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Moderators of Ebola Response and GHDonline staff

IV Therapy for Ebola

By Elizabeth Glaser Moderator Emeritus | 02 Jan, 2015

Attached is a link to an article in the New York Times "Ebola Doctors Are Divided on IV Therapy in Africa" surrounding the use of IV rehydration. There are valid points being made by both sides in this debate.

For those without access to the article, in brief, it discusses that respected clinicians differ in their approach to rehydration and use of IVs in those with Ebola.

Some advocate for IV therapy or even intraosseous infusion with aggressive rehydration and electrolyte replacement, while others take a more conservative approach based on long experience, familarity with the limitations of the care environment, and concern over the increased risk of complications and exposure to staff.

Although some facilities that use IV therapy can boast lower than average mortality rates, some that use more a more conservative approach also have low mortality rates.

The differing success rates with IV therapy could be a function of many factors , such as those mentioned in the article, but I wanted to highlight that varying levels of adherence to standards of infection control, IV line care, and IV protocols between facilities may further complicate matters.

What other issues might be at play - is IV therapy the better way to rehydrate and treat Ebola or is it the quality of the therapy which matters more? The debate is ongoing.

Here are a few observations from what I saw or was told was being done as regular practice ( vs written protocols) at facilities run by a number of differing groups ; These items are being brought up to add to the discussion, and are not intended to advocate for one protocol over another, as it is a very complex issue.

Flushing the line: Cannulas were not necessarily being flushed on a daily basis so at the point that the patient might require IV hydration, an IV that was first inserted days before, upon admission, was no longer patent and had to be reinserted requiring another stick.

Infection control for IVs: IV hubs were not necessarily being cleaned prior to the IV being accessed. Since bags were only hung when staff were in the ETU, the lines might be accessed a few times a day, each time presenting an opportunity to introduce microorganisms into an already compromised patient.

Phlebitis, infiltration, extravasation: There were patients that evidenced phlebitis,extravasation, or infiltration. The changes at or above the site may have been due to general irritation,catheter movement, bacterial infection at the site , changes in endothelial tissue as a complication of Ebola , thrombosis, or all of the above but regardless, it made for painful and problematic IVs.

Pressure infusion: Pressure infusion would be used to shorten infusion times due to staffing time limits in the ETU . While fluid bolus may not be an issue in general, Ebola related endothelial changes might place patients more at risk for IV complications from pressure infusion.

Attached resource:

Replies

 

Jean Marie Vianney Namahoro Replied at 7:08 PM, 2 Jan 2015

IV therapy is more important to Ebola patient. The number of case fatality decrease in ETC.
Thank you.

Deborah Wilson Replied at 10:40 PM, 2 Jan 2015

Hi Elizabeth and I assume welcome back!!!

I appreciate all the points that you lay out above. I looked after 80+ Ebola patients a day and was responsible for implementing the IV protocols at the ETU I was at. Having also worked on Cholera both in Chad and Haiti I have to say Cholera was so much simpler. Any non responsive cholera patient I had - well you just aggressively hydrated and they magically improved and walked out in a few days (of course there were some complications like diabetics or other co-morbitidies but... in general)
With Ebola patients I never could predict who would make it and who wouldn't . Aggressive rehydration was never a guarantee of survival. And I never got a handle on what was. I keep reading stuff to see if there are some clear answers - I haven't found anything yet. Even how Ebola is transmitted to humans is up for question again!!!.
Why is Paul Farmer making such a definitive statement - as far as I understand PIH is just starting to work with Ebola and learned from MSF? He is my all time hero and although I have worked for MSF I see a lot of their faults. But surely we need to pool all our experiences and observations and data collection to find out more about Ebola and how to treat it - not start claiming we know better than someone else? I would much rather see PIH and MSF collaborating rather than what seems to me to have the flavor of turf battles.

Elizabeth Glaser Moderator Emeritus Replied at 1:44 AM, 3 Jan 2015

Hi Debbie,

There were comments posted for the NYTimes article which expressed some discomfort with statements from representatives of the groups interviewed, but I would caution that we don't know for sure the tone of the discussion , we only know how the discussion was framed by the NYTimes for that piece.

I am glad to hear from Debbie on this as she likely has more direct experience than all of us..For context , Debbie was the nurse in charge at MSF's facility in Foya, Lofa county Liberia from late August to early October. In mid-August 2014, Lofa county had 153 new cases of Ebola diagnosed during a single week. While at the Foya facility, Debbie initiated more aggressive IV therapy after assuring safety for patients and staff.

The NYT article noted that MSF's facility in Bo had a mortality rate approaching 30 % , which is remarkable. Robert Cannon, who has sometimes commented here, is or was at that facility. It would be very helpful to hear his take on the factors contributing to the numbers reported for Bo.

When I was doing hot training at the IMC facility during the end of November , the mortality rate was approximately 60%, with their lowest ever mortality rate ( to the best of my knowledge) having been about 48%.

There is no doubt that IV therapy can make a difference.

In the NEJM article which detailed the care for Ken Brantly and Nancy Writebol, the article supplement contained the full I/O for both during their inpatient stay in the US. I would encourage people to read it it and look at the chart.

By day, their oral intake exceeded IV hydration except for two or three key days - for Brantly IV replacement was key upon arrival in the US, when he had 2 days of high output from diarrhea. By contrast Writebol did not initially receive much IV fluid because of third spacing. She received IV fluids mostly around the day she began diuresis of liters and liters of urine. At that point, IV fluids were crucial for her continued recovery. In addition to ORS and IV therapy, Brantly and Writebol were receiving experimental treatments to manage the disease, as has been the case with most if not all of those treated in the US and Europe.

The NEJM paper on Ebola outcomes with IV therapy in Conkary is more informative for clinicians in the field , but we still need more and better information.

We need more data to understand what pre-hospital variables contribute to increased survival - age, gender, number of days ill before presenting for care, co-morbidities, especially chronic malnutrition.

We also need to understand what specific treatment factors contribute to increased survival. Does any IV therapy help, are IV fluids plus prophylatic antibiotics better , and what about good IV site care?

Does having a clinician within the ETU at all times who can help patients eat and drink make more difference in outcomes than a staffing model where someone comes in 2-3 times a day to squeeze in a bag of ringers lactate?

Some of the data gathered upon admission can help inform us on prehospital information, but we need more info from within facilities. Obviously there are limitations because of the environment - wearing PPE, being unable to comfortably write when your goggles are getting fogged up, being able to do more than checking off boxes given the limited time in the ETU and the difficulty in getting data safely and accurately moved out of the confirmed unit. Maybe the Ebola hack-a-thon people thought of potential solutions?

I have been back from Liberia for a few weeks but keeping a low profile over the holidays.Will officially complete active monitoring as of tomorrow.

Let's hope that 2015 will bring a time of health and renewal for the people of Liberia, Sierra Leone, and Guinea.

Elizabeth

David Fedson Replied at 4:22 AM, 3 Jan 2015

Donald McNeil's NYT article calls attention to the fluid and electrolyte problems that lie at the heart of the pathophysiology of human Ebola virus disease. Fluid losses are immense, both external and internal (third spacing). Replacing these losses is essential, but it is difficult when the underlying reason for these losses - endothelial barrier breakdown - remains uncorrected. I have argued that the loss of endothelial barrier integrity can be reversed by treating patients with inexpensive generic statins (e.g., atorvastatin ) and angiotensin receptor blockers (e.g., irbesartan) (Fedson DS. J Infect Dis, 2014, first published online on August 25th). The physicians quoted in McNeill's article - Paul Farmer, Armand Sprecher, Rob Fowler and Ian Roberts (and Donald McNeil himself) - know about this idea because I wrote to them many weeks ago. Sadly, they and their colleagues have not tested this approach to treatment, but this is no surprise; Ebola scientists and health officials who have set the international Ebola response agenda (this includes WHO), have shown no interest in it. Fortunately, physicians in Sierra Leone have treated small groups of patients consecutively with atorvastatin and irbesartan, and preliminary reports have been extremely positive. In Freetown, all 22 treated patients survived, and in Port Loko Town, 15 of 16 treated patients survived. We don't yet know if treated patients were representative of all Ebola patients seen in the treatment units, nor do we know the extent of fluid administration and the mortality rates in treated vs untreated patients. There is an urgent need to externally validate these results. If they stand up to careful scrutiny, this information would radically transform the care of Ebola patients in West Africa. Everyone who follows the Ebola discussion on GHDonline, especially those based in West Africa, should pay attention to these developments.

Deborah Wilson Replied at 9:44 AM, 3 Jan 2015

Hi Elizabeth and David,
Can't thank you enough for both your inputs and perspectives. I think in many ways I am still trying to process everything I saw and that terrible feeling as a medical practitioner of just not being able to do enough and at times feeling helpless.
Welcome to the other side of 21 days Elizabeth. In some ways it is an anticlimax ...and beware ....there will still be people that will think you are the bogey man :)

Elizabeth Glaser Moderator Emeritus Replied at 2:32 PM, 3 Jan 2015

Hi David

I mentioned your work on statins with Dr Khan from University of Nebraska when we met at the CDC training, and he did llisten, but I don't know if anything came from it.

Do you have individual practitioners giving the drug or is it being administered through institutions?

What are the indicators for using the drug, specific signs of endothelial dysfunction or just anyone with Ebola??

There can be a higher prevalence of CYP450 and associated polymorphisms in sub-Saharan Africans or people of African descent , do you think that this will cause adverse effects or decreased drug efficacy? How do you estimate the dosage?

It would interesting to hear what comes from the statin trial, please keep us up to date on it.

Elizabeth

Elizabeth Glaser Moderator Emeritus Replied at 2:53 PM, 3 Jan 2015

Debbie,

As you process your experience, please share your thoughts.
What kind of line care or site care was done?
What were the benefits of IV therapy - you have mentioned them to me, but it would be helpful to others to hear your perspective.
What were the drawbacks of IV therapy? Did you see much evidence of phlebitis or other problems associated with IVs?


re coming home. Except for one painful and frustrating incident within my extended family, I have had pretty smooth sailing,
I am very grateful to the Mass DPH staff and PIH's occupational health physician who have been very responsive to my questions and very reasonable about the whole thing.

Robert Cannon Replied at 5:18 PM, 3 Jan 2015

Hi,

This particular discussion started in response to the NYT article about ‘aggressive rehydration’ for Ebola patients and its potential role in reducing mortality, the article used a few examples of differences in approach, and the conflicting comments of a few experts to add drama to the piece.

In the absence of rigorous evaluation of approaches in well-defined populations these differences between the experts should be expected – by default, personal bias and perspective define and validate the ‘evidence’. And the enormity of the suffering and a sense of frustration tend to inflame the rhetoric.

How to resolve the uncertainty is probably obvious to everyone, however, until now there seem to have been a slew of seemingly intractable impediments to doing the studies needed to begin resolving the issue. The international response has never been adequate to control a complex, hugely challenging, and evolving disaster that absolutely no person, organization, or country anticipated. In this setting research has never really had a place at the table.

The arguments about rehydration are really just a subset of the problems of defining optimal care for Ebola patients and how that care can be delivered in West Africa. The studies need to be done.

I would like to mention some of the challenges of doing studies, and comment on the limitations of: 1) using existing published data to define optimal achievable care and 2) comparing mortality rates of the different centers.

To be able to compare sites, those reporting the their results must define their populations using those parameters that have already been identified as associated with mortality – e.g., viral load on presentation, age, gender, time since infection, time to onset of therapy from onset of symptoms, and signs and symptoms at presentation. As a necessity, one would need to stratify the patient population by these indicators when evaluating efficacy to allow comparisons between sites, or within sites using different treatment regimens.

Furthermore, that are likely to be other factors that determine outcome that have not been examined in any detail – such as host factors (e.g., nutritional status, renal, hepatic and cardiac function, past and concurrent infections, the presence of chronic diseases, immune status, and genetic predisposition); virus factors (it is not plausible that there are strain differences that vary in space and over time?); care and treatment prior to presentation to an ETU (anecdotal stories about ‘traditional’ practices and medicines received make one wonder about their potential negative effects); referral practices from health facilities and by governmental authorities (e.g., the quality of care one receives before transfer, who gets sent in for treatment and who doesn’t, and time to transfer varies considerably); self-referral practices that are influenced by multiple considerations (e.g., stigma, distance, reputation of center); the health care staffing at a center (e.g., expertise, experience, type, ratio to patients); the specific protocols and functional efficacy, not just around hydration, at a center (e.g., physician specialty, nursing roles, time in high-risk zone and how often); and the available lab support (e.g., availability of PCR and other diagnostics), etc.

In the NYT article it was mentioned that the mortality rate at the Bo Ebola treatment unit was ‘only’ 36%. Elizabeth asked if I might comment on this. The preceding two paragraphs are a preamble to doing so.

The Ebola treatment unit in Bo, for the majority of the time I was there in October and November, had a policy of only accepting patients that had already had been confirmed as having Ebola. Sierra Leone is divided into Districts, only a few of the Districts had treatment units and so the organizations and/or authorities in the Districts without units had to send their patients elsewhere. In Bo we ended up taking patients from many other districts, including those in and around Freetown as the infection exploded there. Several, like Freetown, were 4 hours or more (up to 8 hours) away, and some over terrible roads. The unit in Bo was not always able to take all the patients that could have been referred so there were delays. It is was assumed that the combined delays of needing confirmatory testing and/or availability of spots led to some bias in the patients being admitted – i.e., a greater proportion of those who would normally survive made it to the unit relative to a lesser proportion of those with a higher mortality – because as has been noted in multiple papers and letters, the majority of the mortality due to Ebola is within days to a week after the onset of symptoms.

