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.