Ebola Doctors Are Divided on IV Therapy in Africa
The New York Times
By Donald G. McNeil Jr.
January 01, 2015
(Click here to view the original article.)
Medical experts seeking to stem the Ebola epidemic are sharply divided over whether most patients in West Africa should, or can, be given intravenous hydration, a therapy that is standard in developed countries. Some argue that more aggressive treatment with IV fluids is medically possible and a moral obligation. But others counsel caution, saying that pushing too hard would put overworked doctors and nurses in danger and that the treatment, if given carelessly, could even kill patients.
The debate comes at a crucial time in the outbreak. New infections are flattening out in most places, better-equipped field hospitals are opening, and more trained professionals are arriving, opening up the possibility of saving many lives in Africa, rather than a few patients flown to intensive care units thousands of miles away.
The World Health Organization sees intravenous rehydration, along with constant measuring of blood chemistry, as the main reason that almost all Ebola patients treated in American and European hospitals have survived, while about 70 percent of those treated in West Africa have died.
Every hospital there should have “early, liberal use of intravenous fluid and electrolyte replacement,” said Dr. Robert A. Fowler, a Canadian critical care specialist who leads a W.H.O. Ebola team. Anything less, he said, is “not medically justified and will result in continued high case-fatality rates.”
Experts who favor aggressive rehydration point to several hospitals that claim unusually low death rates as evidence that it is effective. Skeptics say other factors may be at work.
Even two of the most admired medical charities have squared off over the issue. Partners in Health, which has worked in Haiti and Rwanda but is just beginning to treat Ebola patients in West Africa, supports the aggressive treatment. Its officials say the more measured approach taken by Doctors Without Borders is overly cautious.
“M.S.F. is not doing enough,” said Dr. Paul Farmer, one of the founders of Partners in Health, using the French initials for Doctors Without Borders, whose staff members have worked on the front lines of Ebola outbreaks for years. “What if the fatality rate isn’t the virulence of disease but the mediocrity of the medical delivery?”
Doctors Without Borders representatives strongly disagreed, saying that Dr. Farmer’s assumptions about Ebola were incorrect, that intensive rehydration would probably not save as many patients as he believes, and that the W.H.O.’s position has not been proved.
The group’s overwhelmed doctors do what they can, officials said, but it is hard to insert needles while wearing three pairs of gloves and foggy goggles. IVs must be monitored, drawing virus-laden blood for tests is dangerous, and patients yank needles out — sometimes in delirium, sometimes just to go to the toilet when no nurse is around.
Ebola patients lose up to five quarts of fluid a day through diarrhea and vomiting. In that fluid are electrolytes like potassium, magnesium, sodium and calcium, and proteins like albumin. Electrolyte loss can stop the heart; protein loss can cause fatal internal swelling.
Rehydrating patients and replacing those elements “is the antidote to the idea that everybody’s going to die,” Dr. Farmer said.
Every Ebola hospital, he argued, should have a team that specializes in inserting IVs — or, better yet, peripherally inserted central catheters, or PICC lines. These are thin plastic tubes, inserted in the arm or chest and threaded through a vein, that can be left in place for days and the needle discarded.
Along with doctors at the London School of Hygiene and Tropical Medicine, who published an article on rehydration in The Lancet on Dec. 4, Dr. Farmer has also called for the use of thick needles driven into bone marrow with surgical “guns.” This procedure, known as intraosseous infusion, is slow, but it reinflates veins too shrunken to admit an intravenous line, and the needles are much harder for agitated patients to pull out.
However, not all doctors know how to use PICC lines or bone needles, or how to inject fluids into empty abdominal spaces, another technique endorsed in the Lancet article. (The article was accompanied by a video in which Dr. Ian Roberts, the chief author, had some of those techniques demonstrated on himself. He used minimal anesthesia, he said, to imitate field conditions in West Africa.)
Doctors Without Borders normally puts IV lines in as many Ebola patients as it can manage, said Dr. Armand Sprecher, an Ebola expert with the organization. That practice was temporarily stopped in September, when the disease was spreading so fast that doctors had only one minute per patient during the one hour they could work in their sweltering protective suits.
The fatality rate across the group’s six Ebola treatment centers in West Africa was about 60 percent then, and is now 40 to 50 percent, Dr. Sprecher said. He disputed Dr. Farmer’s contention that rehydration could bring it down to 10 percent.
“It would probably push it down some, but I’d be surprised if it were dramatic,” Dr. Sprecher said.
Dr. Farmer cited the treatment given at a unit in Hastings, Sierra Leone, as an example of the kind of care he endorses.
