Numbers

"If I sit silently, I have sinned."
- Mohammed Mossadegh

I arrived home a week ago yesterday. This is day 8 of my 21-day direct active monitoring. My last contact with a patient with Ebola virus disease (EVD) was 13 days ago. Schieffelin and colleagues (2014) estimated that the incubation period (time from exposure to the virus to onset of symptoms) for EVD in Sierra Leone was 6 to 12 days. The WHO Ebola Response Team (2014) estimated the mean (average) incubation period to be 11.4 days. My risk of becoming infected with ebolavirus while wearing personal protective equipment (PPE) was low and my certainty that I am not infected increases with each passing day.

Unlike some of my colleagues who live in other states, I am not "quarantined" and no restrictions on my movements have been imposed by either the Washington State Department of Health or my local health department - my employer. Yesterday was my first day back at the health department since I left for the CDC Ebola safety training seven weeks ago. I was surprised the first time someone extended a hand for me to shake, a gesture that is discouraged during an epidemic of EVD.

Holly suggested that I post more stories about the patients I saw in Sierra Leone. The problem is that I really don't know the stories of most of our patients. We received very little information about our patients at the time they were admitted and most of my time in the confirmed ward was spent attending to people who were usually too sick to talk. I had only enough time to make small talk with the survivors who were waiting to be discharged. The only story I have to tell is my own.

Then there are the stories that the numbers tell us.

Baize et al. (2014) traced the Ebola epidemic in West Africa to a 2-year-old child in Guinea who died from the disease December 6, 2013. With the exception of a single human case of Taï Forest ebolavirus from a chimpanzee in Ivory Coast in 1994, there had never been an outbreak of EVD in West Africa.

On March 10^th of this year, the World Health Organization (WHO) was notified of an outbreak of an unknown infectious disease characterized by fever, vomiting, and diarrhea in Guinea. A few days later, Zaire ebolavirus was identified in blood from patients who were hospitalized with the disease. The disease spread to Liberia in March and to Sierra Leone in May. On August 8^th, the WHO declared the Ebola epidemic in West Africa a Public Health Emergency of International Concern. At that time, 1,779 cases and 961 deaths due to EVD had been reported to WHO. By the end of the month, the number of cases and deaths exceeded the total numbers of cases and deaths from all previous EVD epidemics combined.

CDC

 The WHO Ebola Response Team (2014) wrote, "Between March and July 2014, the reproduction number in Guinea fluctuated around the threshold value of 1, suggesting that modest further intervention efforts at that point could have achieved control."

The interventions used to contain an outbreak of EVD are the same as those used for other communicable diseases. The challenge has been implementing those strategies in places with very limited health care resources.

Country	Nurses and midwives per 1,000 population	Physicians per 1,000 population
Guinea	0.511	0.1
Liberia	0.274	0.014
Sierra Leone	0.166	0.022
United States of America	9.815	2.452
World Health Organization (2014)

Many health care providers in Ebola-affected areas were infected and died because of inadequate supplies of PPE. Some health workers fled out of fear of becoming infected. Because health care workers are now focusing their efforts on the Ebola response, routine health care services have been interrupted. Obstetric and midwifery services are unavailable to many women because of the high risk of Ebola transmission during childbirth.

This epidemic is not over. The Sierra Leone Ministry of Health and Sanitation estimated that the crude reproduction number for EVD in that country remains above 1, which means that every person with EVD can be expected to infect at least one other person. Transmission of the disease will be sustained until the reproduction number drops below one.



Ministry of Health and Sanitation, Republic of Sierra Leone

 

Number of new Ebola virus disease cases reported, by epidemiologic week — three countries, West Africa, March 29–November 30, 2014 (CDC)

 

Number of new cases of Ebola virus disease reported — Guinea, Liberia, and Sierra Leone, November 9–30, 2014 (CDC)

I started this blog nearly three years ago. On October 14th of this year, a week after my first post on Ebola virus disease (EVD), this blog had 10,000 page views. Now there are over 13,000 page views. Roughly a quarter of all of the hits on this blog have happened in the last 11 weeks.

