Acute Specialized Care of Patients with Ebola Virus Disease: Gaps and Opportunities

Abstract

The World Health Organization received the first notification of an outbreak of Ebola virus disease in Guinea
on March 23, 2014.1
By June 18, the outbreak was considered the largest outbreak of Ebola virus disease.2 On
August 8, the epidemic was categorized as a “public
health emergency of international concern.”1
There were
3343 confirmed and 667 probable Ebola cases in
Guinea, Liberia, Nigeria, and Sierra Leone identified
until September 14. Considerable attention has been
focused on prevention of spread of Ebola virus within
and outside the countries predominantly involved in the
epidemic. There appears to be a lack of understanding of
steps required and effort placed on reducing case fatality
estimated at 70.8% among patients with known Ebola
infection through specialized care.1
Our perspective on the current state of specialized care
is based on observation made during in person visit to
Donka National hospital, Conakry, Guinea (Figure 1),
which serves as the country’s designated hospital for
treatment of Ebola virus infected patients. We conducted
detailed interviews with several healthcare personnel to
understand the capabilities of Donka National hospital
and acute care provided to Ebola virus infected patients.
Of note were our communications with the physician
leaders in the hospital, including Drs. Elhadj Ibrahima
Bah, Moumier Barry, Sidiki Diakité, L. Béavogui
Kézély, and Tokpagnan Oscar Loua.
The acute care of Ebola virus disease patients is conducted within an isolation unit that comprises a single-level
building structure and an open area delineated by temporary fencing and encampment in front of the building
serving as entry and exit points (Figure 1). The isolation
unit comprises small (two beds) and large rooms (three
beds), and there is no severity-based allocation. Patients
are located and shifted based on several criteria but
mainly availability. Protective gear up prior to entry and
gear down upon exit from the building is undertaken at
the encampment. The open area has a section for Ebola
virus disease confirmed patients to come out and meet
visitors. The visitor seatings are separated by 10 feet of
temporary fences. There is an adjacent open location
where a fully geared member of the treating team comes
out and loudly reads the notes regarding each patient,
including vitals, medication administered, and any new
development. The notes are being dictated by two health
care personnel who are sitting 10 feet away and recording the notes.
All patients within the isolation unit have confirmed
Ebola virus infection by means of polymerase chain
reaction test. There were 46 Ebola virus infected patients
in the acute care unit at the time of our visit, which
included two medical students, two physicians, and two
nurses. Acute care is provided in three shifts starting
from 7 a.m. to 2 p.m., from 2 p.m. to 8 p.m., and from 8
p.m. to 7 a.m. There are five teams within each shift,
which rotate across the isolation unit in a sequential
manner resulting in one team within the unit at a given
time. The team members are doctors, nurses, psychologists, and hygienists. Each team member wears protective gear that includes overall clothing, including head
gear, gloves, goggles, boots, and apron. The team members wash hands at several locations prior to entry with
chlorine solution (0.05%). The protective gear is decontaminated by spray of chlorine solution (0.50%) upon
exiting the isolation unit. Any item that that enters the
isolation unit is considered contaminated and cannot be
brought back out. The patient excreta and clothes are
burned.
The patients’ symptoms are broadly grouped into three
categories: 1) fever and headaches, 2) vomiting and diarrhea, and 3) hemorrhagic symptoms. There are occasional end-stage encephalopathic symptoms characterized by restlessness and agitation. Blood pressure and
pulse rate are measured four times daily using cuff
measurements and manual palpation, respectively. There
is no antiviral medication, vaccine, and exchange transfusion (from survivors) in use. Each patient is treated
with antimalarial agents, which are a combination of Artemether and Lumefantrine. The treatment is focused
on symptom relief, which includes oral acetominophen
for fever, headache, arthralgia, and myalgias. Tramadol
is second-line agent for pain control, and intravenous or
intramuscular morphine sulfate is infrequently used as
third-line agent. Oral hydration formulation is preferred
route for maintaining adequate hydration. Intravenous
hydration using lactated ringers, dextrose containing
fluids, and rarely normal saline is next line for treatment
of volume depletion, hypotension, and malnutrition.
Nutritional care for Ebola infected patients is based on
food provided by families, inspected at the Ebola treatment center and subsequently administered to patients.
Patient who are not able to tolerate oral intake rely on
caloric intake from intravenous dextrose containing fluids. There are no other parenteral nutrition formulations
in use. There is no mechanical ventilator available, and
supplemental oxygen via face mask is the only option
for respiratory distress. Blood transfusions are very
rarely used, and no intravenous vasopressors are available. Laboratory tests, such as complete blood count and
basic metabolic panel, are not performed, because samples have to be sent out to routine laboratories in other
parts of the hospital where the risk of contamination and
infection spread cannot be contained. The average stay
within the isolation unit is two weeks. If a patient is afebrile or asymptomatic for three days, a polymerase chain
reaction test is performed and if negative, the patient is
discharged. The survival of confirmed Ebola infected
patients is 60%, with most survivors being discharged
home. The discharge symptoms include fatigue, anorexia, and arthralgias. Infrequently, patients are transferred to other units in the hospital after being infectionfree because of other acquired infections such as pneumonia. The most common cause of death in Ebola-infected patients is hemodynamic shock.