Critical care of Ebola patients: a crisis situation.

Last month, the US National Institutes of Health (NIH) published an article titled “Preparing for Critical Care Services to Patients with Ebola”. It proved timely; 6 days later, the country saw its first case of the disease. As The Lancet Respiratory Medicine went to press, the UK Department of Health was preparing to test its response to a simulated Ebola outbreak. The UK has agreed to deploy troops to Sierra Leone to assist with control efforts; they will join the 3000 or so troops President Barack Obama has pledged to west Africa.

The countries at the centre of the epidemic—Guinea, Liberia, and Sierra Leone—could scarcely have been worse prepared. The region is characterised by mass poverty. Liberia and Sierra Leone are recovering from hugely destructive civil wars. Guinea spends a mere US$62 on healthcare per year for each of its citizens. The country's largest public hospital does not contain a mechanical ventilator or facilities for piped oxygen; indeed intensive care facilities are virtually non-existent across most of sub-Saharan Africa. Liberia's solitary academic referral hospital is plagued by floods and electrical fires. The NIH article suggested staffing levels to attend a single patient with Ebola for 1 week: six full-time physicians, 12 full-time nurses, and six full-time protective equipment adherence monitors. “Additional staff needs include respiratory therapists; isolation adherence monitors; cohorted laboratory and housekeeping personnel; and administrative staff to manage logistics, supplies, waste, and public relations”, added the authors. It hardly needs stating that this is far beyond the capabilities of west Africa. Before the crisis, Liberia had 51 physicians in the entire country, and Sierra Leone had 136. Given the toll Ebola has taken on healthcare workers (thus far, 401 cases and 232 deaths), there are now likely to be even fewer.

The latest figures from WHO put the total case-load at 8033, with 3865 deaths. But the true figures are certainly much higher: thousands of people are simply unable to access healthcare and there is a tendency for those living in Monrovia's sprawling West Point slum to toss dead bodies into nearby rivers. At the current rate of increase, WHO reckons that the number of Ebola cases will exceed 20 000 by the beginning of November. “We are still very much on the upward curve”, said WHO's Margaret Harris, who is based in the epidemic's hot zone in Sierra Leone. “We are not seeing any evidence of a flattening—there are far more cases than the treatment system can deal with.”

WHO reckons that neither Sierra Leone nor Liberia have the capacity to treat more than 30% of patients in need. The treatment available varies from centre to centre. Some offer intravenous rehydration, others only oral rehydration salts and empirical antibiotics and antimalarials—triage in other words. “With the current human and material resources, it is very difficult to provide appropriate levels of care”, pointed out William Fischer (University of North Carolina, USA). “With Ebola, there is voluminous diarrhoea, and we were unable to test for potassium in most locations—we were repleting blindly.” The dearth of oxygen, however, does not seem to be a problem. “The need for oxygen therapy was at a minimum—there was no sign of hypoxia in Gueckedou [one of the worst affected places in Guinea] though to some extent this was likely due to under-resuscitation”, said Fischer.

The University of Toronto's Robert Fowler notes that a relatively small number of patients with Ebola develop respiratory illness. “We see pulmonary involvement more frequently in patients who have the ability to get sufficient intravascular volume, and some of it spills into the lungs”, he explained. “We have not been able to properly volume replete people in west Africa to have that become a problem.” So this is really an issue for resource-rich settings, where volume repletion can be adequately administered.

Fowler believes that with aggressive supportive care Ebola mortality can fall below 40% (mortality rates for the current epidemic hover around 70%). “We could make a substantial dent in the mortality simply with enough personnel and basic routine laboratory testing to know whether our therapies for at least dehydration prevention and treatment are on track.” Fischer agrees. “It is possible with minimal effort to bring the necessary supportive care to austere environments”, he said. “Things like IV fluid and electrolyte management can go a long way to improving the outcomes of patients with Ebola infection.” And once the epidemic is over, a surge of investment in healthcare in the region is vital—after all, there is every chance that Ebola could become endemic to west Africa. On October 1, the WHO Emergency Committee warned African nations to ready themselves for the possible seasonal spread of Middle East respiratory syndrome coronavirus (MERS-CoV) in the first half of 2015. Ebola has vividly shown the ability of pathogens to exploit weaknesses in healthcare infrastructure. Until now, MERS-CoV has been restricted to the Middle East. But until last December, Ebola was restricted to Central Africa.