 

It seems that what I began as my effort to keep my friends and family informed about my work in Sierra Leone got the attention of far more people than I had anticipated. I was encouraged to know that there were so many people reading this blog and am very grateful for the support that I have received from people who have read my posts.

As the title suggests, this blog was intended to be a forum for discussions about vaccines and vaccine-preventable diseases. I don't mean to minimize the importance of the current Ebola epidemic, but I will end this post by bringing the discussion back to vaccine-preventable diseases.

This epidemic dwarfs all previous EVD epidemics. This should serve as a warning that every EVD epidemic deserves an immediate and decisive response. As I write this, there have been a total of 19,463 cases and EVD and 7,573 deaths in Guinea, Liberia, and Sierra Leone.

 

 

In 2009, there were an estimated 79,292 cases of meningococcal disease in the African Meningitis Belt. The World Health Organization estimates that there were 145,700 deaths from measles in 2013. There were 610 cases of measles in the U.S. between January 1 and November 29, 2014, the highest number of cases since measles was eliminated from the U.S. Most of cases of measles in the U.S. are in people who have not been vaccinated against the disease and most are associated with importation of the virus from countries with low measles immunization coverage.

On the other hand, these numbers are small compared to the millions of deaths due to liver disease prevented by routine hepatitis B vaccination in China (Hadler et al., 2013).

The current EVD epidemic began as a small outbreak in a remote part of Africa and became an international public health emergency. Yet, there are tens of thousands more deaths from vaccine-preventable diseases every year than there have been deaths from EVD since the disease was first identified 38 years ago. Those deaths deserve our attention too.

Merry Christmas!



Andrew with his Grandpa Esvelt

References

Baize, S., Pannetier, D., Oestereich, L., Rieger, T., Koivogui, L., Magassouba, N., et al. (2014). Emergence of Zaire Ebola virus disease in Guinea. New England Journal of Medicine, 371(15),1418-1425. doi:10.1056/NEJMoa1404505.

Bernstein, L. (September 20, 2014). With Ebola crippling the health system, Liberians die of routine medical services. Washington Post. http://www.washingtonpost.com/world/africa/with-ebola-crippling-the-health-system-liberians-die-of-routine-medical-problems/2014/09/20/727dcfbe-400b-11e4-b03f-de718edeb92f_story.html.

Briand, S., Bertherat, E., Cox, P., Formenty, P., Kieny, M-P., Myhre, J. K., et al. (2014). The international Ebola emergency. New England Journal of Medicine, 371(13), 1180-1183. doi:10.1056/NEJMp1409858.

Boozary, A. S., Farmer, P. E., & Jha, A. K. (2014). The Ebola outbreak, fragile health systems, and quality as a cure. JAMA, 312(18), 1859-1960. doi:10.1001/jama.2014.14387.

Centers for Disease Control and Prevention. (June 6, 2014). Measles – United States, January 1 – May 23, 2014. Morbidity and Mortality Weekly Report, 63(22), 496-499. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a4.htm.

Centers for Disease Control and Prevention. (October 10, 2014). Assessment of Ebola virus disease, health care infrastructure, and preparedness – four counties, Southeastern Liberia, August 2014. Morbidity and Mortality Weekly Report, 63(40), 891-893. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6340a3.htm.

Centers for Disease Control and Prevention. (September 26, 2014). Estimating the future number of cases in the Ebola epidemic – Liberia and Sierra Leone, 2014-2015. Morbidity and Mortality Weekly Report, 63(03), 1-14. http://www.cdc.gov/mmwr/preview/mmwrhtml/su6303a1.htm.

Centers for Disease Control and Prevention. (December 12, 2014). Ebola virus disease in health care workers – Sierra Leone, 2014. Morbidity and Mortality Weekly Report, 63(49), 1168-1171. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6349a6.htm.

Centers for Disease Control and Prevention. (December 12, 2014). Rapid assessment of Ebola infection prevention and control needs – six districts, Sierra Leone, October 2014. Morbidity and Mortality Weekly Report, 63(49), 1172-1174. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6349a7.htm.

