE) for long periods. As Dr Brown reports, ‘in some of the big treatment centres there is more of a time pressure and it is quite difficult to have medical staff spending a lot of time with the patients, both from the practicalities of seeing as many as 80 or 100 patients in one time, but also given the limitations of wearing personal protective equipment for long periods of time’. Ensuring patients drink enough oral fluids is time consuming.
Patient and clinical monitoring is minimal
Monitoring often relies on crude estimates of fluid intake and output. Electrolyte imbalance is rarely documented, with electrolytes provided empirically to patients as part of rehydration but not tailored to individual needs based on biochemistry results.
Providing intravenous treatment safely is a challenge
Intravenous lines may often need to be replaced. Intravenous access may also be difficult in patients who are admitted late in their disease course due to severe dehydration. Other methods of rehydrating patients, such as subcutaneous or even intraosseous infusions have been proposed, but are not widely used.
Perceptions of care
Oral rehydration is preferred for those who are not very ill. However, the ways in which communities perceive the quality of care may also depend on whether or not treatment facilities provide IV therapy, as discussed in the video.
Lack of treatment options
For patients developing multiple organ failure, more aggressive forms of supportive treatment, such as appropriate ventilation and oxygenation, are largely unavailable.
Pregnant women with Ebola probably have a higher case fatality rate, though published evidence is based on small numbers. Miscarriage, stillbirth or neonatal death is probably universal. See this minireview. Miscarriage or delivery pose huge risks to health care workers due to the loss of large amounts of blood and amniotic fluid which both contain the virus, and invasive procedures are usually avoided.
Recording the treatment patients receive and their clinical state is also challenging. No materials can be removed from the high risk zone and although some units use radios or photographs it can be difficult to transfer the information out. In many units, basic information is shouted out from the high risk to the low risk zone. This has impeded the ability to analyse what is happening and learn what works.
Experiences from Europe and the US suggest that with good supportive care, patients’ outcomes can be substantially improved and mortality reduced. In the absence of effective and available anti-Ebola therapies, the emphasis in epidemic settings should be on providing the best supportive care possible with the resources available.
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