Clinical Management of Ebola Virus Disease in the United States and Europe

Abstract

Background Available data on the characteristics of patients with Ebola virus disease (EVD) and clinical management of EVD in settings outside West Africa, as well as the complications observed in those patients, are limited. Methods We reviewed available clinical, laboratory, and virologic data from all patients with laboratory-confirmed Ebola virus infection who received care in U.S. and European hospitals from August 2014 through December 2015. Results A total of 27 patients (median age, 36 years [range, 25 to 75]) with EVD received care; 19 patients (70%) were male, 9 of 26 patients (35%) had coexisting conditions, and 22 (81%) were health care personnel. Of the 27 patients, 24 (89%) were medically evacuated from West Africa or were exposed to and infected with Ebola virus in West Africa and had onset of illness and laboratory confirmation of Ebola virus infection in Europe or the United States, and 3 (11%) acquired EVD in the United States or Europe. At the onset of illness, the most common signs and symptoms were fatigue (20 patients [80%]) and fever or feverishness (17 patients [68%]). During the clinical course, the predominant findings included diarrhea, hypoalbuminemia, hyponatremia, hypokalemia, hypocalcemia, and hypomagnesemia; 14 patients (52%) had hypoxemia, and 9 (33%) had oliguria, of whom 5 had anuria. Aminotransferase levels peaked at a median of 9 days after the onset of illness. Nearly all the patients received intravenous fluids and electrolyte supplementation; 9 (33%) received noninvasive or invasive mechanical ventilation; 5 (19%) received continuous renal-replacement therapy; 22 (81%) received empirical antibiotics; and 23 (85%) received investigational therapies (19 [70%] received at least two experimental interventions). Ebola viral RNA levels in blood peaked at a median of 7 days after the onset of illness, and the median time from the onset of symptoms to clearance of viremia was 17.5 days. A total of 5 patients died, including 3 who had respiratory and renal failure, for a mortality of 18.5%. Conclusions Among the patients with EVD who were cared for in the United States or Europe, close monitoring and aggressive supportive care that included intravenous f luid hydration, correction of electrolyte abnormalities, nutritional support, and critical care management for respiratory and renal failure were needed; 81.5% of these patients who received this care survived.

Diagnosis of Ebola Virus Disease: Past, Present, and Future

“…Given the challenges inherent in generating authentic antigen preparations from viral cultures in a BSL-4 facility, ELISAs that utilize recombinant viral proteins have been developed (13,14), but to date they do not appear to have been validated for clinical use. However, a commercially available Ebola Zaire virus IgM and IgG ELISA kit (Alpha Diagnostic International) that utilizes recombinant viral proteins expressed in Escherichia coli has been employed in recent clinical research efforts (15). Limited data are available to assess the sensitivity or specificity of these ELISAs.…”

“…The reported durations of persistence of detectable RNA in the serum or plasma of EVD survivors appear to depend on the RT-PCR assay used, although differences in study populations between testing centers render comparisons between assays difficult. Field laboratories in the 2014-2015 epidemic (employing a variety of commercial and laboratory-developed assays) reported variable times to clearance of detectable RNA in their survivor populations, ranging from day 13 to 45 of illness (12,15,35) (Fig. 1).…”

“…Unpublished reports have linked two cases of Ebola in neonates to breast milk from an asymptomatic mother confirmed by PCR to harbor viral RNA (T. Brooks, personal communication). More extensive evidence has accumulated for the persistence of viral RNA in body fluids, with detection by RT-PCR in sweat or skin swabs as late as day 40 of illness (15,116), in vaginal secretions as late as day 33 of illness (15,28,118), in urine as late as day 30 of illness (116,118), in rectal swabs or stool as late as day 29 of illness (15,28,118), in conjunctival fluid as late as day 28 of illness (28,118), in saliva as late as day 24 of illness (15,118), and in amniotic fluid (timing unspecified) (119). Sampling methods and testing strategies have not been consistent across studies, and little is known about the correlation of positive RT-PCR results with risk of viral transmission.…”

Airway Management of Patients with Ebola Virus Disease

“…Acute hypoxemic respiratory failure is uncommon in patients with EVD in West Africa in comparison to patients treated outside of Africa (22). During the recent epidemic, of those patients cared for in US and European hospitals, 47% had respiratory failure (23). This generally occurred later in the illness with mean onset at day 9 (23).…”

“…Intubation and invasive respiratory management is more likely to be employed in patients repatriated to Europe or the United States. During the 2014-2015 epidemic some 27 patients received care in US and European hospitals (10,16,19,23). Of these 27 patients, 9 (33%) received non-invasive or invasive mechanical ventilation (23).…”