It is also fairly well established that only a minority of Ebola patients are seen in Ebola treatment units and/or appear in government statistics – it is not clear what all the reasons for this are – but many are obvious, (e.g., myths, misconceptions, fear, stigma, ignorance, economic, geographical.) So at a minimum, this also creates a major bias in assessing the impact of infection.

Without accounting for the potential biases in patient accession and the covariates determining survival it is not possible to accurately attribute to any specific factor, or collection of factors, why the rates in Bo where less than other centers – likewise this would apply to the Hasting rates, or conversely to centers with higher rates. Without understanding the determinants of mortality and their distribution within a center it is unjustifiable to compare across centers and to make definitive statements about efficacy of a single component of care.

There is a lot of data out there that hasn’t either made into electronic form and/or has not been analyzed. Getting this done should be a high priority as it has the potential to substantially improve our understanding of how best to care for our patients.

Perhaps, more importantly it is time for everyone in the Ebola care provision arena to sit around a table with an ‘adult’ to moderate a discussion how everyone can contribute to a better understanding of what is optimal care in the West African context – what are the priorities, and the next steps to do the careful studies to confirm and extend what we think we know.

(However, for me the even more important discussion should be around prevention strategies that have yet to be designed, implemented, and refined – as always. But I will not go there now.)

One last comment – 38 years ago (between my first and second year of medical school) after working 6 months in a village clinic in Mobai, I spent 6 months helping Joe McCormick get the CDC Lassa Fever Research Program get started in Segbwema, Sierra Leone. Even accounting for my presumed substantial loss of memory (and cognitive function) over the intervening years – it was very disconcerting and disheartening to see how very little has improved in the lives of the people there. Ebola will be vanquished relatively soon, and then the real work to improve the health of populace needs to begin once again.

Thank you.

Deborah Wilson Replied at 12:14 PM, 8 Jan 2015

Hi Elizabeth,
The biggest issue I found with IV insertion was keeping the IV in. Often when patients required IV hydration they were also delirious and because of the impossibility of constant monitoring we inevitably would find a patient had pulled an IV out when we were not there. Taping and bandaging did not help much. The worst was when this would happen just before sundown as we had a policy of not inserting IVs after dark because of the increased risk of needle sticks.

with children we started NG tubes and had success with this surprisingly - even tho it took time to very slowly give fluid while in there so that the child would not vomit.
We struggled with measurements of intake and output - that was a hurdle we were addressing as I was leaving. Also trying to time the flow - in all honestly when we got an IV in the tendency was to let it run wide open because we were never sure if the patient would pull the IV out as soon as we left or would lie on it blocking the flow.

A boring issue was that of taping the IV. The nurses would wrap so much tape to try and keep it in that the line would infiltrate. The other issue was if the IV did stay in more than a day the tape inevitably got covered in body fluids and changing it risked accidentally pulling the IV out.

Introducing diazepam for sedation of delirious patients helped us hydrate them but that was controversial with the staff and provoked a lot of interesting discussion.

It was like the wild west but by the time I left more control was being established as the protocol of establishing IVs was in place and working so we were refining it.
As for phlebitis - I did not see much of that but it was a desperate time and we were overrun with just trying to get IVs in and keep them in for more than 24 hours.
We had an Anesthesiologist who wanted to try PICC lines and had some but Admin would not allow it. With such a skill there it could have helped but without a doctor with that kind of skill we would not have been able to continue such a practice. I wonder if any other projects were able to try this.
I hope this is of some help.
Debbie

Tracy Kelly Replied at 12:35 PM, 8 Jan 2015

Debbie I had very similar challenges with IVs in Port Loko Sierra Leone. We did insert IVs, but very often they were pulled out when we came back to check on them. It was difficult to know how much IV fluids really was administered. We tried to tape the site carefully but this did nto seem to make a difference. More concerning was that the IV site was often bleeding quite profusely if it was pulled out. Indeed the patients neurologic status is directly related to the duration and security of the IV catheter. More often than not we gave a 0.5L bolus right after starting the IV, then disconnected the tubing from the catheter so we could save the IV for our next round and give another bolus. This was a challenge for the pediatric population as we were cautious about not wanting to overload small children especially those with severe malnutrition. We only hung 0.5 liter bottles on children less than 6 years old, and we did not have any minidrippers or buretrols to control the volume infused. We did have success with intraosseus needles on several small children but we placed them after consultation and agreement with several clinicians and pulled them when there was no one to monitor the site. We did not place any PICC lines but I think if they could be taped in securely, they may offer a good alternative to simple catheters. This is a very challenging issue. / Tracy Kelly Port Loko Sierra Leone

Deborah Wilson Replied at 12:55 PM, 8 Jan 2015

Thank you Tracy,
So good to hear from some else that was struggling with solutions.
Debbie

David Fedson Replied at 1:35 PM, 8 Jan 2015

For Tracy Kelly (and Elizabeth Glaser)- While you were working in Port Loko, did anyone discuss with you the results of treating 15 patients at the Port Loko Government Hospital with atorvastatin and irbesartan? (See my post on January 3rd.) This once-a-day oral treatment (atorvastatin 40 mg and irbesartan 150 mg) was given to all comers. The extraordinary increase in survival needs to be externally reviewed, but if the result could be validated, this information would radically transform the fluid management of Ebola patients, and much of the GHDonline discussion of the difficulties of IV treatment would be beside the point. I have been both surprised and disappointed that no one has commented about this innovative treatment. Except for a handful of healthcare workers in Sierra Leone, does no one else in West Africa know about it?

Elizabeth Glaser Moderator Emeritus Replied at 3:03 PM, 8 Jan 2015

Tracy and Debbie
Thank you for your contributions.
Sharing of best practices and problem solving is what will help us figure out how to give the best Ebola care possible.
How is/was staffing done in at your sites - were there always at least one clinician in the unit or were there periods with no staff inside?

I was surprised that at some places no one went in during the night, when it was cooler and one could tolerate being in PPE for much longer,and it would allow for time for IV and for sitting down and giving ORS to patients.

When you are hanging bags and having to attend to IVs, who is helping give ORS? The aides ?

In the the NEJM article on Ebola treatment for the first two Americans, the supplemental material clearly shows that they were taking in ORS even when they were on IV fluids, it was being encouraged the whole time. Given your constraints is that possible to do or at the point where it IV fluids are necessary, do you focus on that and just stop with ORS?

I would also like to know what experimental or non-standard treatments, if any , are being employed on site.

Elizabeth Glaser Moderator Emeritus Replied at 3:52 PM, 8 Jan 2015

Robert,
Thank you for your reply. It gives us a lot to think about.

At a national level, both countries had made impressive gains over the past five years in some sectors, but after two decades of conflict, with no schools open, and no functioning health system during much of that period, and now with the disruption caused by the outbreak, it will take quite a while to move forward, Hopefully you can be a part of the health strengthening process, too.

I don't know who is going bring the big guys to the table to talk, but we can certainly share information here.
Even at this informal level, it may make a difference.

Elizabeth

Diane Hallinen Replied at 4:22 PM, 8 Jan 2015

Hi,
My passport has been sent to PIH and I'm waiting to hear about a visa. A couple of questions...
1. Does PIH or the organizations you have worked with have meds on hand for staff, specifically HIV post - exposure drugs? I imagine the fear of ebola far exceeds an HIV exposure, but I think I would still want to take it if exposed.
2. Have you heard of any staff actually sleeping in tents at this point. I'm okay with the idea, I just want to know if I should be bringing a sleeping pad, I recall the cots I slept on during Katrina as being less than comfy.
3. Was an ultrasound machine available at any of the sites? If we are talking picc lines, US would be essential. I'm also a big fan of checking vena cavas for hydration status, although I doubt too many patients get enough IV fluids to go into fluid overload. Were an of your patients going into fluid overload?
4. Did anyone participate in any clinical trials, or hear of any? I'm really curious about the mechanism of decreased visual acuity in ebola survivors. The statin question is interesting.
5. I agree Elizabeth, night shifts sound good to me. Was there electricity available 24/7?
6. What sort of record keeping was done? Electronic? Were there scales for weighing diapers to estimate output?

I've not had contact with anyone clinical from PIH since my interviews, is there a person who might have an idea of the big picture.

alice werbel Replied at 4:37 PM, 8 Jan 2015

Elizabeth Glaser asks who is bringing the big guys to the table to talk. Below are two events next week where, it seems, they will be talking.

Clinton Global Initiative
RSVP http://forms.clintonglobalinitiative.org/tracks/public/view.php?id=393

CGI Call
Ebola Outbreak: Shifting the Discussion to Long-Term Investments
Jan 14, 11:30 am -1:00 pm

The current Ebola outbreak—-most prevalent in Liberia, Sierra Leone, and Guinea—-has claimed thousands of lives and put significant stress on West African economies. Within these countries, already-vulnerable health care systems, lack of infrastructure, unreliable power supplies, and deficits in health worker capacity have crippled the ability to combat the spread of the disease. In addition, overwhelmed healthcare facilities have compromised the availability and quality of existing primary health services, resulting in a silent death toll from non-Ebola-related issues. While the international community continues to take the immediate necessary steps to stop the outbreak, it is simultaneously investing in health worker capacity and infrastructure that will help prevent future outbreaks.

This conversation will explore opportunities to build partnerships and generate commitments that prioritize long-term investments in health infrastructure, human resources, and energy and water systems. This call is the second in a series of conversations that brings members together to address the Call to Action on the Ebola crisis, which was launched at CGI’s 2014 Annual Meeting.
***********************************

Kaiser Family Foundation-CSIS

January 13 Event: Where Do We Stand in The Fight Against Ebola? A Conversation with CDC Director Tom Frieden

On Tuesday, January 13, the Kaiser Family Foundation and the Center for Strategic and International Studies (CSIS) will hold a conversation with Tom Frieden, M.D., M.P.H., director of the Centers for Disease Control and Prevention (CDC), to discuss his recent trip to assess the Ebola outbreak in Sierra Leone, Liberia and Guinea. The discussion will focus on efforts to contain the Ebola outbreak in West Africa and the ongoing response by the U.S. government.

Josh Michaud, associate director of global health policy at the Kaiser Family Foundation, will make opening remarks, and Stephen Morrison, senior vice president and director, global health policy center at CSIS, will moderate the conversation.

WHEN (note NEW time):

Tuesday, January 13, 2:00 p.m. (Registration and light refreshments at 1:30 p.m.)

WHERE:

Barbara Jordan Conference Center
Kaiser Family Foundation Offices
1330 G Street, NW
Washington, D.C.
(one block west of Metro Center)

RSVP:

Please register online to attend this event in person.

The event will be recorded and made available on kff.org the following day.

Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.

Elizabeth Glaser Moderator Emeritus Replied at 5:01 PM, 8 Jan 2015

Hi Diane,
First good luck on your trip.
I think that your deployment questions are better answered this point by contacting PIH HR directly, or alternately, the people who did your interviews might be able to help you.

The systems in Sierra Leon are different than in Liberia but the way care is delivered and the tools used to deliver it seem to differ by site as much as by the organization delivering the care. If the Ministry of Health has a strong presence then records and data being gathered may be on standardized forms. Some ETUs have forms that simply require you to check a few boxes to indicate that the patient received oral medications and IV therapy. It sounds relatively easy to do but can be quite difficult when you are trying to make a pen mark on damp paper while your googles are beginning to fog up. I know there has been talk about tablets , not sure if this was a proposal or was actually in use by other groups.


Elizabeth



All of our members with direct care experience can speak about differing protocols for care.

Robert Cannon Replied at 5:53 PM, 8 Jan 2015

Hi Elizabeth,

I’m certainly not the best person to answer the question of how to get ‘the big guys’ together to discuss and reach a consensus about how to determine what optimal care looks like in West Africa, but I will give it a shot from my perspective.

As a first approximation, I would guess the opinion leaders/influential persons from all the key organizations would be highly motivated to make this happen themselves if the setting and organization was optimal. From my past limited experience with several of them – they are universally committed to doing the absolutely best job they can. They are all highly intelligent and driven to make a difference – even though they may disagree on how to do that. And, at the end of the day, they really are complementary to each other because of their differences in experience and perspective – together they represent a sweeping overview of the crises and the challenges (though maybe not enough time in the trenches themselves).

Then, as a start, I would talk with Sue Desmond-Hellman (CEO of the Gates Foundation). Sue has extensive experience and an amazing track record of getting things done both in industry (Genentech) and academia (UCSF) and she has an affinity for Africa. This combined with the organizational strengths of the foundation, if they are interested, could be a way to make it happen.

I would also talk with Peter Piot (now Director of the London School of Hygiene and Tropical Medicine). In addition to his extensive experience, this is also very personal for him, and the influence and resources he has at hand are massive.

Alone, or more likely together, these two could get absolutely everyone around the table and insure that the resulting discussions were fruitful.

As a personal preference, I would pick Kevin De Cock (currently Director of the CDC mission in Kenya) as the moderator. Kevin has been incredibly effective in the multiple high level positions he has had at WHO and CDC, and his experience and understanding of the health challenges and how to get things done in Africa are unparalleled.

These are people I know personally, but I am sure there are probably many others out there that could also make it happen. Talking with the organizations themselves could certainly help identify those others.