Centers for Disease Control and Prevention. (December 19, 2014). Update: Ebola virus disease epidemic – West Africa, December 2014. Morbidity and Mortality Weekly Report, 63(50), 1199-1201. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6350a4.htm.

Doucleff, M. (November 18, 2014). Dangerous deliveries: Ebola leaves moms and babies without care. NPR. http://www.npr.org/blogs/goatsandsoda/2014/11/18/364179795/dangerous-deliveries-ebola-devastates-womens-health-in-liberia.

Gire, S. K., Goba, A., Anderson, K. G,. Sealfon, R. S. G., Park, D. J., Kanneh, L., et al. (2014). Genomic surveillance elucidates Ebola virus origin and transmission during the 2014 outbreak. Science, 345(6202), 1369-1372. doi:10.1126/science.1259657.

Hadler, S. C., Fuqiang, C., Averhoff, F., Taylor, T., Fuzhen, W., Li, L., et al. (2013). The impact of hepatitis B vaccine in China and in the China GAVI Project. Vaccine, 31(Supple. 9), J66-J72. doi:10.1016/j.vaccine.2013.03.043.

Ministry of Health and Sanitation, Republic of Sierra Leone. (6 December 2014). Weekly Ebola surveillance report. http://health.gov.sl/?p=1692.

Schieffelin, J. S., Shaffer, J. G., Goba, A., Gbakie, M., Gire, S. K., Colubri, A., et al. (2014). Clinical illness and outcomes in patients with Ebola in Sierra Leone. New England Journal of Medicine, 371(22), 2092-2100. doi:10.1056/NEJMoa1411680

World Health Organization. (2014). Number of suspected meningitis cases and deaths reported: highlight on 2009 epidemiological season. http://www.who.int/gho/epidemic_diseases/meningitis/suspected_cases_deaths_2009_text/en.

World Health Organization. (2014). WHO warns that progress towards eliminating measles has stalled. http://www.who.int/mediacentre/news/releases/2014/eliminating-measles/en.

World Health Organization Ebola Response Team. (2014). Ebola virus disease in West Africa – the first 9 months of the epidemic and forward projections. New England Journal of Medicine, 371(16), 1481-1495. doi:10.1056/NEJMoa1411100.

Will you come back?

Greetings, once again, from Freetown, Sierra Leone. I should be home in a couple of days.

The stories are heartbreaking. I saw people who had lost their spouses to Ebola virus disease (EVD), people who lost children, and children who had lost one or both parents. I saw people of every age die; the elderly, young adults, children, and, yes, infants. One woman, whose baby had died in the confirmed ward, complained that her breasts hurt. She was still producing milk.

I was prepared for the deaths. I came with the awareness that ebolaviruses are highly lethal pathogens and that the mortality of EVD is high. I was most affected by the survivors.

I transferred a three-year-old boy from the suspect ward to the confirmed ward after he had a positive PCR for ebolavirus. Both of his parents had died. I stopped by his bed every time I went in the confirmed ward to get him to drink oral rehydration solution (ORS) and talk to him. I didn't see him get out of bed for several days. I was pleased when I saw him outside playing with some of the other boys. A few days later, those boys were discharged and an older woman started looking after him. Not long after that, the woman taking care of him tested negative and was being discharged. I thanked her for looking after him, but I was afraid he would be left alone again. Fortunately, we received a negative test result for him the same day. I ran out to the street as he was being discharged to say goodbye to him and show him a picture of Andrew. I told the aunt who was there to pick him up that he was a brave little boy. I knew he was frightened, but I never saw him cry. Then I found a place where I could be alone, sat down, and cried.

