Lessons learned from treating the first known patient with Ebola virus infection in the United States offer a sobering look into the enormous challenge this disease represents.
These lessons are especially relevant—and poignant—in that Thomas Duncan, the first person to succumb to the disease in the United States, died the day Bruce S. Ribner, MD, MPH, of Emory University Hospital, Atlanta, GA, presented his findings during a special plenary session at IDWeek 2014.
Dr. Ribner began by describing July 30, 2014: “Early that morning, I received a telephone call from an air ambulance service, which is headquartered roughly an hour north of Atlanta. They informed me that they were about to take off for West Africa. They had just been contracted by a private nongovernmental organization to bring a patient with Ebola virus infection back to the United States. This would be the first known patient with Ebola virus disease to be treated in the United States and, oh, by the way, he’d be coming to our facility in 3 days.
“What followed was a complex set of interactions and decisions, which we made both with internal entities in our healthcare system as well as with government agencies and other outside entities in trying to decide how to safely and effectively manage a patient with Ebola virus disease.”
Dr. Ribner, speaking on behalf of the Emory Serious Communicable Diseases Unit team, outlined his institution’s experience to “help guide many of you who are currently involved in your facilities in trying to figure out how to manage your first patient with Ebola virus disease.”
This included how to plan for the care of patients with serious communicable disease, what was learned about its clinical management, use of biocontainment units, the need for a dedicated laboratory space, staff and environmental safety, waste management, and media and communications.
Clinical pearls include that patients will be hypovolemic, even while their body weight increases as much as 15–20kg, due to low albumin and vascular damage. Large volume losses of 5–10L/day are not uncommon. The first patient cared for was more than a week into the course of illness and had marked electrolyte abnormalities and nutritional deficiency that included hypokalemia, hypocalcemia, and hyponatremia requiring both intravenous and oral replacement.
Although evidence of viral RNA was found on the skin, in blood, urine, semen, endotracheal suctioning, vomitus, and stool, none was found in dialysate or in multiple room samplings performed on the day of patient discharge, focusing on bathroom and high touch room areas.
“The ability to provide high-level nursing care and supportive care had a significant impact,” he said, with round-the-clock 1-on-1 nurses allowing for rapid response to changes and adjustment of care and the ability to provide nutritional, physical therapy, self-care, and emotional support.
Asking a patient about travel history within the past 30 days is key to triaging patients within any facility, Dr. Ribner said. For the near term, control of the Ebola virus epidemic will depend on implementation of effective clinical care, rigorous infection prevention and control, careful contact tracing and follow-up, and effective risk communication.
Ebola virus disease currently has no vaccines or medicine approved by national regulatory authorities for use in humans. However, the World Health Organization (WHO) does allow use of experimental medicines and vaccines under the exception circumstances of the Ebola epidemic. WHO reports that the current outbreak in West Africa, with the first cases dating to March 2014, “is the largest and most complex Ebola outbreak since the Ebola virus was first discovered in 1976. There have been more cases and deaths in this outbreak than all others combined.”