Treatment: The Missing Piece in Ebola Prevention

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Kenny Pettersen

Kenny Pettersen

Kenny Pettersen holds a Master of Public Health and is currently finishing medical school at UC San Francisco. He has worked extensively in Haiti since 2004 and among homeless populations in the US. He is particularly interested in improving chronic disease management through health systems strengthening efforts, such as eHealth and health workforce development.

An Ebola diagnosis need not be a death sentence. Here’s my assertion as an infectious disease specialist: if patients are promptly diagnosed and receive aggressive supportive care – including fluid resuscitation, electrolyte replacement and blood products – the great majority, as many as 90 percent, should survive. 
Dr. Paul Farmer (October 1, 2014)

The 2014 West African Ebola outbreak has greatly surpassed all prior outbreaks combined, now affecting at least six African countries with additional cases reported in Spain and the United States. The WHO recently reported in the New England Journal of Medicine that the current outbreak has a 70% mortality rate.

Yet, experiences with Ebola in the West paints a slightly different picture. In addition to fewer cases contracted locally (only one in Spain and two within the United States as of early November), there have also been very few deaths.

The difference? Early diagnosis and optimal (though basic) supportive care.

In West Africa, the average time between onset of symptoms and presentation to a hospital is 5 days. The situation among evacuees and patients in the US and Europe is quite different. In Liberia, Dr. Kent Brantly was tested at the first sign of disease. He received quick, supportive care, first in West Africa and then at Emory University in Atlanta, Georgia where he made a complete recovery. All other providers from the United States and Spain, including the three cases of nosocomial transmission, also made full recoveries after early diagnosis and quick but basic supportive care – including fluid resuscitation and electrolyte monitoring.

On the other hand, Mr. Thomas Duncan, was less fortunate. With recent travel from his home country of Liberia, he became the first person ever to be diagnosed with Ebola in the US, albeit not until 4 days after the onset of symptoms. Ironically, this is on par with the delay in diagnosis seen in West Africa. And thus, like many of those infected in his home country, he also died of the virus. Though he received optimal care at the hospital, he was probably too far along in his illness. The two reported deaths in Europe (two priests from Spain) also had delayed care.

Though there are numerous factors in determining who does and does not recover from the disease (age, comorbidities, experimental treatment, exposure load etc.), three decades of treating Ebola outbreaks in Africa shows that early diagnosis and treatment is clearly a matter of life and death.

As with any acute infectious disease outbreak, the art of containment and ultimate elimination of disease consists of basic public health principles: identification, isolation, contact precautions, and tracing of close contacts. Yet, the difficulty in achieving these principles is made exponentially worse when patients do not receive immediate care.

Delayed care results in increased exposure to close contacts, not only as a function of time, but also from an exponential increase in the shedding of viral particles. The longer the delay, the greater the chance the virus will spread to close contacts. Experts believe that the there is fairly low viral shedding at the onset of disease (fever). But, as the disease progresses, loss of bodily fluids from vomiting and diarrhea can expose close contacts to millions of viral particles. By the time someone finally obtains care, they’re often severely dehydrated and on the verge of death. At this time, overcoming fluid imbalances and severe organ failure become extremely challenging. As a result, the mortality rate is significantly higher for those who do not receive early care.

The question at hand, therefore, seems obvious: how do we get people to treatment faster?

On the one hand, the answer is fairly simple. We need more of everything: treatment units, health care workers, supplies, and contact tracing.

On the other hand, progress will be difficult as long as an average of 5 days lapse between the development of symptoms and receiving care. Reports from the “hot zone” indicate that a sizable portion of the population are terrified to present to treatment centers. They are seen as places where people go to die, not recover.

Progress will be made once people see hope in seeking treatment. With hope for survival, patients will present sooner, ultimately exposing fewer people to the virus. Early treatment also leads to better cure rates. Lower overall mortality among patients in treatment units will further encourage patients to present for early treatment. Progress will continue until the virus is eliminated from the population, assuming other basic measures remain in place.

To date, debates in the West involve quarantines and travel restrictions. Hospital workers threaten to walk out if their employers fail to offer better guidance. Too often, these strategies distract from the larger, more urgent need of fighting the outbreak at its source: West Africa. We need considerably more healthcare professionals, key supplies, and better systems in place to ultimately prevent the spread of disease. Above all, the key to prevention may in fact be treatment.

This article references to several key journal articles hyperlinked throughout the text. To learn more about the evolving outbreak and its history, please visit our Ebola timeline here.