There's a 9-year-old girl who was brought to the confirmed ward about two weeks ago. She had profound neurological symptoms; nystagmus, tremor, and ataxia. For a while we thought she might be having seizures. We thought she was going to die. We spent a lot of time taking care of her – getting her to drink ORS and take a few bites of food, changing her urine- and diarrhea-soaked clothes, and washing her a couple of times a day. Her symptoms gradually improved. The nystagmus stopped, her tremor improved, and she started eating a little more. Thursday I made my last trip into the confirmed ward and saw her sitting up in bed feeding herself. I asked one of the local nurses to tell her that I was very happy to see her getting better. Then she turned and smiled at me. That was the best going-away gift anyone could have given me.

The work has been challenging. Working in full personal protective equipment (PPE) in the heat and humidity of tropical Africa is uncomfortable. My scrubs were drenched with sweat when I left ward. Sometimes my N95 respirator would become soaked with sweat, making breathing difficult. Working in PPE in an Ebola treatment unit (ETU) is not conducive to proper body mechanics, so my muscles often ached. The chlorine solution used to decontaminate our PPE irritated my lungs and occasionally gave me cough so severe that, the first time it happened, I thought I might have pertussis.

In spite of all of the challenges, this has been one of the most rewarding experiences I have ever had. When we first arrived in Port Loko, no Ebola survivors had ever been discharged from the Maforki ETU. By the time I left, we had discharged 60 survivors.

 

 

I have been asked several times if I am coming back to continue working in the Ebola response. The answer is that I am going home to be with my wife and son. One of the doctors who recently arrived in Port Loko remarked that I am "outside of the demographic." It seems that most of the expatriates working in the Ebola response either have no children or have adult children. I am an outlier; the only expat with a young child.

I love Africa. I became a nurse to work in Africa and I plan to return to this continent whenever I am able to do so. For now, it's time for me to go home and be Holly's husband and Andrew's daddy.

I've worked with a lot of remarkable people here, both local staff and expatriates. All of us have made personal sacrifices to be here. Some of the nurses and doctors with whom I've worked quit their jobs to be here. Everyone I've worked with found ways in which she or he could best serve in this response.

I can't possibly do justice to all of my colleagues in this response by naming them individually and describing their invaluable contributions to this response, however, there are two people whom I would like to thank: Larry, who came here with me, and Christian, who arrived a week later. Both of them worked with me in the confirmed ward, going in twice and sometimes three times nearly every day that we've been here. Christian and Larry helped establish high standards for patient care and there are people who are alive today because of their efforts. I am honored to have had the opportunity to work with Christian and Larry and proud to call them my colleagues.

Maforky Treatment Centre: 30 discharged survivors in one month

Time Person of the Year 2014: The Ebola Fighters

 

 

Ebola: Rob's questions

Rob McSweeny is a nurse whom I have known since we worked together at Harborview Medical Center in Seattle in the early 1990s. He was my best man at Holly's and my wedding. Rob recently posted several questions about my work in Sierra Leone on Facebook. I decided to use (most of) them as the basis for this post.

Are you guys also giving the IV fluid replacement?

We use intravenous (IV) hydration for people who cannot drink; those who are not alert enough to drink and those who are too nauseated to drink.

Is it Lactated Ringers or a special mix?

Yes, LR – although here it's called RL (Ringer's lactate).

What kind of tape do you use in the sweltering heat?

It's similar to the cloth adhesive tape that you and I used when we were new grads – nurse's duct tape. It's difficult to work with while wearing double gloves.

How do you keep your face mask from fogging up so you can place a line?

I haven't placed an intravenous line since I left the bedside five years ago and don't want to try here. There's not much I can do about my face shield fogging up. Another issue is that I can't wear my reading glasses under my face shield. I can't place a tuberculosis skin test without my readers, so I doubt I'd be able to start a line without them.

Can you give us a more detailed clinical picture? What I imagined to be people bleeding out of every orifice sounds more like cholera from your earlier description.

The U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) are using the term "Ebola virus disease" (EVD) instead of "Ebola hemorrhagic fever." EVD causes disseminated intravascular coagulation (DIC), a hypercoagulable state in which clotting factors are sequestered in small blood vessels blocking blood flow to tissues and organs while leaving the rest of the vascular system deficient in clotting factors. People with EVD are also thrombocytopenic. In short, people are more likely to bleed, but frank bleeding is seen in a minority of patients. The most blood I've seen was from a patient with a nose bleed.

