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Whoa! This evolving Ebola pandemic is really starting to gather some steam now. Another day goes by and more bad news emerges. Now the focus has turned to cases within the first world. Today we hear that a nurse in Dallas “may have broken protocol” while treating the Ebola patient there and has become infected. Last week there was news of a similar event in Spain marking the first new infection outside of Africa. There has been news coverage of poor processes in the USA when effectively screening, and then ignoring, the first case there.  All the while the impact of the disease continues to worsen in West Africa. Conditions there seem truly awful. There are massive hurdles to overcome, inadequate resources and support in the midst of a climate of fear and death. 

The official toll is now over 4000 with ongoing exponential growth. The doubling time for that figure appears to be about a month, making the fight to gain control more difficult by the day. It appears that the ship is leaving the harbour, if it hasn’t already sailed.  It seemed not too long ago that there was discussion revolving around how sensationalistic the reporting of Ebola was. The virus is, after all, only transmitted via body fluids and it seemed that surely it should come under control with the institution of basic public health measures. Now it appears that, of only a few cases to leave Africa, 2 have caused further infection to medical staff treating them within first world systems of isolation and infection control. We have an evolving pandemic

This situation raises several concerns.

Due to the fact that Ebola has previously only been present in relatively small outbreaks in third world countries, there has been a degree of uncertainty over both its virulence and deadliness.  Prior to recent events, I was confident that should Ebola somehow come ashore here, that it would be easily contained and likely far less deadly than advertised. However, there have been deaths within the few cases in the USA and Spain combined with a lack of easy containment despite significant efforts to do so.  This makes me less confident.

Has the virulence or transmissibility changed? I am not a microbiologist and so not in a real position to comment on this. However it does appear unusual that, for a disease that is allegedly only transmitted through bodily fluid exposure and in previous epidemics seemed containable, both western centres which have managed the virus have failed to protect their staff from infection despite introduction of full protective measures on admission. First reports are that the nurse in Dallas cannot recall any protocol violation that may have put her at risk. If there is an increase in transmissibility, then that has severe implications on the likelihood of pandemic development when combined with a 3 week incubation period.

I am also still unsure of the deadliness of the virus.  We have too little first world data to know how it will fare in our system of treatment. Mortality in West Africa for this epidemic appears to sit at approximately 55% in a severely resource restricted environment.  Here is an excellent article giving the perspective of doctors on the ground in West Africa (along with Crit-IQ journal club review here). They indicate that with appropriate intensive care that the mortality will fall significantly. They describe significant problems with fluid and electrolyte replacement, appropriate monitoring and organ support in West Africa. This epidemic, should it reach an ICU near you, is possibly far more treatable than advertised. Hopefully, but nobody really knows yet.

This brings up the topic of best treatment for Ebola victims, and specifically, whether there is a place for experimental therapies.  My view is that, although it is reasonable to try to test and produce treatments and/or vaccines for this virus, this must be done carefully. In the panic of such an illness, it is often the opportunists who step into the fray.  Money can be made and treatments peddled without usual due diligence. I have previously blogged about the disappointing Tamiflu data on efficacy which was one such treatment bought up in enormous quantities in such a climate of fear following bird flu scares.  Desparate times apparently call for desperate measures but this epidemic is still most likely to be managed through good public health measures augmented by standard supportive care and that is where resources should be directed. A silver bullet is unlikely to materialise in any hurry.

With that in mind, any unproven therapy introduced (such as the monoclonal antibody cocktail ZMapp which has already been approved and given) should have strict monitoring for efficacy and side effects. These are experimental therapies and, as such, should really be given with research principles in place. Without such measures, it is impossible to tell whether they are efficacious. Ideally, plans for research in epidemic/pandemic setting should already be drawn up and ready to roll out - a pandemic is perhaps an ideal opportunity to mobilise the research networks and perform a cluster crossover trial to get rapid answers. Here is an excellent article covering the ethical considerations in using experimental therapies. 

Why is this important to discuss on a critical care blog? Because if this gets out of hand (as it appears to be doing), then we will be on the front lines. Over 5% of all deaths so far have been health workers. 

I have talked about the SARS epidemic with 2 intensivists who worked in affected ICUs at the time (one in Hong Kong, another in Toronto). Their stories are sobering indeed. Quarantine sounds horrible and terrifying. One described bed-wetting due to the trauma of it. Staff in both centres died, devastating the morale of the units. 

How prepared are you should Ebola, or any pandemic, hit your unit? Do you have a plan? Has your unit,hospital and region got a reasonable plan and is it ready to roll out at any time? How are your universal precautions? A 21 day quarantine period has massive implications - how would that affect rostering. What could quarantined staff be doing? Is there a case for utilisation of technology (ie. drones, paperless systems) to reduce human to human contact during an outbreak? I reckon that now is a good time to think about this - maybe the risk of Ebola coming ashore is very low, but the odds are shortening daily, the stakes are high and there are plenty more pandemics to worry about in the future when this one passes. 

Meanwhile here are a couple of useful resources:

Crit-IQ has done a useful summary here

Critical Care Reviews has compiled a list of useful articles here

Science has made a series of articles on the topic freely available here