I don’t think we have much time to get the research started – I believe this has to happen soon to have the chance to give us some of the answers we desperately need.

And I don't believe an informal approach will have enough horsepower to resolve some very contentious and complicated issues – this has to be a discussion with give and take, and the decision makers have to be participants.

Lastly, I believe we need the same type of meeting to hash out prevention strategies.

Thanks.

Elizabeth Glaser Moderator Emeritus Replied at 4:35 AM, 9 Jan 2015

Robert,

Granted, anecdotal information is highly prone to bias; we remember our successes or our notable failures and forget the data between the two, but through our forum, I was hoping we could at least allow direct care staff to informally exchange information that might be of use to them. I realize that it does not make a difference in the big picture but it may for individual practitioners or groups as it is certainly within our mission and capacity to do so.

It is clear that those in charge in this effort care about improving services and saving lives. That passion usually works to good effect, but sometimes it may get in the way of progress. I have neither the connections, the capacity, nor the diplomacy to bring this about , but it certainly seems feasible for someone to do it given what you have shared - I very much hope so and would be willing to help within my limited capacity if you or someone else wants to try to make it a reality.

The Ebola response is an interdisciplinary effort, but much of the acute care component is centered around basic nursing care, therefore I would urge that nurses would not only have a seat at the table, but be involved in the design , planning, implementation and evaluation of policy and programs.

As you noted and I want to expand on a bit, such a meeting(s) has to focus on consensus and consolidating gains to improve the current acute AND prevention response ,including a rational research agenda that will allow useful open access data to be generated, to assess the efficacy of interventions, and allow an economic analysis of the impact of interventions. The WHO road maps certainly suggest some of this has occurred but it is unclear how much that reflects the interests of certain groups over an evidence based effort as without openly accessible data we cannot be sure of the validity of the evidence to support various approaches.



Two additional notes, of varying general interest:

1. The first few chapters of Piot's memoirs are very helpful for understanding the initial response to Ebola, to consider what has or has not changed since that time. In particular, he writes very movingly and compassionately of the Belgian nursing sisters, whose work inadvertently amplified the initial outbreak and of meeting Mayinga N'Seka, the young Zairean nurse whose name graces the protocol strain of Ebola. Some parts of the book are free to read on google books. Piot, Peter. No time to lose: A life in pursuit of deadly viruses. WW Norton & Company, 2012.

2.I would very much like to do an economic analysis of interventions for Ebola to get a sense of what works and how to design and finance efforts in future outbreaks. That cant happen unless we have enough good data on the types of interventions, their efficacy , and a full costing of the interventions. I have already made a stab at estimating the burden of disease, but need more data to flesh it out. If members know of anyone working on it, I would love to help, whether formally or informally, in that particular effort.


Elizabeth

Deborah Wilson Replied at 10:40 PM, 9 Jan 2015

Elizabeth,
To clarify teams did go in at night to hang fluids, clean patients and give ORS. They were just not allowed to establish or reestablish IVs as the lighting at night was bad .

Also does anyone have a solution for how bad ORS tastes. I forced myself to drink it every day as that was what we were asking all patients and local staff to do. It is the most disgusting stuff ever - I cannot imagine trying to take it when sick.
We started to add a powered "orange juice" that the locals liked and got a little more in that way but if anyone finds a way to make that stuff more plantable it will be huge advancement in my book!

Robert Cannon Replied at 12:20 AM, 10 Jan 2015

Hi,

Just a quick comment - for ORS to be effective, the people who need to drink it, need to drink it, and if they don't like the taste they won't - simple.

WHO and others have invested a lot of thought and effort into making sure the current formula has the optimal osmolality and concentrations of Na, K, Cl, buffer, and glucose to maximize absorption to replace GI losses. But again, all that science isn't very helpful if you can't get people to drink it.

When altering the ratio of ingredients just be aware of how you are altering the various ratios, and what effects that may have. And it may very well be that the losses in Ebola patients are different than those with say cholera, but I wouldn't know. Certainly there has been a lot written about the low K, Mg, and Ca levels in these patients. It may make sense to spike ORS with these - though this is just speculation.

I have to think the problem Deborah is describing is probably very common and also very important, and that there may be age and cultural taste preference components that need to be addressed as well. An ER doc friend with the International Rescue Committee running the High Risk area at Bo Government Hospital had fairly good success when he used Apple juice flavored ORS - as far as I know the reason he picked apple juice was that he liked it and he could buy it in Bo. Certainly there must be folks out there that have looked at this in some detail.

And don't forget the importance of temperature. A cool/cold drink in a hot environment is much more inviting than one at room temperature or warm - (despite how the Brits drink beer in pubs in the UK - mad dogs and noon day sun and all).

Elizabeth Glaser Moderator Emeritus Replied at 12:43 AM, 10 Jan 2015

Debbie,
Glad you did so(went in at night).
I agree that If we could improve the taste of ORS it might help the patients increase their oral intake. Sometimes dumping a can of fanta in with the water made it palatable. I think the packets were from UNICEF (?) but there were some other types around with better flavor that were harder to obtain. Freezing them into pops might help "mute" the taste but obviously it is not feasible.

The flavor of ORS made me nauseous so I avoided it if at all possible. I believe that I still have a packet of ORS around here somewhere, if anyone has suggestions to improve the taste I would be willing to try it and report back.


Elizabeth

Elizabeth Glaser Moderator Emeritus Replied at 1:12 AM, 10 Jan 2015

Apple juice may neutralize the sweet flat taste enough to make it palatable.

Has anyone asked survivors about this - what can we do better with foods and fluids to help people take in more when they are ill?

Re culture and comfort : In Liberia they say that hot pepper soup is the equivalent of mom's chicken soup in the US, people eat it for comfort when sick and it was served periodically in the ETU in Bong .

Robert Cannon Replied at 1:18 AM, 10 Jan 2015

Hi,

This is a link to an article in the Guardian. It is not about IVs or ORS, it is about the people who make giving fluids to patients possible.
Enjoy.

http://www.theguardian.com/global-development/2015/jan/09/ebola-workers-sierr...

Elizabeth Glaser Moderator Emeritus Replied at 5:19 PM, 10 Jan 2015

Dear Robert,Thank you for posting this.
It is a good reminder of the value of every contribution in the response. One of the cooks said she made whatever the nurses asked ( for the patients).

We have drifted into the broader challenges of hydration, of which IV therapy is only a sub topic, some of the challenges are:
1. Difficult to get accurate input/output
2. ORS can be unpalatable, how can we increase appeal while maintaining the balance of component parts
3. Maintaining IV access
a. How can we safely and easily secure cannulas
b. Patients can pull out IVs, may require mild sedation for safety, what sedation is most effective with least side effects
c. Sites can bleed profusely when pulled, how do we minimize it?
4. Intraosseus needles are a good option for hydration, especially in children, but hard to safely monitor sites
5. Ebola patients are at risk for overhydration and refeeding syndrome , attention to IO helps, peds have increased risk.
6. Although WHO and other groups have guidelines for care, we need more data from the field, both quantitative and qualitative, to share best practices. Best practice information should be by outcomes data, while adjusting for age, location, pre-morbid health status and other factors.

What did I miss? Lots; please contribute your ideas.

Elizabeth

Diane Hallinen Replied at 5:50 PM, 10 Jan 2015

Excellent summary Elizabeth. I read a few abstracts on doctoring up ORS...

http://www.ncbi.nlm.nih.gov/pubmed/9434992 states a bit of unsweetened Kool-aid doesn't alter the electrolytes much. Another article, http://www.ncbi.nlm.nih.gov/pubmed/15572897 says fruit juice doesn't make it taste that much better, and if you add too much the electrolytes are no longer in balance. My next trip to the grocery will involve getting a few Kool-aid flavors. I'm thinking grape. I'll report my taste test soon.

I'm curious if anyone is adding calcium and magnesium to ORS. I'm sure that would make it taste even more horrible, but according to what little clinical information that has been published, it would be good to be replacing those in patients with massive GI losses.

I was happy to hear that some of the children are tolerating ng tubes for hydration.

Is anyone trying to tape a longitudinally cut plastic cup over the IV hubs?

David Fedson Replied at 6:30 PM, 10 Jan 2015

I hope everyone working in West Africa who is following these comments will start asking questions about using inexpensive generic atorvastatin and irbesartan in all patients. Preliminary evidence, not yet externally validated, indicates treatment would do lots of good. If it is shown conclusively to work, this would cut down on the fluid needs of each patient and would benefit staff as well as patients.

Robert Cannon Replied at 6:50 PM, 10 Jan 2015

Hello Elizabeth,

Your list has many of the key issues concerning hydration, here are a few more that occur to me:
1. Many Ebola treatment centers are often at the end of a protracted referral process. Before arriving at the centers, many (maybe most) patients have either: a) languished at home, and/or b) waited in the few remaining local health facilities, and/or c) been lying in ‘holding centers’ awaiting confirmatory testing and/or available beds, and/or d) often been subjected to long uncomfortable rides in a crowded hot ambulance. If it were possible to ensure adequate ORS availability at each of these interim locations – it probably would make a difference. Not that it would be easy – but, in this context, what is?
2. If it were possible for the MoH, other organizations, and each treatment center to somehow improve the hydration prior to arrival it certainly might make a meaningful difference in mortality – assuming clean water, appropriate mixtures etc. – remembering that the majority of Ebola mortality occurs within days or a week or so of arrival at a treatment center.
3. There has to be greater availability of methodologies to assess electrolyte imbalances to help guide replacement. The technology is there but isn’t sufficiently available to care givers – this needs to be improved substantially.
4. Given how hot and humid it is in some of these centers – I assume that patient dehydration is substantially increased under these conditions. By whatever means are possible this has to be corrected. Electricity should not be limiting, just get more generators – as far as I can tell money really isn’t a major limiting factor (at least for the heavyweight organizations).
5. Please also cool the ORS – it has got to make a difference.
6. Given also the difficulties of inserting, maintaining and ensuring consistently placed lines and intake, clearly better training, and staffing is key. Getting the places cooler could really positively impact staffing as well.
7. Research, research, trial and error, trial and error … are desperately needed to get a better handle what is, and what isn’t, necessary and effective. Excuse me, if I repeat myself.
8. Again, I would plead for meetings of the key parties to accelerate and better focus the efforts. Unfortunately, without some rigor in determining what is optimal, we will all continue to wander about in cyber space speculating without making much headway.
9. But to really make an impact – a) prevention of infection has to be greatly strengthened and b) people infected have to get treatment – so attitudes and behaviors have to change and case finding greatly improved. Anyone want to discuss this?

Thanks.

Elizabeth Glaser Moderator Emeritus Replied at 6:58 PM, 10 Jan 2015

Great contribution, Diane.

Tell us how the ORS+ koolaid combo works out
Using the paper you linked I did a search and found this site which is primarily talking about ORS for children
http://rehydrate.org/ors/index.html

I am repeating myself here but here are some recommendations from the NEJM article on fluid replacement , whether ORS or IV fluids. The link to the supplement is relevant as it shows the overall I/O for both patients.

Aggressive hydration is important,but patients must be monitored closely for third spacing - vascular leak syndrome, including pleural effusions.

Accordingly, adjustment of fluid replacement based on patient respiratory status.

There are changes in a number of electrolytes, placing patients at risk particularly for hypokalemia, hypocalcemia, hypomagnesium and these electrolytes shifts must be taken into consideration when using ORS and IV solutions:

Commercial sports drinks may increase the risk of hypokalemia.

Oral rehydration solution recommended by the WHO contains some potassium.

Most intravenous fluids recommended for rehydration do not have substantial levels of potassium, calcium, or magnesium.

The authors recommend supplementing oral rehydration with oral potassium, calcium, and magnesium, especially in patients with large-volume diarrhea.

Elizabeth Glaser Moderator Emeritus Replied at 7:37 PM, 10 Jan 2015

Robert,

There will be an interest in prevention and case management. To increase visibility and ensure that those with an interest will see it, please start it in its own thread. Otherwise it will be buried here under the IV therapy header.

I would be willing to collaborate on a letter encouraging key parties to come to a consensus in order to better focus the effort. Do you think the Lancet would be interested in convening such an event ?

Elizabeth

Robert Cannon Replied at 7:45 PM, 10 Jan 2015

Hi Elizabeth,

Is it possible to talk off line?

Bob

Elizabeth Glaser Moderator Emeritus Replied at 11:14 PM, 10 Jan 2015

Edward Krisiunas Replied at 4:14 AM, 11 Jan 2015

The ORS remineds me of Gartorade in the early '70s..we drank it between
morning and afternoon football practice in August...

Has anyone considere coconut water? Nothing ventured ..nothing gained...

Elizabeth Glaser Moderator Emeritus Replied at 6:36 AM, 11 Jan 2015

Hi Edward,

Gatorade or sports drinks were found to cause problems for rehydrating ebola patients because these drinks do not have the right electrolyte balance given the way Ebola effects the gut.

Coconut water is an intriguing suggestion
eight ounces of coconut water has 46 calories, 9 grams of carbohydrates and 2 grams of protein.
250 mg of sodium 600 mg of potassium 60 mg of magnesium 45 mg of phosphorus

You may have something here....

Elizabeth

EPHRAIM PALMERO Replied at 7:16 AM, 11 Jan 2015

We use BP 100 biscuits dilute them in 500 ml and used it ssuccessfully in our ETU. All adults and kids have been resuscitated.

