We are not being critical of our colleagues in west Africa. They suffer from a terrible lack of infrastructure and the sort of testing that everyone in our society takes for granted, such as the ability to do a complete blood count—measuring your red blood cells, your white blood cells and your platelets—which is done as part of any standard checkup here. The facility in Liberia where our two patients were didn’t even have this simple thing, which everyone assumes is done as part of your annual physical.
What we found in general is that among our Ebola patients, because of the amount of fluid they lost through diarrhea and vomiting, they had a lot of electrolyte abnormalities. And so replacing that with standard fluids [used in hospital settings] without monitoring will not do a very good job of replacing things like sodium and potassium. In both of our patients we found those levels to be very low. One of the messages we will be sending back to our colleagues is even if you don’t have the equipment to measure these levels, do be aware this is occurring when patients are having a lot of body fluid loss.
Our two patients also gained an enormous amount of fluid in their tissues, what we call edema. In Ebola virus disease there is damage to the liver and the liver no longer makes sufficient amount of protein; the proteins in the blood are very low and there is an enormous amount of fluid leakage out into the tissues. So one of the takeaway messages is to pay closer attention to that and perhaps early on try to replace some of these proteins that patients’ livers lack.
Certainly in the United States they are adequate. The major way one would diagnose Ebola virus disease is through a process called PCR or polymerase chain reaction, where you take the patient’s blood, put it in a machine and it tells you in a few hours if the nuclear material from the Ebola virus is present. CDC is doing that for patients coming back from infected areas where virus is a potential. There are a number of labs, both local and courtesy of CDC, that are doing this testing in west Africa, and my sense is it’s not that difficult to get it done.
Given that there is no treatment for Ebola virus disease, the main intervention that will determine if someone lives or dies with this infection is supportive care: The ability to replace fluid and electrolytes if a patient is losing them. The ability to replace platelets if that count is low and a patient is starting to bleed. The ability to replace protein in the blood that may be deficient. A developed country has the capability because of our infrastructure to provide that level of support is at a much higher level than a hospital dealing with patients in west Africa.