High-quality care for patients with Ebola virus disease
Ebola virus disease (EVD) is a viral hemorrhagic fever and part of the Filovirus group. Prior to the 2013-2016 West Africa Ebola epidemic, individuals who were diagnosed with EVD faced mortality rates of 70-90%. Similar mortality rates have been observed with Marburg virus disease, another Filovirus, except for the 1967 outbreak in Marburg, Germany, where the mortality rates were 23%. When the 2013-2016 Ebola epidemic began in West Africa, the primary responders were CDC, WHO, and MSF in collaboration with the local governments, and the focus was on control and containment efforts rather than clinical care. During the early period, mortality rates were being reported around 70-90%, along with horrific pictures of dead bodies in under-resourced hospitals and overwhelmed Ebola treatment facilities. As the international community and many non-government organizations became involved, clinical care improved, patients started receiving aggressive fluid hydration, and studies describing clinical care started to consistently report mortality rates lowered than 70%. One study in Sierra Leone reported mortality rates of 31%, though most studies reported mortality rates of 40-60%. Then in the United States and Europe, returning health providers with EVD received supportive care that included intravenous fluid hydration, correction of electrolyte abnormalities, nutritional support, and clinical care management for respiratory and renal failure, and they had a mortality rate of 18.5%.
The implementation gap was two-fold, one was the administration of intravenous fluids (IVFs) while the other gap was broader, high-quality supportive care. While there were some attempts to re-create high-quality, ICU-level care, these attempts in West Africa during the epidemic fell short. Most of the addressable implementation gap focused on the controversy between organizations providing Ebola care and the differential benefit of mortality when using oral rehydration salts (ORS) vs. IVFs. The studies in West Africa reporting the lowest mortality rates (<40%) used IVFs; several service delivery organizations used IVFs. Other groups claimed substantially lower mortality rates than 70% but tended to use ORS, noting an increased risk of nosocomial EVD transmission to their healthcare workers when they placed IV catheters as well as staffing storages, challenges related to data collection, and the ethics of research (timing and type) vs. clinical care. In general, the highly affected West Africa countries didn't have the high-quality ICU-level care required to achieve mortality rates below 20% as seen in Europe and the United States. However, even though the Ebola response community broadly recognized the value of aggressive fluid hydration as a life-saving therapy for EVD cases, including the WHO, the controversy of how to delivery aggressive fluid hydration (IVFs vs. ORS treatment strategies) never resolved over the epidemic.
Given the unresolved adoption issues at the end of the epidemic, it is unclear how the clinical care of EVD cases in future outbreaks will be managed. Pointing to the evidence in Europe and the United States appears to be insufficient. A higher burden of evidence in Africa will likely be required to guide evidence-based practice, but decisions on certain study designs such as adaptive randomized controlled trial for aggressive fluid hydration, perhaps unless there's a 'sepsis protocol' twist, may lead to additional controversy. We learned many lessons about the 2013-2016 West Africa Ebola epidemic, and while we learned about the ever important role of supportive care in saving lives, will we still give ORS to EVD patients in need of IVFs?