Patients with EVD look "toxic" – similar to patients with sepsis.

How long do you spend on the floor working, I mean overheating?

I usually shoot for an hour. An hour and a half is pushing it for me.

Who built your facility?

It's commonly referred to as "the Red Cross treatment center." It appears that the part of the ETU used as the suspect ward used to be a Red Cross clinic. We were told that it had been built by the British military, but there's no sign of either the Red Cross or the British military now.

Suspect ward

I hear on NPR that rapid response teams are being sent into the bush as a way to isolate outbreaks. Rapid response meant a very long walk the lady said.

I heard that too. We are supposed to visit some of the "community care centers" (CCC) in the district but, so far, only one person from our group has made a trip out. The CCCs that we are visiting are accessible by road.

Don't burn out. You're not such a young buck any more you know.

I pace myself. I usually take it easy for an hour or so after doffing my personal protective equipment (PPE). I usually make no more than two trips into the treatment area in a day. There are plenty of other tasks that need to be completed outside of the treatment areas. As Dirty Harry said, "A man's got to know his limitations."

PPE doffing area, confirmed ward in the background

What do you use to replace your electrolytes?

I drink oral rehydration solution (ORS), but I dilute it in 1.5 liters of water instead of 1 liter. I was drinking about 9 liters of fluid a day when I first started working in the ETU. I think I'm down to 6 liters per day now. I've had some muscle cramps a few days ago and suspect I may have been a little hyponatremic.

What do you eat at work and after work?

Most of our meals come from the only restaurant in town – fish, chicken, peanut soup, rice, beef stew, chips (French fries). I sometimes eat lunch with the local staff in the canteen at the ETU – usually peanut soup over rice or some type of chopped leaves over rice. Lately I've been ordering papaya and fried plantains for lunch. There's no kitchen in the guesthouse where we've been staying.

Would you recommend volunteering at an ETU as a way to lose weight?

I recommend working in an ETU as a way to help end this epidemic. I couldn't tell you if I've lost any weight while I've been here.

How many nationalities are you working with and why are you writing on whiteboards in English and not French?

Other than the local staff most of my colleagues are U.S. citizens. One of the nurses is French but a U.S. citizen. She spent ten years working at Harborview – long after you and I left.

Sierra Leone is Anglophone.

Incidentally, Seattle Times, October 6, 2014: Harborview open to emergency Ebola cases

Thanksgiving dinner with Paul Farmer, one of the founders of Partners In Health:

 

References:

Geisbert, T. W. (2014). Marburg and Ebola hemorrhagic fevers (Filoviruses). In J. E. Bennett, R. Dolin, & M. J. Blaser (Eds.). Mandell, Douglas, and Bennett's principles and practice of infectious diseases, 8th Ed. [Electronic version]. Elsevier.

Hartman, A. L. (2013). Ebola and Marburg virus infections. In, A. J. Magill, D. R. Hill, T. Solomon, & E. T. Ryan (Eds.) Hunter's tropical medicine, 9th Ed. [Electronic version]. Elsevier.

Hoenen, T., Groseth, A., Falzarano, D., & Feldman, H. (2006). Ebola virus: unravelling pathogenesis to combat a deadly disease. TRENDS in Molecular Medicine, 12(5), doi:10.1016/j.molmed.2006.03.006.

Kortepeter, M. G., Bausch, D. G., & Bray, M. (2011). Basic clinical and laboratory features of filoviral hemorrhagic fever. Journal of Infectious Diseases, 204(Supple. 3), S810-S816.

Ebola: stigma

Friday was my first day off since arriving in Port Loko. I spent the day getting caught up on some reading I had started before leaving the U.S., listening to some great music, and going for a long walk. While I was out I bought some vicious looking chilies. I had seen okra in Freetown and hoped to find it here but didn't. Eventually, we're supposed to move into a house with a kitchen and I'll want to make gumbo.