Dr Butch Palmero
Medical Director
Tubmanburg ETU

Rebecca Duff Replied at 5:31 AM, 15 Jan 2015

Although I have used peripheral IV statlocks to make IV stable in the US hospitalized and outpatient settings only, they have made a huge difference as to accidental dislodgment and pulling out of IV cannulas. I think they may make a difference with difficulty in the ETU's. http://www.bardaccess.com/statlock-piv-universal.php

Rebecca Duff, RN

Elizabeth Glaser Moderator Emeritus Replied at 2:38 PM, 15 Jan 2015

Thank you Rebecca
what kind of stabilization devices are available at health facilities/ETUs in Sierra Leone ?

Ephraim,
Are you giving the BP bars during active symptoms such as vomiting/ diarrhea or during the recovery period?
I tried to find the electrolyte content for one 57 g bar of BP-100, which contains 300 kcal. but could only find the information on F-100 formula for severe malnutrition, which the BP-100 is based on. 100 ml of F-100 contains: Energy 100 kcalth (420 kJ) ; Protein 2.9 g ;Lactose 4.2 g; Potassium 5.9 mmol ; Sodium 1.9 mmol ; Magnesium 0.73 mmol; Zinc 2.3 mg; Copper 0.25mg. The BP-100 biscuits have equivalent plus Iron.

Elizabeth

Elizabeth Glaser Moderator Emeritus Replied at 11:04 PM, 27 Jan 2015

This was an op-ed in the Washington Post from Jan 15th from Paul Farmer, explaining a bit more about his remarks from the New York Times article on IV therapy. Do you agree with his take on this?

http://www.washingtonpost.com/opinions/paul-farmer-the-secret-to-curing-west-...

Attached resource:

David Fedson Replied at 2:44 AM, 28 Jan 2015

Paul Farmer has called for better fluid and electrolyte management for Ebola patients (Washington Post, January 16, 2015). This might be achieved by treating the underlying physiological derangement in these patients - endothelial dysfunction - by using inexpensive generic drugs that target the host response to infection instead of the virus itself. Six months ago, this suggestion was made to Ebola scientists and health officials who have defined the international Ebola response, but it was ignored. However, in recent months we've learned that local physicians in Sierra Leone have used a combination of a statin (atorvastatin) and an angiotensin receptor blocker (irbesartan) to treat at least 100 Ebola patients, 25 of them in the Port Loko Government Hospital. All but two of these patients are reported to have survived. These results were not obtained in randomised controlled trials, and they need to be rigorously validated. Moreover, for whatever reasons, physicians in Sierra Leone have not released information on their treatment experience. Nonetheless, it’s possible that this dramatically simple treatment could reduce Ebola case fatality rates to less than ten percent, the goal of the Port Loko Accords.

Elizabeth Glaser Moderator Emeritus Replied at 9:49 AM, 28 Jan 2015

David,
You have pointed this out previously. Have you written it up and submitted it as correspondence for Lancet, Lancet Global Health or similar journal, or alternately for the New York Times or Washington Post?

I want to believe that there is an effective therapy to reduce vascular leakage and other septic like syndromes associated with Ebola, but have no idea what kind of bias might have been present in your sample. If a doctor was innovative enough to use an unknown treatment, they might also have done other things that altered the course of the disease. In addition to treatment factors, we do not know if there were patient factors involved ( younger age, quicker time to treatment) that could have led to lower mortality in the group. If you can present that data then it certainly help make your case.

Although your data is not from a randomized trial, decent observational data, even with a small n, can be very useful but only if there we have the right set of variables to thoroughly analyze it for confounding and bias.

Elizabeth

David Fedson Replied at 10:18 AM, 28 Jan 2015

Elizabeth - My most recent comment was posted online in response to the Washington Post article by Paul Farmer in which he wrote about the Port Loko Accords - reduce Ebola mortality to less than10%. My first attachment is an article published online in manuscript on August 25th and in hard copy last week. The second is an Op-Ed article that was published on August 15th, and that I've referred to earlier. The third attachment is an unpublished essay that was rejected without peer review by JAMA, Lancet and Lancet Infectious Diseases. The fourth attachment brings the story up-to-date. The 16 slides were presented to a WHO-sponsored teleconference on January 15th. WHO staff and local officials are working to validate the results of the treatment experience in Sierra Leone. WHO staff, Ebola scientists and international Ebola experts have known about this idea since late July/early August.

Attached resources:

Elizabeth Glaser Moderator Emeritus Replied at 1:15 PM, 28 Jan 2015

Thank you for the information. The WHO presentation illustrates your theory which is supported by research on sepsis , but the data on EVD patients has so many gaps it is hard to know if there is anything there. On the other hand your honesty about the missing data is to be lauded. What was WHO's conclusion?

As an aside, statins typically can cause transient, reversable, asymptomatic changes in liver enzymes, however the drugs are known to cause liver injury on about 1 out of every 3000-5000 patients in the US. Those number may be far different in West Africa as Sierra Leone , Liberia and Guinea have some of the highest Hep B prevalence in the world , between 10-20% of the population.Could statins cause more liver injury in a population with such high Hep B prevalence?
Is it reasonable to be concerned that statins might complicate the care for those with co-morbid conditions such as hep b, and/or increase the propensity for liver damage in EVD? I suppose that randomized trials might answer those questions, but since we don't have those right now, is liver damage a complication that you are concerned about or do you believe that the reduction in endothelial leakage is worth any potential risk of liver damage?

Elizabeth

Robert Cannon Replied at 1:22 PM, 28 Jan 2015

The secret to curing West Africa from Ebola is no secret at all
By Paul Farmer January 16
Paul Farmer is the Kolokotrones University professor at Harvard University, an infectious disease physician at the Brigham and Women’s Hospital and co-founder of the nonprofit Partners In Health.
PORT LOKO, Sierra Leone

Farmer: Port Loko is not far from Freetown , the capital of Sierra Leone and a global hub of maritime commerce. City and town, linked by paved roads, remain epicenters of Ebola transmission and deaths. Getting to zero new infections is the overarching goal of what is now the world’s largest public-health undertaking. But it’s still far from an ambitious clinical endeavor. The numbers say it all. Not a single American has died of Ebola;

ROC Comment:
Two Ebola patients have died despite care in the US.

Not sure how Farmer is defining an American – however, I’m guessing he meant those who were allowed to be treated in America with its ‘state of the art’ medical care. The emphasis would then be the quality of the medical care, not the nationality of the patient, which seems to be his emphasis.

Thomas Eric Duncan was a Liberian national who was asymptomatic when he arrived in America, he developed symptoms here, was misdiagnosed in Texas initially, but then diagnosed with Ebola and despite American hospital care – died.

Dr. Martin Salia, lived in Maryland with his wife and children and was a legal permanent resident of the US. He became infected in Sierra Leone and returned to US for care where he died at the Nebraska Medical Center.

Both of these patients were Black

Farmer: the majority of Europeans infected have survived; a Cuban survivor is already back here at work. Across West Africa, 70 percent of those afflicted die. And that figure applies only to the sick who receive care at treatment centers: More than 90 percent of those who stay home perish.

ROC Comment:
The 70% mortality rate cited for patients receiving care in treatment centers in West Africa is clearly an error, it is too high. I am not sure why he chose this number when there are now several reports of substantially lower case fatality rates – for example in Bo, Sierra Leone, the rate was approximately 36%, and the rate at Hastings in Freetown was on the order of 40% and dropping.

The 90% mortality rate he cites for Ebola patients who do not get treated is questionable. I am not aware of a prospective study that has followed a cohort of individuals and then assessed mortality rates after exposure to Ebola infection. I don’t believe we know yet the full spectrum of disease manifestations, but there is reason to believe that there are symptomatic cases, and cases with minimal symptoms, as well as the ‘classic’ severely ill patients. Without prospectively determining who is susceptible to infection and then following them with clinical and serological follow-up, it is impossible to know what proportion of all those infected die from untreated disease.

Farmer: A year into the epidemic, with billions of dollars pledged to fight Ebola, what accounts for the extreme variation in death rates? How can an ambitious public-health effort be so unambitious clinically? There are many reasons for variations in survival, but among the top five are not that shipped-home expatriates received experimental treatments. What kills most Ebola patients is a massive loss of the body’s vital fluids — up to 10 liters of day — along with proteins and electrolytes, primarily through vomiting and diarrhea.

ROC Comment:
I am assuming he is commenting on the different rates between ‘Western’ medical facilities and those in West Africa, but he may also be referring to the differences in rates between centers in West Africa (I tried addressing that in a previous post).

I am also not sure about his reference to ‘an ambitious public-health effort’ – I only spent 2 months in Sierra Leone, but my assessment of the public health there was that is was not very ambitious – in Bo for example, MSF had no outreach activities until recently, and those of the Ministry of Health, WHO, and the several NGOs were rather meager.

As for the ‘unambitious’ clinical effort – it was certainly less than stellar, and no one I encountered was happy with its extent and capacity, and several were very frustrated with the level of care and advocated for doing more. The care was certainly far less than one would expect in Europe and America – so if this is bench mark for ambition, it will never be ‘ambitious’ except perhaps in a very few centers that can mobilize all the human and material resources to make it happen.

As for the proportion of patients dying from dehydration and/or electrolyte imbalance and protein loss – I don’t know what the numbers are, but it is substantial, and if it can be addressed effectively this would logically be expected to make a major impact.

Farmer: And that’s not counting fluid losses from fever in broiling treatment centers, whose makeshift appearance offers a clue to the quality of care within. Clinicians and other staff in the hot zone can barely stand more than a couple of hours inside the centers, their protective gear sloshing with sweat, rubber boots brimming with a foul mix of perspiration and chlorine.

ROC comment:
Agreed. I have tried to change this within MSF, and have posted before about this in this forum.

Farmer: We often hear there’s no treatment for Ebola or other hemorrhagic viruses. That’s not true. What the expatriate survivors all received was excellent supportive care, most of it from nurses. In medical parlance, the term “supportive care” does not mean hand-holding but the replacement of fluids and electrolytes; treatment of secondary infections (bacteria escaping from the gut, say, or malaria); and, in some cases, renal dialysis and assisted ventilation. All of this is standard practice in countries pleased to be able to call themselves “donor nations.”

ROC comment:
What is he says is true and it is classic Farmer speak – attempting to shame to induce change. I would only add that he doesn’t mention is that several of the expats also received convalescent plasma, which may have improved survival.

Farmer: Parents from these nations know how difficult it is to get a sick toddler to take in Pedialyte; vomiting kids can’t keep it down even when it’s made to taste like fruit drinks. Here in West Africa, we need swift and better intravenous access and intraosseous needles, which can infuse large volumes of fluid when patients arrive at clinics so dehydrated that it’s difficult to find a vein. Three weeks ago, a baby named Jariatu was found by a burial team, barely alive, in a house full of dead family members. She was taken to Port Loko, where nurses and doctors were unable to locate a vein for an IV; the baby was dying, too unresponsive to drink. So the Partners in Health team, Sierra Leoneans among them, did what they would do in Boston or Haiti: They inserted an infusion needle into the bone marrow of her tibia. It was three days before Jariatu was conscious enough to show any interest in taking anything by mouth. She’s expected to survive.

ROC comment:
A heartening anecdotal story with special references to the Mecca of medical care (Harvard) and Farmer’s amazing success in the medical complex/outreach program (Zanmi Lasante) he created in central Haiti – both rather unique and so far, not readily reproduced in America or Haiti.

Farmer: What we need — what we’ve always needed — to improve survival in West Africa is the capacity to safely deliver excellent supportive care. So what’s the debate about? It’s hard to deliver supportive care here, due to the obvious lack of staff and stuff and space, and it’s dangerous. Though they’re afraid of Ebola, as any sane person should be, thousands of medical professionals, most of them African, show up for work every day (a lack of electricity makes it hard to make a similar claim about night shifts, which is another cause of high mortality). Doctors Without Borders deserves special praise, since it was the first to sound the alarm and has brought thousands of volunteers and staff into the battle. When I noted to the New York Times recently that Doctors Without Borders wasn’t “doing enough,” what I meant was that we all need to provide better supportive care to increase survival. Double standards between such settings as Atlanta and Freetown are also harming efforts to find all patients with Ebola, which hampers efforts to isolate them from uninfected family members. Could there be a relationship between poor-quality care and people’s reluctance to seek it in hot and raggedy Ebola units, where patients are interned until death or until blood tests show no circulating virus?

The primary task of the doctors, nurses and others working in treatment centers is to unlink these two events, infection and death. The quality of care in this part of West Africa — not simply for Ebola but for more common ailments and injuries — must be improved. Improving care means introducing capacity to monitor electrolytes, which we’ve recently done in rural Sierra Leone, instead of doing a single lab test for Ebola. It means cooler units — even fans would help — and personal protective gear made for tropical conditions. It means improved nutrition and a lot more support for the public health delivery system.
Since hospitals with poor infection control have always amplified Ebola’s spread, the two tasks — stopping transmission and improving care — are the means by which the world’s largest outbreak will be halted and proper health systems built.

ROC comment:
Stating the obvious has rarely been done so well, especially while positioned on a pedestal.

Farmer: Since the most shockingly inadequate part of the response has been clinical, the Partners in Health team recently signed what we jokingly called the Port Loko Accords: a pledge to drop case-fatality rates to less than 10 percent. We were extremely serious about the number, which is still higher than that in the affluent world. If we try and fail, we’ll keep trying while awaiting new and better ways to treat Ebola and other pathogens far more deadly for some — those bereft of decent health systems — than for others.