In a Dec. 24 letter to The New England Journal of Medicine, the Sierra Leonean doctors running that center with Western advisers said they had had a 48 percent fatality rate when they opened in September and had since reduced it to 24 percent.
Each of the 581 patients the center has treated immediately received IV fluids with electrolytes, they wrote. Even without lab tests, each patient also received an antibiotic, an anti-parasitic drug, an antimalarial drug, an anti-vomiting drug, pain pills, vitamins, zinc and a nutrition supplement.
“That’s effective case management,” Dr. Farmer said. “We’re cheering them on.”
The fatality rate at the unit Partners in Health runs in Port Loko, Sierra Leone, is 35 to 40 percent, its director, Dr. Corrado Cancedda, estimated.
Up to 80 percent of patients there receive IV rehydration, Dr. Cancedda said, and some have had bone needles inserted; no PICC lines have been used. Battery-powered electrolyte monitoring machines are being introduced.
Dr. Sprecher said death rates at Doctors Without Borders’ six hospitals in the region varied, with the lowest being 36 percent in Bo, Sierra Leone.
But he could not explain why. Some of the hospitals see more young adults, who tend to survive. At rural centers, the sickest patients die on the way there.
Rehydration was only one lifesaving factor for the handful of patients transported to American or European hospitals, Dr. Sprecher argued, because all of them also received intensive nursing, and some receiveddialysis, ventilation and experimental therapies.
He was reluctant to have his doctors seen using bone-needle guns on patients. “Not long ago, we were being accused of stealing organs,” he said. “You have to be sure people understand what the heck you’re doing.”
Dr. Sprecher also disputed Dr. Farmer’s comparison of Ebola to cholera, which both medical charities fight with aggressive rehydration. Ebola, he said, does more organ damage and makes blood vessels leak fluid.
“In cholera, you can get fatalities down from 50 percent to 1 percent,” he said. “We’ve been putting people on IVs for Ebola for 14 years. If just tanking them up worked, we’d be doing it.”
Lab testing is a crucial issue. For example, while low potassium can kill, so can overdoses. Potassium is used in executions by lethal injection.
West Africa has at least eight laboratories run by various American, Canadian and European government agencies, Dr. Sprecher said. Until recently, they tested only for Ebola and diseases that mimic it, like malariaor Lassa fever.
Now, he said, about half can test for electrolytes.
Because heat and humidity knock out the machines that analyze blood chemistry, labs must be air-conditioned, said Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention. The C.D.C. runs two large laboratories in the region, only one of which now tests for electrolytes.
Sometimes, conservative guesswork is called for, Dr. Frieden said. His father, a physician, gave potassium to patients who needed IV rehydration long before such tests were routine.
The best-equipped treatment center in West Africa is the 25-bed United States Public Health Service hospital in Monrovia, Liberia, which is reserved for doctors, nurses, burial teams and others fighting the epidemic. It is fully air-conditioned and has 32 medical personnel, who wear high-tech protective gear that sucks in fresh air. Its on-site lab tests blood for electrolytes and proteins. The pharmacy has drugs to raise blood pressure or increase coagulation, and patients can be fed through tubes.
Since it opened in November, it has had 14 Ebola patients. Seven recovered, five died, one was transferred and one is in treatment, a spokeswoman said. (Ten other people who were admitted did not have Ebola.) That is a 42 percent fatality rate, though based on a small sample, for the 12 patients whose fates are clear.
Other units tread a middle ground, relying on what measures they have at hand. The fatality rate at the International Medical Corps hospital in Bong County, Liberia, is about 55 percent, said Dr. Pranav Shetty, the agency’s international emergency health coordinator.
All patients who need IV lines get them, Dr. Shetty said. But when there are too few nurses around, usually at night, the IVs are unhooked, so patients may get only one quart of fluids a day. And only patients still urinating, indicating that their kidneys are working, receive electrolytes.
Spending money on air-conditioning “doesn’t even cross our minds,” Dr. Shetty said, because other needs are more urgent.
When IV lines are impractical, the W.H.O. urges doctors to make patients drink six quarts of rehydration solution a day.
Nigeria’s victory over its Ebola outbreak in September was attributed in part to that. Dr. Adaora Igonoh, a 28-year-old Nigerian physician who survived the disease, became a symbol for the cause: The W.H.O. distributed pictures of her giving a thumbs-up while drinking the solution, and Bill Gates blogged about her story, telling how she forced herself to drink despite the repulsive salty taste and her vomiting.
Still, even oral rehydration is hard, doctors say. Patients need anti-nausea drugs and must be pressured to drink. The solution tastes better when refrigerated. But, like air-conditioning, that requires electricity.