 Saturday we discharged several Ebola survivors from the confirmed ward; people who had recovered from Ebola virus disease (EVD). That was the first time survivors had been discharged from this Ebola treatment unit (ETU) since it opened.



The door on the right is the exit from the confirmed ward. The one on the left is the exit from the suspect ward.

Although discharging Ebola survivors was a cause for celebration, I will not post photographs of patients on this blog or any other social media. Survivors in this epidemic and in previous epidemics have been stigmatized and even become the victims of violence.

During previous Ebola epidemics in Central Africa, survivors were turned away from their homes, abandoned by their spouses, and their children were not allowed to touch them. Survivors were harassed and suffered discrimination. Children whose parents died were left to fend for themselves, becoming heads of households (Davtyan et al., 2014; De Roo et al., 1998; Hewlett & Amola, 2003; Hewlett & Hewlett, 2005).

Health care personnel have also been stigmatized and victims of violence (Hewlett & Hewlett, 2005). Today I talked to some of the nurses at the ETU about their experiences. Several nurses told me that they had been forced to leave their homes. Another said her fiancée had stopped calling her.

 

 

Many of my colleagues from the U.S. have also experienced discrimination because of their work in the Ebola epidemic response. One of the physicians I worked with was asked not to return to her apartment for 21 days after leaving Sierra Leone. A firefighter I met was harassed by her coworkers. Several of my colleagues quit their jobs to come here after their employers refused to allow them time off. Several people have told me that they are not welcome at their families' holiday celebrations.

I am fortunate. My colleagues at the health department have been very supportive of my decision to come to West Africa to work in Ebola response. They also understand that my risk of becoming infected with the ebolavirus is extremely low and that, even if I were infected, I could not transmit the virus until I developed symptoms of EVD. As far as my fellow nurse epidemiologists are concerned, I could return to work immediately after I return to the U.S. from Sierra Leone, provided I take my temperature twice daily and report any symptoms to the local health jurisdiction, that is, my colleagues at the health department. In fact, I am one of the people who will monitor other travelers returning from countries affected by Ebola.

I am reminded of the stigmatization and abuse that people infected with HIV (or perceived to be infected with HIV) suffered at the beginning of the AIDS epidemic as the result of fear of disease and misunderstandings of its modes of transmission. EVD and AIDS are both frightening diseases. Both diseases tend to affect specific populations (Davtyan et al., 2014). There are no vaccines available for either HIV or Ebola. Unlike HIV infection, there are currently no drugs available to treat EVD.

I have tried to address concerns about EVD in these posts. All of the responses I have received so far have been very positive. I am extremely grateful for the support and prayers that I have received from my family, friends, colleagues, and community. I hope that the support that I have received will be extended to others who have made sacrifices to work in this epidemic.

References:

Davtyan, M., Brown, B., & Folayan, M. O. (2014). Addressing Ebola-related stigma: lessons learned from HIV/AIDS. Global Health Action, 7(26058). http://dx.doi.org/10.3402/gha.v7.26058.

De Roo, A. D., Ado, B., Rose, B., Guimard, Y., Fonck, K., & Colebunders, R. (1998). Aurvey among survivors of the 1995 Ebola epidemic in Kikwit, Democratic Republic of Congo: their feelings and experiences. Tropical Medicine and International Health, 3(11), 883-885.

Hewlett, B. L. & Hewlett, B. S. (2005). Providing care and facing death: nursing during Ebola outbreaks in Central Africa. Journal of Transcultural Nursing, 16(4), 289-297.

Hewlett, B. S. & Amola, R. P. (2003). Cultural contexts of Ebola in northern Uganda. Emerging Infectious Diseases, 9(10), 1242-1248.

Washington State Department of Health. (2014). Interim guidance for local health jurisdictions regarding follow-up of asymptomatic persons with potential exposure to the Ebola virus. http://www.doh.wa.gov/Portals/1/Documents/5100/420-132-Ebola-LHJ-MonitoringGuide.pdf.

