Saturday, November 15, 2014

Some Hopeful News on Ebola

First I would like to state that this epidemic, in all likelihood, is still raging out of control in West Africa. The numbers being reported by WHO and CDC are likely nonsensical and the motivation for under-reporting is that the 3 hardest hit countries are under tremendous financial pressures. In many villages there are no signs of life and many people are struggling to find food. The fact that the number of dead in Liberia keeps going down, offers ample proof that this number is bogus.  Our best solution to keep our own country stable is to institute strict quarantine on travel from West Africa and do everything we can to prevent this disease from reaching our shores.

Furthermore, as this disease spreads beyond Liberia, Sierra Leone, and Guinea, the number of infected travelers to the U.S. will briskly increase once there is a significant outbreak in Nigeria and the Ivory Coast. The reason for my statement is partly anecdotal as, in my 8 years of working for a city hospital, I don't recall treating anyone from these 3 countries but I have had several patients from the Ivory Coast and numerous patients from Nigeria. The population of Ivory Coast is about 23 million and Nigerian Population is 174 million, while the combined population of Sierra Leone, Guinea, and Liberia was around 15 million.  Obviously we have many more commuters to the U.S. from these 2 larger populations.

I predicted that people would run from there, once the threat of Ebola became bad enough, and obviously some people like Duncan did run. Perhaps these countries are so destitute that most people simply don't have the means to travel outside their area and so far, the rapid transit of Ebola stricken people to the rest of the world hasn't been as severe as I feared. For the reasons stated above, I believe all this can change once these other countries, that border the 3 currently affected, become heavily infected.

By this point, you are probably wondering where is the hopeful aspect of my post. The hopeful aspect has to do with the ability to survive this infection inside the U.S. or other first world countries. While we haven't had tons of experience dealing with this virus here, thank God, we have had some. The early case named Duncan didn't make it, no matter what we threw at this illness, but several others have. What we can offer here that is unavailable in West Africa is appropriate management of kidney failure and appropriate fluid management. It appears that the early period of a severe Ebola illness is marked by profound diarrhea, to the tune of 6 litters per day and inability to drink enough fluid - probably due to vomiting. They can set up an IV in West Africa, but they are unlikely to get quick lab results back and manage the associated electrolyte disturbances as well as we can here. This has to do with having a good lab in your facility that can give you results within an hour or 2.  Another item they don't have as good an access to is dialysis, which seems to have played a role in stabilizing several Ebola patients who were treated successfully with 1st world medicine.  Duncan did receive dialysis, which was a very risky procedure for the staff, but he still died. However others lived, and consequently Ebola mortality here hasn't reached the 70-90% range seen elsewhere. As the illness progressed further and complications of bacterial sepsis occurred in the severely ill man treated in Germany, he had access to effective and powerful antibiotics and mechanical ventilation. These things are also not widely available in West Africa. Bottom line, he lived because of his access to such medical treatments whereas, if he had stayed in Africa, he would have died.

So in this hopeful part of my post, I have reason to believe that mortality from Ebola in the U.S. will not be as severe as it is in Africa. If I had to guess based on known survival patterns for sepsis and organ failure, I would guess it will be somewhere in the 25% range. Still, you should take such assessment with a grain of salt because it is impossible to do good statistics on so few cases as we have treated here, and often times theory based predictions turn out to be poor predictors of reality.

Another important point to make is that our ability to deliver such high level of care to someone infected with such a deadly pathogen is very limited. Outside the 20 or so BL4 beds available in this country, the other hospitals attempting to treat such patients will place themselves and their other patients in great risk. In terms of financial risk, the hospital that treated Duncan in Texas lost millions, even before they settled with Duncan's family. This was a 900 bed hospital and patients continue to avoid it like the plague, and therefore much of it remains empty. I would not be surprised if it goes belly up soon. Just imagine such financial impact hitting multiple hospitals throughout the U.S. The key to avoiding this devastating burden on our already severely stressed medical system here, is to send all such infected patients to the few operational BL4 beds we have. The best way to keep a manageable low census of such patients remains through effective quarantine.  I sure hope our politicians will take this threat seriously and not become fooled by the obviously false estimates coming out of West Africa.

5 comments:

creakypavillion said...

Another Ebola death.

Ex-Dissident said...

Yeah, no surprises there. This man was brought here in such bad shape that it is a miracle he didn't die on the plane. The only interesting fact about this story was a report of him being given zmap which I previously heard we no longer had, and I figured the very small supply was being reserved for important government officials. Mali is a more interesting development as it may be the next country which develops widespread transmission and becomes overwhelmed by this bug.

creakypavillion said...

I wonder how they transported him - in a commercial aircraft? what about people there? pilots, stewards, airport personnel? medics who accompanied him?
I think his wife acted irresponsibly - insisting to bring highly contagious patient,at 4 days after developing symptoms' stage, into a populated area.

Did you see the news that Japanese developed anti-ebola drug?

Ex-Dissident said...

Etat,

The Wikipedia page is very informative and I have read about several drugs that we hope will be useful in treatment of Ebola. However, all these meds are in preliminary testing stage, so at this time only zmap was tested in several people and prior to this, was found to be effective in lab animals. Blood transfusion from someone who recovered from Ebola is another method that may be beneficial but there is not a lot of such blood around and we don't know just how effective it will be. If you are unfortunate to be in some God forsaken clinic in Monrovia, you will probably die from this because they can't even manage fluids properly. In the US, I think your chances are better but no one knows just how much, and I hope we never develop the numbers here to do proper statistics on. However, the way everything is going, we probably will suffer such numbers and I sometime next year remains my forecast.

Rose said...

Someone I was talking to wondered if there was a genetic susceptibility component in all this.... but it's more likely that we have more sanitary conditions here, and are thus better able to fight it.

There's an article about the utter decimation of maternity wards in ebola stricken areas - really awful.