ROC comment:
No one who has read “Mountains Beyond Mountains” by Tracy Kidder and understands the enormous challenges that Farmer has identified and effectively overcome – in areas of dire poverty or prisons, in multiple cultural settings, with inadequate and/or inappropriate or nonexistent healthcare, and overwhelming disease burden with tremendously treacherous pathogens such as HIV and TB, could ever doubt that his genius, his passion, his compassion, his commitment, or his abilities are insufficient to radically improve the provision of care for Ebola patients.

I look forward to seeing what he and his team can do to improve survival. I trust that they thoroughly document every aspect of their patients’ demographic and clinical findings, their staffing (training, experience, and expertise), their treatment, and their management and infrastructure along with its costs.

No effective intervention is ever due to a single component, however, Farmer has attributes that enhance his projects beyond what is usually achievable by others. He has the stature to state things that are readily accepted as gospel, however, it never hurts to have empiric evidence that he and others can replicate his assertions.

And because, there seem few other Farmer equivalents in circulation, I would hope too that Farmer and his team see the value of comparing their maximum efforts to what is currently achievable in other centers to discern the relative value of the each component of their intervention.

Thank you.

Elizabeth Glaser Moderator Emeritus Replied at 11:10 PM, 28 Jan 2015

Thanks for the commentary Robert. I am going to comment on two points, the mortality numbers and on prevention.

Re " Across West Africa, 70 percent of those afflicted die. And that figure applies only to the sick who receive care at treatment centers: More than 90 percent of those who stay home perish."

This statement does not seem correct based on the currently available data. Some strains of Ebola have had high mortality in the past but if you take all the cases and all the deaths and aggregate them, then of the strains that have been associated with human deaths, (Zaire, Sudan, and Bundibugiyo) Ebola Zaire has the highest mortality at 79% overall ( all known cases and deaths ), Sudan is 54% and and Bundibugyo is 32%. The mortality rate for the the concurrent but unrelated Ebola Zaire outbreak in August -September 2014 in DCR was ( I think) ~60%. Initially the mortality rate for the West African variant of Ebola Zaire was reported as 70% for those _not_ receiving care in health facilities but between 50-60% percent for those receiving care, and this was prior to more intensive use of IV therapy. However the mortality clearly differed greatly by facilities/areas.. As I recall even Dr. Gupta at CNN noted in the Summer/ early Fall 2014, that the untreated mortality rate was 70% which was bad enough , but still somewhat better than that of earlier individual outbreaks , some of which hovered around 90% .

The current outbreak is the largest to date, but it is unlikely to be the last, as we have seen that the DCR and Uganda now have sporadic, but increasingly frequent, outbreaks of the disease. Given the scope of the outbreak, now is our opportunity to learn how to better prevent cases as well as treat Ebola, so that future outbreaks can be quickly brought under control with a minimum of illness and death. In Uganda they have had much success in bringing outbreaks quickly under control by early identification and containment of cases with an emphasis on prevention.

I agree with Robert that there is much discussion of treatment in the current epidemic, which is certainly important, but not a lot on the work of prevention - we need to do more to prevent illness in communities aside from isolating and containing cases. I had not mentioned some commentary in late October by Farmer , but will do so now because it directly relates to prevention.

" Despite anthropologists’ fondness of recounting such practices ( meaning burial or funerary practices), these rites are not suspected of having played a major role in outbreaks of Ebola in Congo, Uganda and Sudan over the last forty years. The inhabitants of coastal West Africa have eaten bush meat for centuries and they have prepared the dead for burial without taking precautions to stop transmission of a pathogen like Ebola. Even so, it isn’t improbable that these practices helped to spark and then fan this outbreak, which began in the Upper Guinea Rainforest." - Paul Farmer Diary, London Review of Books, Vol. 36 No. 20 · 23 October 2014 pages 38-39

On 28 August 2014, Pardis Sabeti's team published in Science their initial sequencing of the West African variant of Ebola Zaire, based on early cases in Sierra Leone. They documented that the virus traveled from Guinea to Sierra Leone and Liberia through attendees at a funeral for a local traditional healer. Peter Piot 's recounting of first outbreak of Ebola in Zaire ( Congo) in 1976 notes the role of funerals and poor hospital practices in the spread of the disease. Yet Farmer discounts this major form of transmission with the caveat that it was " perhaps not improbable" that it could have contributed to the epidemic. To what end?

Funerals are important to families and communities the world over. Even in the midst of the outbreak family members have knowingly placed themselves at risk because they believe that it is important to fulfill their duties to the deceased, their other family members, their religion and their community. We need to acknowledge the importance of funerals to communities, and find better ways to respectfully bury the dead so that families can feel that duties are fulfilled even as everyone is kept safe.

Eating bush meat is not a choice for people living in the small villages of the rain forest in West and Central Africa, it is a necessity. Food insecurity and frank malnutrition are is common enough as it is , and it would be far worse if families did not have bushmeat for additional protein. But eating it will provide other opportunities for Ebola to enter the human population again. There are no good answers: if substantial amounts of land were cleared for cattle, pig farms, or other larger sources of protein then there could be problems there, too. This is why is it important to acknowledge that bushmeat is in the diet, and learn more about diet in these remote communities in order to best minimize risk given people are not going to stop eating this food source in the near future.

When the reservoir was not present in the rainforest, neither a typical West African funeral, nor eating bushmeat would have placed people at increased risk for Ebola, but now that Ebola has entered the ecosystem from the Congo basin, it changes things. To dismiss the importance of either in its potential to spread Ebola in present or future outbreaks is akin to saying in the early days of HIV that we never died from having sex before so why should we believe that it is a problem now?

Robert Cannon Replied at 11:44 PM, 12 Apr 2015

Hello all,

I would like to open up this thread again, using the following article in the NYT as the focus. This particular discussion began with Elizabeth's post about a NYT article and evolved - however, at the core were the rather hubristic statements of Dr. Paul Farmer of PIH. I have already written several posts addressing several of the germane issues, and so defer to others at this point.

"Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak"
By SHERI FINK
"Safety deficiencies at a treatment center staffed by Partners in Health, a charity that pledged to fight Ebola in Sierra Leone and Liberia, led to the closure of the center after two clinicians were diagnosed with Ebola."

http://www.nytimes.com/2015/04/13/world/africa/pattern-of-safety-lapses-where...

Thank you.

Attached resource:

Elizabeth Glaser Moderator Emeritus Replied at 3:36 AM, 13 Apr 2015

Based on the numbers from MSF's annual report, the NYT article and numbers for Port Loko facility, the table below roughly lays out cases treated , survival and mortality numbers, overall, by facility and over course of time on the ground. Granted the numbers for PIH only apply to Port Loko but I do not believe that many other cases have been treated by PIH at other facilities, if anyone can help with these numbers and correct any errors, please do so as I want it to be fair and accurate.
If you have numbers for IMC, IRC, or other groups please send. I have attached the spreadsheet in case the table does not work with this formatting.

Table. Ebola outcomes and costs per facility and by month
overall MSF PIH* Difference # note* PIH Port Loko facility
confirmed ebola 4962 350 4612 MSF treated over 4600 more patients than PIH
recovered 2329 174 2155 MSF saved over 2100 more lives
died 2633 176 2457 PIH's survival was 2.8% higher than MSF
months on ground 12 5 7 MSF has been on the ground for 7 months more

Averages per facility MSF* PIH Difference # * MSF had 15 facilities in 3 countries for much of response
confirmed ebola 311 350 19.2 By facility, PIH might treat 19.2 more patients
recovered 155 174 18.7 By facility, PIH might save 18.7 more lives
died 176 176 0.0 By facility, deaths in number might be the same

Averages by month MSF PIH Difference #
confirmed ebola 414 70 344 By month MSF treated more patients than PIH
recovered 194 35 159 By month MSF saved more patients than PIH
died 219 35 184 By month, PH had fewer deaths in number and by % treated

Cost in Euros MSF PIH Difference # No costs available for PIH
cost per 12 months 59,054,680
average cost per month 4,921,223

Attached resource:

Elizabeth Glaser Moderator Emeritus Replied at 3:39 AM, 13 Apr 2015

I need to correct/ clarify ( already!) Averages by month = average per month on the ground

Margaret Chirgwin Replied at 9:59 AM, 13 Apr 2015

Hi

Just to introduce myself - I am a medical doctor but actually practice more as a manager. I volunteered to Save the Children and returned 2 weeks ago from working in the Kerry Town Ebola Treatment Centre - Sierra Leone. I was Quality Assurance Adviser. I have just been told about this site by a friend at Public Health England and have read it with interest. So much of what is being discussed was our reality.

The comparison of mortality is going to be almost impossible I think for all the issues you have raised. Not least the quality of data collected may simply not be up to concluding much! For me there were three sets of patients - those who died incredibly quickly - pretty much on arrival - often in a very bad state when they arrived - could we have done more for these people - not clear - perhaps better care before arrival would have put them in the second group? The second group arrived not so bad and then got very sick with severe diarrhoea +/- vomiting - a percentage of these died - some of these guys arrived almost completely well (one had strong history of contact and a slightly red eye). Third set of people were those who barely got sick at all and obviously there were grades in between. Most of our deaths were in this first group but I think the second set are the ones where we should be able to look at all our experiences and come up with guidelines that maximise survival.

ORS - disgusting stuff - I tried to get flavours to add but by the time I left still not arrived (the logistics constraints were enormous through out the response)- some people brought flavourings from the UK and this helped. Did also make it in to ice lollies but not in any quantity. We also did get some "jelly water" - coconut water - to a small number of patients. We did not however have a consistent or large effort at getting individuals to take ORS/oral fluids during the 8 weeks I was there. Because of staff being only there fore 5-6 or 8 weeks there was a lot of change of practice which makes any research/analysis difficult. I feel we needed a type of worker whose role was oral fluids, food/nutrition and cleaning patients - maybe other centres had this but we did not have people focussed on these tasks and we were weak in all these areas. We were able to keep all (except 1) health and WASH staff safe so I feel we could have had more people in the Red Zone than we did and I would have trained local volunteers to do these roles - sitting with patients to help them eat and drink - almost no time was spent on this. A decision was taken for all clinical staff (nurses, doctors, CHOs and CHAs) all to do all jobs. For me this did not work well and was perhaps a consequence of what nurses in the NHS does whilst Sierra Leonian nurse could have been very suitable to focus on these tasks but one way or another we did not consistently get oral fluids into people or food in early convalecence.

Before commenting on IV fluids I would like to make a plea for rice based ORS - I feel that everyone gets way too hung up on the exact content of ORS - there has been good evidence since the 1980s on rice based ORS being BETTER than sugar based ORS because it does not increase the diarrhoea in the way sugar based ORS does . http://rehydrate.org/ors/rice-based-ors.htm. For reasons that I will not hypothesise about here WHO feels that sugar based ORS is "good enough" so does not choose to promote it. It does not as easily come in sachets (???really??) but think can come in sachets but is also easy to make - Sierra Leone is a rice based culture - maybe we could have made a rice based version of pepper soup? I believe that we should be moving to rice based soups/drinks as more palatable and therefore more likely to get the patient to take it particularly in a situation where supervision is limited). We did have pepper soup as the semi-solid diet.

So IVs. Whilst I was there (not during the peak activity) we did not put in fluids with NG tubes or intra-osseous. All was IV fluids. We did not have particular problems with infected sites but we did have patients pulling them out - both adults and children - and bleeding from these. We have very poor records of how much fluids people actually got. Did boluses and then binding the cannula and coming back and doing another bolus. No one has spoken of sub-cut fluids and I wonder if anyone tried this for those so severely dehydrated could not find a vein? Anyway generally we did get fluids into patients. There was significant belief that this was the key thing that could help. Lots of different antibiotics also used. I have concerns about the fluids we used. Not sure why but we did not follow the WHO protocol in terms of Potassium - basically using ringers lactate which has very little potassium. We had access to U&E results and basically everyone had a low and sometimes extremely low Potassium. I believe we need to workout what fluids people should be given where no U&E available - I am told (may not be true) that elsewhere there were sudden deaths in some convalescent patients - maybe low potassium. We did not have such deaths but we did have the U&E so did then push the potassium and Magnesium. We need to have a fluid regime that will avoid this problem for most patients - NHS staff were not willing to put potassium into the Ringers. SO - should we put more potassium in Ringers or have a particular fluid for severe watery diarrhoea?? I understand that cholera also has a problem with low potassium so why are we not putting in more potassium and magnesium - I realise that high potassium is also dangerous so we have to get a balance but at the moment it seems we are not getting this right. Does the potassium matter? Does it contribute to the deaths? I do not know but there is some evidence pointing this way for the later deaths. Surely we must have some data we can use to come up with a better IV fluid regime than we presently have? Early deaths may be more related to low sodium??? These are these things we need to sort out so we can provide a good fluid regime for future outbreaks - a regime that can be followed out in the community too with basic PPE.

