Caring for Patients with Ebola Virus Disease

The largest Ebola outbreak to date has originated in West Africa where healthcare and sanitation resources are limited, populations are dense, and infrastructure is insufficient. Unfortunately, the virus is easily transmitted, has a high mortality rate, and has widely available cure. This outbreak has already yielded a number of lessons regarding pathology, recognition, and treatment.

The World Health Organization was notified about the Ebola Virus outbreak on March 21st, 2015. The primary risk area originated in southeastern Guinea and has since spread to Sierra Leone, Liberia, Senegal, and Nigeria. To date, there have been over 9,000 reported cases and 4,500 resultant deaths making it the most devastating Ebola epidemic in recorded history. Due to a seriously lacking infrastructure, health concerns are exacerbated by low health literacy, unstable water supplies and poor infection control in a very dense, mobile population.

Though the current Ebola virus epidemic is making headlines, there have actually been a dozen outbreaks over the last 30 years. Prior outbreaks, however, were contained in sparsely populated rural areas with little potential for external transmission. This occurrence, unfortunately, occurred in West Africa where the populations are dense increasing the potential for amplification of transmission. Few countries have had experience with such levels of contagion in the past. China, Hong Kong, Singapore, and Toronto had a similar experience in treating Severe Acute Respiratory Syndrome (SARS). Lessons from SARS include the need for immediate response upon awareness, and not lifting protocols too early in an outbreak.

Ebola is an RNA Filovirus transmitted through mucus membranes or exposure to infected body fluids. Monocytes, macrophages, and dendritic cells, spread the virus to the lymph nodes and throughout the body. Initially, the virus causes fatigue and myalgias and creates progressive gastrointestinal symptoms including anorexia, nausea, vomiting, and diarrhea. A late manifestation is gastrointestinal bleeding, but this only develops in a minority of cases. There are similarities between Ebola and bacterial sepsis including a systemic inflammatory response.

Treatments for the Ebola virus include early detection, oxygenation, rehydration, and treatment of fever and gastrointestinal symptoms. Unfortunately, many cases are delayed too long before being diagnosed, and in the case of the recent outbreak, basic instruments such as blood pressure cuffs, thermometers, and pulse oximeters are significantly lacking.

One of the greatest threats to effective Ebola treatment is the need to maintain electrolyte balances and hydration. This requires regular monitoring and adjustment of patient treatments, however, the prevalence of body fluid discharge presents a significant threat to healthcare professionals.

Identified challenges of donning the required personal protective equipment include the patient-provider connection, and the difficulty in effective care while in full protective garb. Though it may not seem medically significant, the connection that providers make with their patient can help reinforce hope and a feeling of wellness. Masks and hoods that block facial expressions and other non-verbal cues can impede this effect. Additionally, providers fully enclosed in protective gear are subject to increased heat, moisture, and rapid energy drain.

As the outbreak continues to spread, healthcare workers are encountering more resistance and communication challenges. The international response, though necessary for treatment, is overwhelming, scary, and unfamiliar for locals creating a level of mistrust. This compounded with the high mortality rates has caused a rift between the afflicted and global health workers.

In order for continued treatment of the Ebola Virus Epidemic to be effective improvements must be made in:

- Education and awareness of the disease and related concerns

- The need for assessing, monitoring, and balancing body chemistry

- Utilization of laboratory markers for individual diagnosis and treatment options

- Making therapies available in rich and poor environments

- Supportive care will make treatment more effective