Useful hints on how to contain the rampaging Ebola Virus Disease has been offered by an Emory University Hospital expert, under whose watch two American aid workers who had contracted Ebola while working in West Africa were recently released and pronounced “recovered”.
The hospital's Infectious Disease Unit’s medical director, Bruce Ribner, had in a recent interview with a US journal, Scientific American, disclosed how the two US aid workers – Kent Brantly, a physician with the humanitarian group Samaritan’s Purse, and missionary Nancy Writebol, of SIM USA – were able to survive the strain of the disease that kills 52 per cent of its victims.
According to the medical expert, who led a team of 25 nurses and five physicians, lessons learnt from the care of the aid workers could be useful in the management of the disease across Africa.
He identified “a terrible lack of infrastructure and the sort of testing that everyone in our society takes for granted” as among the challenges facing health workers in West Africa. He said countries in the region lack “the ability to do a complete blood count—measuring your red blood cells, your white blood cells and your platelets—which is done as part of any standard check-up here. The facility in Liberia where our two patients were didn’t even have this simple thing, which everyone assumes is done as part of your annual physical.”
“What we found in general is that among our Ebola patients, because of the amount of fluid they lost through diarrhoea and vomiting, they had a lot of electrolyte abnormalities.” Continuing he said “And so replacing that with standard fluids [used in hospital settings] without monitoring will not do a very good job of replacing things like sodium and potassium. In both of our patients we found those levels to be very low. One of the messages we will be sending back to our colleagues is even if you don’t have the equipment to measure these levels, do be aware this is occurring when patients are having a lot of body fluid loss. Our two patients also gained an enormous amount of fluid in their tissues, what we call oedema. In Ebola virus disease there is damage to the liver and the liver no longer makes sufficient amount of protein; the proteins in the blood are very low and there is an enormous amount of fluid leakage out into the tissues. So one of the takeaway messages is to pay closer attention to that and perhaps early on try to replace some of these proteins that patients’ livers lack.”
Explaining the dramatic recovery of the two American patients, he attributed it to their development of immunity to the Zaire strain of the virus, which they had contracted. “They develop antibodies against the virus and they also developed cell-mediated immunity—the lymphocytes important to form viral control of pathogens,” he explained.
“In general, the finding is basically like being immunised—it would be unusual to get infection with the same strain.”
But uncertainty hovers over whether or not that immunity protects them from the other four known strains of the virus. While stating that the possibility is still being evaluated in the two patients, he acknowledged that “cross-protection” among the five strains of the Ebola virus “is not quite as robust”, adding, “Even though that data is not great, the feeling is there is potential for being infected if you go to a different part of Africa and get exposed to a different strain.”
An implication of “still evaluating” the two discharged patients is their being monitored as outpatients, part of which involves their undergoing additional testing to help the experts throw more light on the immunity to the virus.
As part of new Ebola care guidelines, he cites the several articles on the disease submitted to major medical journals, working with several government agencies, including the U.S. State Department, to help them come up with lessons which could be shared with other countries.
A caveat by WHO, however, upholds the assertion to the effect that patients could still remain vectors of the disease via their sexual fluids for several months after recovery. “There are data that go back several decades—over several outbreaks—that suggest when you have individuals that have recovered from Ebola virus infection they may still be shedding nuclear material [genetic material from the virus which could potentially help spread it] in semen in males and vaginal secretions in females and also, potentially in urine.”
Dr Ribner, however, added that the “epidemiological investigations” had not shown people shedding these nuclear materials as a source of infection after their being discharged.
“Looking at Ebola survivors who were discharged and successfully resolved the infection, following up several months later and evaluating their family members, there has never been any evidence that family members became infected. A lot of the thinking now is this probably was not live and is not important in terms of control of infection. We did give both of our patients the standard recommendations, which are contained on the CDC [U.S. Centres for Disease Control] Web site—not having unprotected sex for three months.”
On the experimental drug ZMapp, which could not save the lives of some of the few patients that received it, he said that it being an experimental drug implies that it cannot be guaranteed to cure the virus.
“We are a long way from being able to say that someone that received one of these agents benefited, it had no impact or it may be that their outcome may be impeded. Until we have good studies looking at outcomes of patients who received these medications, compared to patients who didn’t receive them, we should be very cautious,” he said.
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