Ten people have been treated for Ebola in the United States since September. Eight lived. Two died.
The difference between life and death was often a matter of time and fluids as much as technology and drugs — a finding that could hold vital lessons for thwarting an epidemic that has left thousands infected and dead in West Africa.
The case of Dr. Martin Salia illustrated those points, tragically.
The full force of Western medicine could not save Salia, a surgeon who contracted Ebola in Sierra Leone, one of three nations at the epicenter of a health crisis that has captured headlines worldwide for six months.
He was flown from Africa to Nebraska for treatment. In Omaha, he received continuous dialysis to do the work of his ruined kidneys, mechanical ventilation when he could not breathe, plasma from an Ebola survivor, the experimental drug ZMapp, and the round-the-clock ministrations of a skilled team that had saved two previous Ebola patients.
What Salia did not get was prompt treatment. He arrived in Omaha unresponsive, bleeding, his kidneys no longer working — 13 days after he first felt ill. Two patients treated earlier at Nebraska Medical Center had arrived on day six and day eight of their symptoms.
“At some very basic level, whether you live or die is essentially whether your immune system is able to catch up with the virus and overcome it,” said Dr. Adam C. Levine, who worked in Liberia with the International Medical Corps and is now developing training materials for the organization. “It’s kind of a race between your immune system and the virus.”
The other patients treated in Nebraska — Massachusetts family doctor Richard Sacra and Rhode Island journalist and activist Ashoka Mukpo — each received a different experimental drug. It is unknown whether those treatments helped.
But Dr. Philip Smith, medical director of Nebraska Medical Center’s biocontainment unit, said, “If I had to guess, I would think the supportive care is most important.”
Supportive care keeps a patient alive until the virus clears. A key aspect for Ebola patients involves providing ample intravenous fluids to replace what is lost from vomiting and diarrhea.
“Forget the high-tech interventions,” Smith said. “One can do an awful lot of good by getting IV fluids available and by getting good venous access. The good news is that something relatively simple could be done in at least some places in Africa and have an effect on survival.”
Levine, who is an emergency department doctor at Rhode Island Hospital in Providence and an assistant professor of emergency medicine at Brown University, spent five weeks in Liberia in August and September, working in an Ebola treatment unit in a rural area north of Monrovia.
Levine said there is little research showing who will live and who will die, but experience with past Ebola outbreaks suggests that people between the ages of 5 and 40 have the best chance of survival, while pregnant women are particularly vulnerable.
Another factor is the amount of virus that gets into the patient’s bloodstream. Health care workers accidentally stuck with needles containing the blood of Ebola patients have the highest death rate, approaching 100 percent, Levine said. People who contract Ebola after rubbing their eyes with a contaminated glove have better prospects.
“The most important thing is supporting them so they can survive long enough for their immune system to fight off the virus,” Levine said.
Pumping in plenty of fluids is critical. Patients stricken with Ebola lose as much as 10 liters of fluid that need to be quickly replaced with water containing a balanced mixture of electrolytes and sugar.
Patients should also get antibiotics, because inflammation in the gut allows bacteria to leak into the bloodstream, Levine said. Beyond that, symptoms are treated: drugs to stop vomiting, lower fevers, relieve pain, and maintain blood pressure.
In Africa, the death rate from Ebola is greater than 50 percent, climbing as high as 70 percent in some areas. The West African countries do not have enough nurses, doctors, and monitoring equipment to provide the kind of care offered in the United States. The patients in Nebraska, for example, had a dozen people caring for them at any given time.
In Africa, “in the Ebola treatment units, you have a situation where there are maybe 40, 50, up to 100 patients on the wards,” Levine said. “Those patients are only being seen a few times a day.”
Hospitals in the United States and Europe can more aggressively provide fluids and also test blood to make sure the right balance of electrolytes is provided. Blood pressure can also be tested and then treated with medication that requires careful monitoring.
“In most of the Ebola treatment units, we’re not even able to test blood pressure,” Levine said of the clinics in Africa.
Salia, 44, was the 10th Ebola patient treated in the United States. The only other patient to die was Thomas Eric Duncan, a Liberian visiting Texas, whose treatment was also delayed until the disease had advanced.
Smith, the head of the Nebraska biocontainment unit, said the staff sensed when Salia arrived that the virus may have already outrun the surgeon’s immune system.
“The disease has a somewhat exponential course,” he said.
Salia’s kidneys were damaged, and he was bleeding from the mouth and intestine, a sign of advanced disease. The staff provided blood and fluids. An infusion of plasma from an Ebola survivor helped restore fluids and also provided antibodies. Salia also received a dose of ZMapp, the antiviral drug.
The doctors and nurses were saddened by the outcome, Smith said, but “anxious to continue to do what we can to help take care of the world’s Ebola problem.”
Felice J. Freyer can be reached at email@example.com.