 

Ebola: oral rehydration solution (ORS)

Greetings from Port Loko, Sierra Leone. Chris, Jennifer, Larry, Nahid, who is a physician who joined us in Freetown, and I arrived here a week ago. We've been working in the Ebola treatment unit (ETU) 10 or more hours every day. A new crew of nurses and doctors arrived a few days ago, so now we're able to work overlapping six hour shifts. This is the first time I've been able to sit down, listen to music, and write a post. I'm tired, sore, and a little sunburned, but I enjoy the work that I'm doing.

I could tell you heartbreaking stories of the deaths that I've seen here. Several people die in the ETU every day. I've chosen not to write about those deaths in this post.

Two of the most prominent features of Ebola virus disease (EVD) are vomiting and diarrhea. Death from EVD is usually due to dehydration and loss of sodium and potassium, electrolytes that are required for normal cellular function. There are no medications that treat the viral infection itself, so treatment of EVD is aggressive replacement of water, sodium, and potassium. That can be achieved using intravenous (IV) fluids but, for most people with EVD, the risks associated with IV rehydration outweigh the benefits.



Today I discussed the risks and benefits of ORS versus IV fluids with the staff of the ETU

Oral rehydration solution (ORS) is a mixture of water, sugar, and salts. The ratio of water, sugar, and salt in ORS increase the absorption of water from the intestines into the blood vessels. ORS has been proven to reduce mortality from diarrheal diseases.



ORS

There are few published studies of the effectiveness of ORS for the treatment of EVD. It would be a simple hypothesis to test, but it's very difficult to collect data in an ETU. Most of the evidence supporting the use of ORS for the treatment of EVD is anecdotal – the observations of people who have treated people with EVD with ORS. Rather than tell you about the deaths I've seen inside the ETU, I want to tell you my anecdotal observations.



Jennifer reporting data from the ETU

It can be challenging to administer ORS to a person with EVD. They are often lethargic, have muscle and joint pain, and don't want to sit up to drink. Administering ORS to a person in that condition can be time-consuming and require a lot of coaxing. Some patients are nauseated, so they can only tolerate small amounts of ORS. Of course, there's also a language barrier. Many of our patients speak or at least understand Krio, the lingua franca of Sierra Leone. Krio is an amalgam of English and several African and European languages. I do my best to imitate Krio and seem to be able to get my message across.



Krio: "Together we defeat Ebola to come out of Sierra Leone"

A few days ago I spent some time giving ORS to a young woman. She was very lethargic and reluctant to sit up and drink, but I was persistent. I asked her brother, who was in the bed next to hers, to encourage her to drink ORS. I came back later to find her bed empty. My heart sank; I thought she had died, but I was told that she was outside walking around. A few days ago I didn't know if she would survive. Now I'm convinced that she will. Today I saw another patient up walking around who had previously looked severely ill. Again, he is someone I thought might die but now believe that he will survive.

There are other factors that influence a person's likelihood of surviving EVD. Survivors tend to mount an antibody response to the virus earlier and much more effectively than people who die from the disease. I can't say with absolute certainty that ORS saved the lives of these two patients and others I have watched improve over the last week but, like others who have treated people with EVD, I believe it greatly improves a person's chance of survival.

 

Partners In Health

References 

Atia, A. N. & Buchman, A. L. (2009). Oral rehydration solutions in non-cholera diarrhea: a review. American Journal of Gastroenterology, 104(6), 2596-2604.

Geisbert, T. W. (2014). Marburg and Ebola hemorrhagic fevers (Filoviruses). In J. E. Bennett, R. Dolin, & M. J. Blaser (Eds.). Mandell, Douglas, and Bennett's principles and practice of infectious diseases, 8th Ed. [Electronic version]. Elsevier.

Kortepeter, M. G., Bausch, D. G., & Bray, M. (2011). Basic clinical and laboratory features of filoviral hemorrhagic fever. Journal of Infectious Diseases, 204(Supple. 3), S810-S816.

Mahanty, S. & Bray, M. (2004). Pathogenesis of filoviral haemorrhagic fevers. Lancet Infectious Diseases, 4(8), 487-498.