Cooling has been mentioned a bit - I have been very interested in this area - I believe that some ETCs had air-conditioning - Kerry Town did not and the nursing station (outside the Red Zone) had only fans. We were getting to 40 degrees in March. We kept times in the RedZone down during March because of this additional heat but one way or another we need to make the PPE less of a stressor - I do not think anyone's brain is working properly whilst in the Red Zone. I feel we need a good review of the different kit - wet vs dry doffing but also the kinds of eye protection - we had goggles - others had less enclosed eyes - this would mean less fogging - did it make any difference to the infection rate of staff? But most importantly cooling inside the suits. We did have one ice jacket - a few people used - me included - really did not seem to make enough difference to matter. My google search on core temperatures also mean I had concern about the impact of the ice jacket on core temperate. There is a Stanford University team working on another system which uses some sports medicine research. If we could make it feasible to stay in the RedZone safely for 3 hours this would transform the whole management situation - would make it possible to have people on the wards all the time perhaps??

Lots of thoughts!

Margaret

Diane Hallinen Replied at 11:02 AM, 13 Apr 2015

I returned March 15 from Maforki, the infamous ETU that Dr Fink just wrote about. My experiences are similar to Margaret.

We also had difficulty with the IV sites. We didn't have luer locks so we had to disconnect the LR before we left the red zone. I would stand there watching IV fluids drip while feeling my sweat pour off me at a rate 10 times that of the IV fluids. I was amazed at the diarrhea fluids losses. It is one thing to read that patients are losing 14 liters in a day, its another to actually watch it happen. We too had those three groups of patients, those that you carried in and then died before you doffed, those that looked fabulous the entire time and that middle group. Those in the middle group who were malnourished did poorly. A few that we made a difference on received 10-14 liters LR a day. We had an Istat machine, but when we ran out of KLC I didn't see the point in bothering with it. When we had KCL I know it made a huge difference, some patients were so weak they couldn't hold an ORS bottle and did so much better during my second round after the KCL. I worried that giving 2-4 liters over an hour was stressing our third spacing patients. During my last week we had an ultrasound machine that was helpful. I taught 14 nationals how to check the respiratory collapse of the inferior vena cava diameter as an indicator of fluid responsiveness. I was very sad Maforki closed before we could really see if it was feasible and clinically useful on a large scale. I did get to scan an end stage patient and saw small pleural effusions, dilated ventricles, flat IVC, hydronephrosis and crazy bowel wall edema surrounded by fluid.

We had an IO gun, which we should have probably used more often. I love that thing.

We had a survivor program that was doing patient care. That was just getting going when we closed. The survivors helped give patients baths, which they so appreciated. They also helped feed patients, which was great. I don't think they pushed the ORS. One survivor told me that she preferred to just eat the ORS out of the pack and chase it with water. I tried it, it was okay. I actually craved plain ORS when I came out and was drinking 3 liters of it a day. I think the rice based solution makes a lot of sense, maybe cook the rice in coconut water/milk. Our patients were getting coconuts and oranges, which I think helped those patients who were in that fragile recovery phase.

In regards to Dr. Fink's article, I really want to see that WHO report she quotes. I have a lot of questions about how two of my colleagues got infected probably within hours/days of each other. Working with MOH was difficult, to put it nicely, but I understand why PIH does it that way. I for one ALWAYS checked my PPE for breaches before I put it on, and I found a few. I also insisted on rechecking my teammates/buddies before going into the red zone. We had a wonderful woman named Esther who looked us over before giving us a "safe" stamp on our glove. I'm wondering where Fink got the information that we didn't check. I think a doffing reminder card would have been helpful in doffing.

I agree about the hyperthermia induced red zone brain dysfunction. I had to have my red zone plan completely organized and written out, I was really bad at improvisation in there. Every second I wasted in there would make me furious. Sometimes I would feel this weird euphoria after doffing during those 40 degree rounds. Strange thing, all my little annoying chronic arthritis issues completely went away during my weeks in the red zone.

Our record keeping was horrible by USA standards, but I think if MOH digs into they will find some useful information. I think all the antibiotics in confirmed patients were a waste of time and the damage to gut flora exceeded any theoretical benefit of preventing gut bacterial translocation. Antibiotics in suspect patients probably were helpful in those that had pneumonia, pyleo, etc. The anti-malarials were fabulous, we saw some amazing responses in kids.

Diane

Elizabeth Glaser Moderator Emeritus Replied at 7:40 PM, 13 Apr 2015

Welcome Margaret, thanks for your great insights.
Diane, you could try to email Dr Fink and ask her about the report.

I am sorry that my table did not come out, but the gist is that
MSF treated 4962 confirmed Ebola patients and PIH treated about 350 ( likely more because some staff were in ccc's)
MSF had about 2329 patients survive, while PIH had about 174 at Port Loko. If these numbers are correct then , PIH's survival rate was just 2.8% higher than MSF .

According the NYT article in January about use if IVs , Dr. Cancedda, the director of the PIH Port Loko unit, estimated the fatality rate as about 35 to 40 percent., which differs 10-15% from the 50% that I have estimated here. If the numbers are not correct, then please inform me and I will adjust them and revise.

A 2-5% difference is not very much considering all we have heard about the advantages of aggressive rehydration. In fact those numbers appear to lie well within the range for MSF and IMC ( IMC's mortality in Liberia ranged between 48-60%).
As PIH scaled up their approach it may very well have made a more significant difference, but those rough numbers do not point to a dramatic improvement in outcomes. This would tend to support the assertion of the Head of MSF, Dr Sprecher who said " We’ve been putting people on IVs for Ebola for 14 years. If just tanking them up worked, we’d be doing it.”

Diane, you have pointed out that prehospital factors, such as malnutrition play as important a role in mortality as anything else. I think that this is quite likely the case and it calls for us to try to find better methods for supplying nutrition while in treatment , and of course, for working diligently to reduce food insecurity in country.

Let 's keep talking and sharing ideas, and writing about this to keep the focus on collaborating to improve outcomes!

Margaret Chirgwin Replied at 8:23 AM, 14 Apr 2015

Elizabeth

I am concerned that you are concluding things you cannot from this data and I find it rather surprising after this conversation has had contributions on the issue of why it is going to be hard to compare data and mortality rates from the different treatment centres. I do not think you can just take these high level figures and conclude anything at all. I believe we will have lost the information that may be there and I find your apparent conclusions - MSF probably got it right - untenable because there is no statistical difference between the survival rates between MSF and PIH. I was not there but I understand that in some parts of this outbreak MSF chose not to put IVs up so their overall data is mixing the outcome of different treatment protocols. I do not know why you must focus on PIH - Kerry Town was aggressive with fluids through out the time it was open - however our death rates are not particularly good but this includes people who tumbled out of ambulances and were dead in minutes and hours.

The attached file gives the data on confirmed cases and deaths by each of the ETCs in Sierra Leone but as noted not sure what you can really conclude from this. If we could look at those patients that do not die in the first say 2 days they are in an ETC and also take out those who do not get significantly sick and then looked at which ETCs do best with the middle group and you can show me aggressive fluids does not make a difference than I will accept this. I know MSF has been at this for a long time but their cumulative cases from before this out break are not large so relying on their experience just because it has years does not seem particularly helpful. Before they had this outbreak I do not think they had the opportunity to know if "tanking up the IVs" makes a difference - numbers not that large - we are looking for a good general guideline that will decrease the mortality in a resource poor setting and for me tanking up the fluids with the right electrolytes for all patients with diarrhoea may well be the best we can do. I do not personally know that it does but we have to look at the information we have and on the whole the health professionals in Kerry Town thought it did - the diarrhoea is like cholera diarrhoea so why do we not think pouring in fluids will reduce mortality significantly- it does for other causes of this type of diarrhoea? I know people are also concerned about the 3rd space and patients who get into the third stage of ebola do have this problem but once you get into this sage mostly you die - keeping them out of this stage however seems to be related to aggressive fluids. I am sure it does not work for all patients but we need good guidelines that will help the most not vague and complex guidelines that require highly qualified doctors and nurses and lots of testing equipment. We need something a poorly equipped general hospital in Africa can do - sensible basic PPE + aggressive fluids (with KCL and Mg) IV (ORS as well but not instead of) + Zn + ? antibiotics + ?atovostatin perhaps. We are after all hoping that we will manage to contain a future outbreak within the local health system not purpose built ETCs.

Malnutrition is interesting - I was there late in this outbreak but most people who came to us did not have a malnutrition problem before the disease hit them and those that died quickly were on the whole longterm well nourished - the disease does however burn energy and patients lost weight fast and in the convalescent stage our patients were ravenously hungry and we did not get good at addressing these issues early enough. The Cubans we worked with (who were there for most of the outbreak) did believe that if patients did not start eating as soon as the worst of the vomiting was over they would not survive. So I am sure that nutrition has a role after the hydration but it is the hydration that will help people not to get into stage 3 disease. Once in stage 3 - this is where the fluid management probably gets complicated and a simple aggressive fluids strategy may not help but maybe it will not make much difference and that therefore overall recommending aggressive fluids (probably with magnesium and potassium) will reduce the mortality more than being equivacol about this.

I am not sure that this is particularly coherent - my greatest ask is that you do not use the mortality data as you did in the previous posting - we will miss the really important findings by looking at this level of data.

Margaret

Elizabeth Glaser Moderator Emeritus Replied at 10:00 AM, 14 Apr 2015

Margaret,
As moderator my goal is to get us to exchange ideas and talk ,I do not mean to offend you. If it helps to understand my view point, let us say that I am a universal skeptic - a doubting Thomas -you have to show me so I can believe, whatever the issue.
To give you some context, I went to Liberia in November and December with Partners in Health . I respect the work they do in health strengthening all over the world. I was trained at IMC, who also used IV fluids in care, and who did a decent job, but no group is perfect, MSF, in fact, is far from perfect.

I understand how it is to care for people when there are few options, as I came into health care in the 1980s in the US when we could do so little for our patients with AIDS, and when not a few healthcare workers refused to care for them. I remember when AZT came on the market, offering the first glimpse of hope for those men and women.

The problem with excluding those people who arrive near death from one's count is that if a person arrives in that state and by some miracle, he or she survives, you are surely going to count that person as a survivor, yes? So those who arrive in similar shape and die must also be counted, otherwise we can pick and choose who to include and exclude until we get the numbers that we think we should have. It should not work like that.

It is reasonable , however, to break down counts to explain that there are groups who have higher survival rates than others based on age, type of treatment, or other factors, because that helps us learn how to revise protocols and improve chances of survival.

What I see you saying is that aggressive rehydration works very well for some people.
Can you explain the age groups, gender, distance to care, or other factors you saw in those who tended to survive?

Elizabeth Glaser Moderator Emeritus Replied at 10:10 AM, 14 Apr 2015

Red zone heating, There are projects to revise PPE and shorten removal time and ease of removal. I can try to look up any progress in this area, but if you know of anything, please send it, too.

When you finish doffing , make sure to check the water spigot before you place your head under it, 0.5% on the head was not as comforting as I hoped, even if it was a cool temperature. I am still not a blonde, though as my hair is so white anyway that it made no difference.

Margaret Chirgwin Replied at 2:35 PM, 14 Apr 2015

Elizabeth

I am a data girl - this means I too am a sceptic until I have proof - I am keen to have proof about what works but I do not think the calculations you have been doing comparing total mortality rates at different ETCs is going to tell us anything about anything. Too many confounding factors. I do not think that the group that will respond well to pushing fluids is one of age, sex, ethnicity, time from exposure - possibly distance to ETC because if you have a bad response you have longer to get more dehydrated. I think that there is probably a dose issue and an immune response issue but neither of these can we do anything about. I think it is related to an individual's response to the disease. As I described earlier I think there are 3 groups of people - those who die very soon after arrival - those who get very sick and lastly those who never get very sick and at least some of this difference is related to their immune response.

I think probably the most likely to be available information might be Stage of disease on admission. Perhaps comparing the morality rates at different ETCs for the 3 stages would give us some useful information about the effectiveness of our clinical interventions.

1) Stage 3 on admission are basically the group who die very fast - but some do live - I am not sure if pushing fluids helps all of this group but may do so.

2) Stage 2 on admission are the ones that I am sure will benefit from pushing fluids - they arrive dehydrated.

3) Those who arrive in Stage 1 - some stay in Stage 1 and then get better and go home but some of these also go into Stage 2 (when I think they will benefit from the strong push of fluids as they get the diarrhoea - as they arrive hydrated you should be able to titrate the fluids with the diarrhoea and vomiting - so less of a push of the fluids for those with less severe diarrhoea and vomiting).

So that would be my recommendation but the data may not be easily available - for each ETC compare mortality rate of patients by Stage of disease at arrival.

This will make the mortality rates more comparable. The patients that arrive in Stage 3 may be a bit variable - some centres getting them very close to death and other centres getting a bit more time to do something that might make a difference but for Stage 2 (again may be a bit variable with some centres getting Stage 2 with higher levels of dehydration than others) and definitely Stage 1 the state of the patients will be more similar and therefore the impact of clinical care on mortality more significant. I would lay money that we will find that the mortality of those arriving in Stage 2 will be strongly affected by strongly pushing IV fluids. Stage 1 - I am not sure what percentage will progress to Stage 2 but for those that do move to Stage 2 I think pushing fluids will reduce the number progressing to Stage 3 and thus mortality. But I am quite prepared to find the data does not support this.

I do not think speeding up doffing will help much to be honest - still do not think brain will function well in PPE - increases of core temperature have been shown to reduce critical thinking quite significantly. So got to keep the core temp down.

Margaret

Elizabeth Glaser Moderator Emeritus Replied at 4:04 PM, 14 Apr 2015

Re PPE: Getting out quickly and safely might change risk for exposure, it does not fix the basic problem which that PPE are too hot to function in, it merely makes removal quicker and safer. As you noted after being in PPE for a while one is not thinking well , one might be more likely to make errors even though the hygienist should be able to keep you from rushing, inadvertent errors could occur. So decreasing steps and complexity while exiting might reduce error and risk in very hot tired people.

