THE EBOLA EPIDEMIC – Deaths due to Ebola virus disease (EVD) now have reached 6,928 among more than 16,000 cases. Transmission continues to be active in Guinea, Liberia, and Sierra Leone.
Some treatment centers in West Africa are beginning to obtain scientific observations that will guide future therapy. In Sierra Leone, the case fatality rate is higher in those over 40-45 years of age than in younger patients. Data from Liberia indicate that children younger than 5 are also especially vulnerable to severe illness. Patients with a higher serum viral load also have a higher mortality rate. Tissue damage, including rhabdomyolysis and renal failure, appears to contribute to higher mortality risk. Detailed treatment data are available in studies from Sierra Leone and Guinea. General supportive care includes intravenous hydration, antimalarial therapy, and antibacterial drugs. Oral rehydration remains a key therapy for those able to drink without vomiting.
Infection control efforts are important. A quantitative modeling study predicts that a combination of case isolation, quarantine of contacts, and sanitary funeral practices will be necessary to contain EVD in West Africa. Although intravenous therapy has been consistently available only in the best-staffed treatment centers in West Africa, wider availability of general supportive care, including aggressive treatment of dehydration, is likely to improve outcomes. In order to expect patients to seek medical attention and cooperate with case isolation, better outcomes are essential to give patients confidence that hospitals are not just a place to go to die. A program of radio-based education for children in Sierra Leone is attempting to compensate for school closures that were designed to prevent EVD spread.
The nongovernmental medical aid group Doctors Without Borders has contributed the largest share of staff, training, and resources attempting to control the EVD outbreak in West Africa. Other aid from industrialized countries continues to be inadequate and is arriving slowly.
In the US, progress toward preparedness has been mixed. Successful treatment of EVD has been provided at major medical centers with critical care interventions including mechanical ventilation, renal replacement therapy, and “compassionate” use of investigational treatments. The Centers for Medicare and Medicaid Services has issued guidance for all hospitals: all hospitals should be prepared to screen, test, and stabilize suspected Ebola patients, and transfer to an appropriate hospital if necessary. On the other hand, public health agencies have stumbled in communicating reassurance versus risk about EVD in the face of great uncertainty. Quarantine orders for asymptomatic low risk Ebola contacts may have been politically motivated. Many US hospitals express reluctance to be designated Ebola treatment centers because of the enormous unreimbursed costs, thus the critical importance of federal funding to strengthen our public health infrastructure as well as provide better assistance to end the worldwide threat of the West Africa Ebola epidemic.
- CHIKUNGUNYA – In the US, 1,850 cases have been reported by the end of November. Most of these occurred in travelers returning from endemic areas of the Caribbean, South America, Pacific Islands, or Asia. New York State leads with 525 cases, all acquired after travel to endemic areas. 11 locally acquired cases have been identified in Florida.
- MEASLES – Measles infected 603 Americans by late October, the largest number of US cases in the past two decades.
- EBOLA FREQUENTLY ASKED QUESTIONS – Answers from the American Academy of Pediatrics.
- JOURNALISM AND DISASTERS – Sensationalism versus responsible public health communications.
- EBOLA RESEARCH – Improvements in Ebola virus disease therapy will depend on clinical trials of general support and EVD-specific interventions. Limiting factors: ethical and cultural concerns pertaining to randomization of treatment for a lethal disease, inability of most treatment centers with an inadequate workforce to conduct research, and inadequate supplies of therapeutic agents. Clinical trials of convalescent serum infusions and the antiviral agents, favipiravir and brincidofovir, are about to begin in West Africa. Each of these clinical trials will be conducted at Doctors Without Borders centers. Although clinical data collection is at an early stage, investigators hope to derive and validate EVD mortality predictors from clinical observations, essential to perform risk adjustment in interpreting outcomes in future clinical trials.
Edited by: Dr. Bob Kanter