New data could hold the key to surviving Ebola

From Bloomberg: 

The best medical advice for surviving Ebola right now might fit in one word: drink.

With targeted drugs and vaccines at least months away, doctors and public health experts are learning from Ebola survivors what simple steps helped them beat the infection. Turns out drinking 4 liters (1 gallon) or more of rehydration solution a day − a challenge for anyone and especially those wracked by relentless bouts of vomiting − is crucial.

“When people are infected, they get dry as a crisp really quickly,” said Simon Mardel, an emergency room doctor advising the World Health Organization on Ebola in Sierra Leone. “Then the tragedy is that they don’t want to drink.”

Aggressive fluid replacement was deemed critical in saving two American health-care workers with Ebola at the Emory University Hospital in Atlanta, according to a study published in the New England Journal of Medicine last week.

Interviews Mardel and WHO colleagues conducted with six of the dozen patients who survived Ebola in Nigeria, where the fatality ratio was much lower, also point to the importance of drinking.

Ada Igonoh, a doctor who caught Ebola in late July while working at the First Consultants Hospital in Lagos, said she took oral rehydration salts, or ORS, mixed in water as soon her gastrointestinal symptoms started − even before her Ebola diagnosis. Once hospitalized, she trawled the Internet on her iPad for insights from survivors.

Studying in Seclusion

“I knew that in diarrheal diseases, shock from dehydration is the number one cause of death,” Igonoh said in an e-mail. “From my research on Ebola while in isolation, I found that to be true.”

The WHO shared transcripts of interviews with Igonoh and five other Ebola survivors with the patients’ permission to provide insight into clinical experiences and management. Igonoh also answered follow-up questions in a direct e-mail.

Patients in Liberia lost five liters of fluid a day from diarrhea alone, doctors treating cases there wrote in a Nov. 5 paper in the New England Journal of Medicine.

Severe fluid loss can cause a type of shock that prevents the heart from pumping enough blood to the body, eventually leading to multiple organ failure.

“As I took the ORS and treated dehydration, it provided me with energy, and my immune system was able to battle the virus,” 29-year-old Igonoh said.

Simple Message

Patients become “stunningly dehydrated” because they don’t feel like eating or drinking in the early stages of the illness, and then later they lose liters of fluid from profuse sweating, vomiting and diarrhea, according to Mardel.

“You don’t want to drink, then you’re too weak,” he said in a telephone interview from Freetown. “In the last stage, you’re in shock and your gut has shut down.”

Mardel has worked on medical aid and emergency relief operations for 30 years, including responding to outbreaks of Lassa fever in Sierra Leone, Ebola in Uganda and Marburg virus disease in the Democratic Republic of Congo.

Mortality could be reduced by delivering a simple message about the importance of taking fluids and picking the right painkillers, he said. Paracetamol, the active ingredient in Panadol, is the preferred medication for pain and fever, and picking others such as aspirin and ibuprofen can worsen bleeding, he said.

“We will halve the mortality by firstly just stopping anti-inflammatories and giving hydration, and really pushing it,” Mardel said. “I want every man and woman in Sierra Leone to know this. I want sports personalities to be talking about it. I want everybody to be talking about it.”

Ebola Blueprint

In Nigeria, 40 percent of those known to have been infected died. Across the rest of West Africa, the fatality rate is about 70 percent.

Nigeria’s success in stopping Ebola shows how the virus can be stamped out and is a blueprint for other developing countries at risk of the disease, the WHO said after declaring Africa’s most-populous nation Ebola-free last month.

Liberian-American Patrick Sawyer introduced Ebola to Nigeria in July when he arrived on a flight to Lagos, a city with an estimated 21 million people, according to the WHO. In addition to Sawyer, five health workers and the protocol officer who received him at the airport died of Ebola, according to Nigeria’s health ministry. Twelve survived.

Learning from their experience and putting those lessons to use in other West African countries is key, because too many patients arrive at treatment centers severely parched and difficult to salvage, Mardel said.

Spurning Care

Patients typically seek medical aid after five days of illness, according to a study of Ebola cases in Conakry also published Nov. 5 in the New England Journal of Medicine.

“Over eight to 10 days of illness, you will need possibly 40 liters of fluid,” Mardel said. “Day after day, if you’re not getting that, we can’t suddenly give you 20 liters to catch up.”

A fluid deficit and “profound electrolyte derangement” appears to increase the risk of death, the WHO said in a Nov. 6 statement. In that document, the Geneva-based agency recommended intravenous rehydration. Not everyone agrees that that delivery route is the best way to go. Oral rehydration, which is taken up in the gut, seems to help patients maintain a better balance of electrolytes, according to Mardel.

Don’t Gulp

Most intravenous rehydration fluids also don’t have much potassium, calcium, or magnesium, doctors at Emory University Hospital wrote in their journal article last week. They recommend supplementing oral rehydration with all three, especially in patients with large-volume diarrhea.

Still, drinking has its challenges. Patients must overcome recurring nausea, as well as debilitating joint pain that can make gripping and movement difficult.

Ebola survivor Fadipe Akinniyi Emmanuel, another doctor at the First Consultants Hospital where Igonoh works, said gulping down the rehydration solution made him sick.

“Each time I attempted to take the ORS, I vomited,” he told the WHO, according to the transcript. Eventually, Emmanuel found he could keep down 4 liters of fluids a day by taking frequent, small sips between bouts of nausea.

‘Most Important Thing’

Rehydration is “the single most important thing” in the management of Ebola, Emmanuel said in an e-mailed response to questions.

“It really helped restore what I was losing when I was stooling and vomiting relentlessly,” said the 29-year-old doctor, who still suffers occasional joint pain and stiffness as a result of his past Ebola infection.

Flavoring the liquid also helps. The granules that Emmanuel’s colleague Igonoh took at home were orange-flavored and much more pleasant than the flavorless kind she was given in the hospital, she said.

“I had to mentally force myself,” she said, according to the transcript.

Igonoh used less of the rehydration salts per liter of water than recommended because a more diluted brew was easier to stomach, helping her to increase her intake, she said.

“You don’t want to drink anything,” Igonoh said. “You are too weak.” That’s when morale is key, said the doctor, who now sports a shaved head after the viral illness caused most of her hair to fall out. “You should be able to tell yourself, no matter how many people die, you are going to survive. And you will survive.”

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