Crude measures give a general picture, for example WHO lists cases and deaths for each country, this the same but a difference level. Guinea's mortality rate if 66% , Liberia is 45% and Sierra Leone is 32% , why such a large spread?

re : mortality: In the case of NGOs it appears that despite differences in the number of personnel on the ground, the number of people treated, and the mode of treatment, that there might be very little difference in overall mortality. If there was an NGO that had a 30% mortality rate or an 80% rate by this same simple metric, we certainly would want to know why it was the case.

Re staging : Can you clarify, are these stages used in your facility?
This could be a useful metric but would help to have objective definitions for each stage.

Peter English Replied at 6:56 AM, 15 Apr 2015

A colleague who worked previously in tropical developing countries was responsible for managing a large outbreak of diarrhoeal disease.

By the time patients arrived at the main hospital from peripheral clinics they were often moribund. It was not feasible to provide IV rehydration at the clinics; and patients were often unable to tolerate drinks.

Having seen some papers on using oral rehydration therapy via a nasogastric tube,[1,2] this was (he tells me) implemented, with dramatic benefits. It was simple enough to be undertaken in peripheral clinics, it was much easier to document how much fluid had been given, and it was possible to titrate the drip rate against the nausea, thereby minimising vomiting.

Has this approach been in use in the Ebola affected countries?

Peter.


1. Seriki O, Olambiwonnu NO. Management of moderately severe dehydration by continuous intra-gastric infusion of electrolyte solution. Trop Doct 1978;8(3):134-6 PMID: 675804. (http://tdo.sagepub.com/content/8/3.toc).

2. Green SD. Treatment of moderate and severe dehydration by nasogastric drip. Trop Doct 1987;17(2):86-8 PMID: 3576693. (http://tdo.sagepub.com/content/17/2.toc).

David Fedson Replied at 9:49 AM, 15 Apr 2015

When oral rehydration therapy for cholera was being developed in the late 1960s, NG tubes were always used to administer experimental fluid formulations. I know this because I served as one of the "interns" on the wards of the Johns Hopkins cholera project in Calcutta. NG tubes allowed accurate quantitation of fluid intake and comparison with diarrheal output. I have no knowledge of how extensively NG tubes have been used in West Africa, but as long as patients don't pull them out (as they sometimes do with IV tubes), the should be well tolerated and work well. They have the major advantage of bypassing the taste buds.

Appolinaire MANIRAFASHA Replied at 10:00 AM, 15 Apr 2015

Ebola patients has a risk of bleeding easily, it is why NG tubes can not
be used for fluids therapy.Better they give them fluids orally or via IV
lines.

*Appolinaire MANIRAFASHA ,MD*
ASEOWA
Liberia/Monrovia

Elizabeth Glaser Moderator Emeritus Replied at 8:25 PM, 15 Apr 2015

Hi Peter,
Some have advocated for use of NG tubes to provide fluids, but the counter argument is the one provided by Appolinaire , that because people with Ebola have an increased chance of bleeding, NG tube placement might be risky. The WHO guidelines on nutrition for those with Ebola, recommends against using NG tubes. However, I recall that NG tubes may have been tried in some cases during the current epidemic, but I cannot find the reference. If anyone has experience with using ng tubes for hydration with Ebola patients, please post.

http://www.who.int/elena/titles/full_recommendations/nutrition_ebola/en/

Deborah Wilson Replied at 7:08 AM, 16 Apr 2015

We used NG tubes twice both on children that we could not get IV access. In both cases it was highly successful and we had much more control on how much fluid we were actually getting in. It took careful administration so that the child did not vomit.
We would start with the little one and give some fluids through the NG tube then move on and work with other patients and then go back and give a little more.
Is insertion of a NG tube really more risky than inserting an IV? I never had patients "bleed out" from either procedure. I do realize that there is concern because Ebola is considered a Hemorrhagic fever but that to is being debunked now after this outbreak I thought.

Elizabeth Glaser Moderator Emeritus Replied at 1:29 PM, 16 Apr 2015

As you note, Debbie, I recall some people using NG tubes, maybe it was you? The resource I found at WHO, at least for nutritional purposes, recommended against it for feeding and I could not find another reference for using ng tubes for rehydration with Ebola. Hope fully field experience will feed into new recommendations.

The only caveat here is that the hemorrhagic manifestations of Ebola may differ by strain and variant.In addition, visible bleeding does not rule out internal bleeds. I am sure you cared for patients near death with severe abdominal pain. Even if they might not have had nose bleeds or more overt hemorrhagic signs, some of those people were suffering from internal bleeding.

Perhaps if the child is sick enough that NG rehydration is the best option, it may well be worth the risk of a bleed.

Peter English Replied at 5:56 AM, 17 Apr 2015

I've just spent about 10 minutes reviewing the first 40 odd hits at PubMED using the search string "nasogastric tube complications bleeding". (Somebody doing a more rigorous job might reach a different conclusion - I may well be mistaken!)

There was one case report paper reporting a severe haemostaxis (nosebleed) (http://www.ncbi.nlm.nih.gov/pubmed/23334489).

In this extremely quick and dirty search I found no other papers supporting the hypothesis that NG tubes are a significant cause of bleeding.

One or two pointed the other way:

* http://www.ncbi.nlm.nih.gov/pubmed/22736126 found no difference in bleeding rates when investigating NG decompression tubes in gastric cancer patients.

* http://www.ncbi.nlm.nih.gov/pubmed/24983564 found that NG tubes were not a risk factor for bleeding in children in ITU.

* http://www.ncbi.nlm.nih.gov/pubmed/25769589 "Efficacy and complications of enteral feeding tube insertion after liver transplantation" mentioned as complications, in the abstract, only tube dislocation and blockage.

Another paper, http://www.ncbi.nlm.nih.gov/pubmed/25803603, was unclear in its implications: it looked at NG feeding as part of end of life care of geriatric patients, and the abstract concludes "NG tube feeding is widely used in our setting, despite high complication and mortality rates, with likely influences from cultural emphasis on feeding", but does not clarify what the complications were - the implication is that it's not a very useful intervention for these patients; but the risk benefit ratios are unlikely to be comparable to those applying to Ebola patients.

Medicine is rather prone to believing in mythical risks. Intramuscular vaccination is deprecated by many heavyweight guidelines ,for example, due to a mythical risk of bleeding. (I've traced back the citations listed: the evidence is that while very large volumes injected intramuscularly may be a bleeding risk, there is no evidence of risk from the small volumes used in vaccination). Could it be that the "risk" of bleeding from NG tube insertion is similarly based on myths passed down from generation to generation? When the cause of death of so many Ebola patients seems to be dehydration and the associated electrolyte disturbances, and the difficulties of IV rehydration are so great in resource-poor settings, surely there's a need to be really sure of the need to rule out NG rehydration?

Peter.



Dr Peter M B English

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Elizabeth Glaser Moderator Emeritus Replied at 12:32 PM, 17 Apr 2015

Dear Peter,
It could well be that the fears are unfounded, your lit search, even if brief, is compelling. I wonder if people would be interested in writing a letter to Lancet or WHO and MOH in affected countries with a lit search and case reports from the field to make a case for including ng tube rehydration in future protocols?

Elizabeth

Margaret Chirgwin Replied at 3:16 PM, 17 Apr 2015

Treatment Unit Deaths Admissions Mortality
Kenema (KGH) 254 504 50%
Kenema (IFRC) 231 567 41%
Kailahun 260 1061 25%
Bo 171 482 35%
Hastings Freetown 257 778 33%
Magbenteh ETU 60 161 37%
Rokupa 100 562 18%
Mateneh IMC ETC 98 416 24%
Seventh Day Adventist Hosp 15 43 35%
Emergency ETC 47 95 49%
Kerry Town ETC 92 233 39%
Aspen ETC 59 211 28%
MBHS Kissy ETC 2 10 20%
Kono ETC 27 99 27%
Jui 216 812 27%
TOTAL treated in ETCs 1983 6300 31%
Not in treatment centres 1508 2263 67%
Grand total 3491 8563 41%

Margaret Chirgwin Replied at 3:29 PM, 17 Apr 2015

Sorry last post did not show the table. I attach as an excel. What is notable is that the reported mortality of confirmed cases both nationally and by centre is quite variable. From the most recently reported national data from Sierra Leone it is 41% (Elizabeth quoted 32% not sure where this is from but may be because the mortality has changed over time - reducing) and Guinea 66% and Liberia 45% (very similar to 41% for SL). Best ETC has only 18% mortality and this is with big numbers - I have no idea what they were doing at Rokupa??? The mortality for those not treated in the ETCs was 61%. No idea of course how many deaths from Ebola were not identified as being from Ebola.

So working out what impact any treatment has had is going to be difficult. I have been trying to get the formal definition of the 3 stages of the disease. I was not aware others were not using this. I have not managed to get yet but will.

Margaret

Attached resource:

Diane Hallinen Replied at 11:24 PM, 17 Apr 2015

We didn't use NG tubes while I was at Maforki. I think a few of our patients would have tolerated them, but I think most of them would have yanked them out pretty quickly. So many of our patients were confused and we spent so little time at the bedside. I don't think they would have tolerated boluses in via NG, some patient's vomited after just a few sips of whatever liquid we gave them. Our really sick kids had what looked like painful oral mucosa, I assume the nasal mucosa was the same. They were oozing blood and couldn't tolerate a cup touching their lips. During evening and night shifts I would drip baby formula into their mouths and watch them try to swallow. I could tell it was really painful. I spent over an hour at the bedside dripping in formula while the IV ran. It was heartbreaking when they vomited.

My opinion is everybody who presents who meets case defiintion gets a liter of LR no matter how they look, and if they are tachy or look dry, they get two or more. If a patient is taking excellent PO, making urine and is dry and afebrile, no IV fluids. Otherwise, ultrasound the inferior vena cava. If it collapses with respiration, they get a liter, if it still collapses, they get two. If diarrhea is pooring out of them, they get four. I like the idea of a NG tube, but I worry about aspiration, securing it to a sweaty nose, and vomiting. So many patients are malnourished, it would be good to get some calories in them before they get to the super sick phase. I'm curious if any patients in the US got TPN.

Diane

Margaret Chirgwin Replied at 6:35 AM, 28 Apr 2015

Taken me some time but promised I would find out. Kerry Town ETC started putting a disease stage at admission on the notes from 1st December. 3 stages: 1) Dry 2) Wet: diarrhoea/vomiting and 3) Shock/bleeding.

Margaret

Elizabeth Glaser Moderator Emeritus Replied at 1:32 PM, 28 Apr 2015

Thanks Margaret,
Then in your experience,
If a person presents with 3, they are essentially end stage and unlikely to benefit from any treatment.
If they present with 2 they almost definitely will benefit from IV fluids
if they present with 1, then they might benefit from IV fluids, either at admission or later in the course of the illness.
Is that a fair restatement of the situation?

Elizabeth

Margaret Chirgwin Replied at 1:56 PM, 28 Apr 2015

I think is probably true but believe that at least some of those in stage 3 may also benefit from fluids just very few people arriving in Stage 3 survive - so actually a general policy of pushing fluids in all patients will reduce overall mortality.

I was suggesting we look at mortality by the stage on admission to allow us to compare more statistically safely the mortality at different ETCs. You were using total morality data from ETCs to suggest that those being more aggressive with fluids were not getting better total survival rates. The excel spreadsheet I attached previously shows significant variability in mortality rates by ETCs in Sierra Leone. The question is what does this tell us - I think not much because the state of those arriving at different ETCs may be significantly different - masking any difference we might see because one centre is more aggressive with fluids than another. Therefore if we could compare the mortality rates at different ETCs for those arriving in Stages 1, 2 and 3 we would I think remove some of the confounding factors. This might also explain the difference in total mortality rates for the 3 countries - it is highest in Guinea - maybe most patients arrive at treatment centres already in stage 3 in Guinea whilst higher numbers arrive in stage 1 in Sierra Leone and Liberia thus giving treatment a better chance of saving lives.

Kerry Town has quite a lot of staging on admission, done by the clinicians at the time, from beginning of December and where it is missing these is often enough information to give them a stage on admission from the notes but the info is incomplete and may bias the results somewhat though data seems to be mainly missing for those who die fast who I think are probably in Stage 3 on arrival.

Margaret

Elizabeth Glaser Moderator Emeritus Replied at 2:12 PM, 28 Apr 2015

Okay, so if we knew the staging of the patients it would help us better in understanding the mortality numbers.
For example, if a center had many patients presenting at stage 3 , perhaps due to long travel times in a rural area, then that center might have very high mortality due to pre-hospital factors and is not necessarily a fair way to assess the overall effectiveness of treatments such as IV fluids in reducing mortality.

For example if you had a regression with mortality as the dependent variable, you could control for staging, type of treatment and pre hospital factors in your analysis. If you had the data. Missing data is an issue, though. Asking people to reconstruct information can be problematic , as can be various methods for imputation, so we may only get a partial answer to our question on factors influencing mortality.

Margaret Chirgwin Replied at 4:37 PM, 28 Apr 2015

There is I think going to be very variable quality of information on patients and the care they received from different centres but some attempt at assigning, if necessary retrospectively, a stage on admission and looking at mortality of each stage will be a useful exercise and help with our discussions on effectiveness of treatments.

Margaret

Victoria Hill Replied at 4:58 PM, 28 Apr 2015

Margaret and Elizabeth, there might be another confounder. If I remember correctly (always risky!), roll-out of ETCs in Sierra Leone occurred as a geographically staged approach. Patient groups living in the regions near the end of the roll-out plan would've likely included a higher proportion of patients in late disease stages when first presenting, and possibly those ETCs involved would've seen higher mortality rates.

Victoria

Margaret Chirgwin Replied at 6:10 PM, 28 Apr 2015

Victoria

Absolutely - this is why I am suggesting using the Stage at admission -this should help with correcting for both the time from disease onset to admission and the individual's response to the disease. Some people never get worse than stage 1 while others progress to stage very quickly.

Margaret

Elizabeth Glaser Moderator Emeritus Replied at 8:25 PM, 28 Apr 2015

Retrospective staging would require going back and judging the stage based on what little information was available was on admission. Bias can easily be introduced in a situation like that, when you have have iffy cases with sparse data we then unconsciously assign the stage to fit our expectations. To lower bias there are a few ways to do it , here is one way:

1. Establish firm criteria agreed upon in advance, create a checklist
2. Fill out a copy of the checklist for each case reviewed and assigned
3. Have each case reviewed by two people with a third opinion if the two disagree, document criteria used to break tie.
4.Most importantly, no one on the team who is assigning the stage can have any knowledge of the final patient outcome.

In my opinion it would be far better to use admission information on symptom onset, time between symptom onset and admission, and distance traveled to center for several reason.
(1) Distance traveled etc is fairly objective data,
(2) centers( at least in Liberia) tried to get that data upon admission
(3) Staging is in some ways a proxy for the objective data ( time from onset of illness, distance traveled), because the longer a person waited and further they traveled usually meant that they do not do as well.

If we did not have the objective data then the proxies might be okay, but given that admission data is likely to be available it would be be preferable over retroactive staging which even with a checklist might be fairly subjective.
Or rather than staging , just give a score based on certain factors that we believe are associated with increased mortality, I made up an example below:

Ebola mortality score
distance traveled to center in km
time travelled in hours
days since onset (1 day ==1, 2 days ==2 etc)
sex (1==female 0 == male)
age 45yr + ==5
age 25-45yr == 1
age 15-25yr ==2
age 5-15 ==3
age 1-5 yr== 4
age 0-1yr ==5
pregnant ==3, not pregnant ==0
temp, under 96F ==4
temp, 96.1 - 100.5F ==1
temp, 100.5-101.5 ==2
temp, 101.5-103 ==3
temp, 103and over ==4
time since kept in food/ fluids ( hours) <6 =0
time since kept in fluids ( hours) 6-12 ==1
time since kept in fluids ( hours) 12 -24 ==2
time since kept in food/ fluids ( hours)> 24 =3
vomiting ( none=0, occ=1, every hour==3)
diarrhea( none=0, occ=1, every hour==3)
third spacing (none==0, hands and feet==1, abdomen==3)
shortness of breath none=0, yes=1)
bp, supine under 90/60 ==3
bp, supine 90/60-140/90==1
bp, supine above 140/90==2
heartrate(adult)<60 bpm ==2
heartrate (adult)60-100 bpm ==0
heartrate (adult)100-120 bpm ==1
heartrate (adult) > 120 bpm ==3
mental status, alert x oriented tx1 ==3
mental status, alert x oriented tx ==2
mental status, alert x oriented tx 3 ==1
epistaxis, red sclera positive==3, negative ==0
malaria RCT , positive==1, negative==0

David Fedson Replied at 2:52 AM, 29 Apr 2015

ISARIC has developed an Ebola Core Clinical Dataset that readers of GHDonline might find useful. It can be found on the web.

https://isaric.tghn.org/protocols/viral-haemorrhagic-fever-data-tools/

https://isaric.tghn.org/site_media/media/medialibrary/2014/11/ISARIC_WHO_EVD_...

Margaret Chirgwin Replied at 4:15 AM, 29 Apr 2015

Elizabeth

Things are always going to be a matter of opinion. So we will have to disagree - your focus on time from onset of symptoms does not recognise that some patients never get very sick - if they take a week to get to the treatment centre it does not matter - whilst others get very sick very quickly. I do not know why this is the case - I imagine it is probably related to immune response and also the dose of virus the individual received. Staging is an objective measure of how sick the patient is on arrival and as I have suggested this may well be the strongest determinant of whether the ETC treatment makes an difference to survival.

I started this suggestion of using stage of the disease on arrival because it is simple and not difficult for almost all cases to have the information - wet/dry/bleeding and or shocked on arrival - because I objected to your use of total mortality figures from different Ebola Treatment centres to conclude that those pushing IV fluids as a key way to reduce mortality were not getting better mortality rates than those not being so aggressive with fluids. Now you give a huge list generating some kind of "mortality score" which contains complex weighting that I think assumes risk factor knowledge that we do not have. Of note quite a lot of the information for this score would not be available for many if not the majority of the cases at Kerry Town. However if this is a score that people feel comfortable with and have the data for (not sure how you complete a score if any of the information is missing) then it will no doubt be a better way to compare the mortality rates at different centres than the simple total mortality rate you were using. Personally think something less complex will probably be more helpful as untangling the impact of the weighting from the comparison results you get might be very challenging!

For those who have not actually worked in a red zone - recording of information correctly and completely is not as easy as it should be/we might think it should be and the WHO forms etc are very comprehensive- brains of those working in PPE are not working well and how information was transferred out of the red zone is not standardised - I only know how this was done at Kerry Town and it was not easy - those who could sit in a chair on arrival would answer the questions in front of a Perspex screen with doctors outside recording the information - those inside were translating questions into Krio - some patients did not necessarily understand this well - there were children without anyone to provide the info - but in this case much of the information is complete. Examination information was not always done there but at the bedside. Those who went straight to a bed the information was taken at the bedside if at all. Getting this information out into the notes .... Daily information that was collected had to be transferred from the Red to the Green Zone as staff emerged from the red zone or by radio or by shouting through the fence - lots of things were tried and data did get out but quality and quantity is very variable. People will be pouring over this data for a long time to come I am sure.

Margaret

Peter English Replied at 6:59 AM, 29 Apr 2015

But don't forget the option of using a drip set and NG tube to give fluids.


Dr Peter M B English

Elizabeth Glaser Moderator Emeritus Replied at 12:26 PM, 29 Apr 2015

David,
This is a very interesting resource, however it appears that one cannot register for the site and get access to data unless he/she is already involved in a study. If that is not he case, please let me know.
A resource such as this could researchers to do a brief desk study to analyze
pre -hospital factors impacting mortality. It would be great if we could take our shared knowledge, practitioners and researchers from multiple countries and NGOs and apply it to the problem at hand.

Elizabeth

David Fedson Replied at 12:50 PM, 29 Apr 2015

The template itself is available to anyone, but you have to be registered as an investigator in a trial to gain access to actual patient data. I am not involved in a trial, so I don't know how this works. However, you might wish to contact the ISARIC office and ask if there might be a way you could test some of your ideas using actual ISARIC patient data.

Elizabeth Glaser Moderator Emeritus Replied at 1:51 PM, 29 Apr 2015

Margaret,
I don't disagree with you, on the contrary, your information on staging inspired me to devise a score card using data most likely gather at admission, or at a CCC. The score card is not for use in the field but for research purposes to assess which pre-hospital factors alone or in combination, impact mortality.

The staging clearly worked well in the field for your group , the concern is about retrospectively doing staging from data at other centers for the very reasons you have cited, such as the difficulty in getting accurate information. A list such as this gives leeway. We may not have every bit of data but there might be enough to get a clearer picture factors are associated with increased mortality at admission.

The factors on the list include bleeding and wet signs, equivalent to your staging , along with factors mentioned by others. Some factors were left our, for example, Diane had mentioned malnutrition as an important pre-hospital factor, and while I think this is an important question, malnutrition was not included as I don't think enough information might be gathered at admission to include that factor.

I also agree that not every one got very sick, as there were people admitted who did not look bad, in fact they came to the ETU because they were bringing a very ill relative, but then the healthy appearing ones might test positive, began having wet symptoms, and despite IV hydration were dead within a few days. A limitation of population level research is that it is more likely we can figure out factors for those with a typical course, not for those who fit in to much smaller subgroups. Sometimes case studies can help us better understand situations which are less common.

It may end up that the three most important factors are indeed the signs you used at your facility, but we do the research to see if that is the case overall and if so how can that inform triaging and care decisions during future outbreaks.

Although my period in the red zone was very brief compared to yours, I did have hot training at a working ETU in Liberia , so I am aware of the difficulties of getting any data out of the red zone; it was and still is a genuine challenge. I am grateful for the work you and your colleagues did in Kerrytown; without it many more lives would have been lost.

Elizabeth

Elizabeth Glaser Moderator Emeritus Replied at 2:52 PM, 29 Apr 2015

Peter,
A few people offered comments on that, see below . Based on your lit search, David's experience with using them for Cholera, and Debbie's experience at the MSF site, it would tend to support that it is worth a try, however Diane and Appolinaire are more skeptical, expressing concern about bleeding and Diane also mentions the risk of vomiting.

Appolinaire, a physician with the African Union support to Ebola Outbreak in West Africa said: Ebola patients has a risk of bleeding easily, it is why NG tubes can not be used for fluids therapy.Better they give them fluids orally or via IV lines.

Debbie a nurse with MSF said: " we started NG tubes (with children) and had success with this surprisingly - even tho it took time to very slowly give fluid while in there so that the child would not vomit. "and "We used NG tubes twice both on children that we could not get IV access. In both cases it was highly successful and we had much more control on how much fluid we were actually getting in. It took careful administration so that the child did not vomit. We would start with the little one and give some fluids through the NG tube then move on and work with other patients and then go back and give a little more. "

Diane a physician with PIH said: " I think a few of our patients would have tolerated them, but I think most of them would have yanked them out pretty quickly. So many of our patients were confused and we spent so little time at the bedside. I don't think they would have tolerated boluses in via NG, some patient's vomited after just a few sips of whatever liquid we gave them. Our really sick kids had what looked like painful oral mucosa, I assume the nasal mucosa was the same. They were oozing blood and couldn't tolerate a cup touching their lips."

Elizabeth Glaser Moderator Emeritus Replied at 11:10 AM, 6 Nov 2015

I recently learned about the FEAST trial, “Fluid Expansion As Supportive Therapy” which investigated the effects of fluid boluses in the resuscitation of febrile children with evidence of poor perfusion in low resources setting in Africa. Vasopressor agents were not used.

What are the implications of the FEAST trial for those children that received intensive fluid therapy for Ebola, given that some had simple hypovolemia from dehydration(vomiting/diarrhea) and others had evidence of septic shock? A brief on the FEAST trial is below. Any thoughts or reevaluations on fluid administration for children with Ebola or is FEAST not relevant?

Elizabeth

In a multicenter randomized trial
Group 1, n =3141 patients without ‘severe shock’
Group 2, n = 29 patients with ‘severe shock’

Group 1 had 3 arms, a child was randomized to
A.Bolus 0.9% Saline (20ml/kg over one hour) OR
B. Bolus 5% Albumin (20ml/kg over one hour) OR
C. Maintenance fluids (2.5—4ml/kg/hour)
Group 1 had 2 arms, in which a child was randomized to
A. 5% albumin boluses OR
B. 0.9% saline boluses

Primary outcome was mortality @ 48 hours
Secondary outcomes were
mortality @4 weeks,
neuro outcomes @ 4 & 24 weeks,
hypotensive shock within 48 hours of randomization
adverse events -> pulmonary edema, cerebral edema, allergic reaction

Survival was significantly higher in those receiving maintenance fluids over those receiving either type of fluid bolus (3.3% survival benefit at 48 hours , p=0.01)
Mortality at 48 hours was higher in those children receiving any type of fluid bolus
There was no significant difference in primary outcome between the different types of fluid bolus.
87% of all deaths occurred within the first 24 hours
no difference in other secondary outcomes
no evidence of fluid bolus benefit in sub group analysis, excess deaths in all subgroups receiving bolus
no difference in mortality or secondary outcomes based on malaria infection status
Those in Group 2 (severe shock) had greater mortality associated with fluid boluses


1.Ford N, Hargreaves S, Shanks L. Mortality after fluid bolus in children with shock due to sepsis or severe infection: a systematic review and meta-analysis. PLoS One. 2012;7(8):e43953. doi: 10.1371/journal.pone.0043953. Epub 2012 Aug 30. Review.
2.Maitland K, et al and the FEAST Trial Group. Mortality after Fluid Bolus in African Children with Severe Infection. N Engl J Med. 2011 May 26.
3.Maitland K, et al; FEAST trial group. Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial. BMC Med. 2013 Mar 14;11:68. doi: 10.1186/1741-7015-11-68.
4.Myburgh JA. Fluid resuscitation in acute illness – time to reappraise the basics. N Engl J Med. 2011 Jun 30;364(26):2543-4. doi: 10.1056/NEJMe1105490. Epub 2011 May 26.
5.Myburgh J, Finfer S. Causes of death after fluid bolus resuscitation: new insights from FEAST. BMC Med. 2013 Mar 14;11:67. doi: 10.1186/1741-7015-11-67.

http://lifeinthefastlane.com/ccc/feast-paediatric-fluid-resuscitation/

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