London School of Hygiene & Tropical Medicine

Recent positive results from the Guinea Ebola vaccine trial, which suggested a vaccine could provide high protection against the virus, were welcome news. However, it’s also essential that we continue to carry out research to ensure Ebola patients are receiving appropriate care and effective treatment.

I’m part of a research team that has just published a paper in The Lancet Infectious Diseases, which provides insights into how the Ebola virus affects the body, in order to better inform clinical case management. It’s the result of work carried out at the Ebola treatment centre in Kerry Town.

It was late October in 2014 when I found out I was going to Sierra Leone as part of the first cohort of NHS workers recruited for the Department of International Development (DFID). The West African Ebola epidemic was prominent in the news, and cases were increasing week-by-week. As an infectious diseases doctor, I had learned how to don the personal protective equipment that reduces the risk of acquiring Ebola from patients, I knew what the textbooks said about Ebola, I had looked after patients with other severe infectious diseases such as dengue haemorrhagic fever and anthrax, but I hadn’t yet managed a patient with Ebola.

So, I did what every doctor would do in that circumstance, and tried to prepare myself as well as possible. I attended several talks by colleagues who had already returned from the ‘front line’ in West Africa to get tips about how to recognise and manage Ebola patients. I quickly learnt that the many NGOs involved in the Ebola response at that time had quite different strategies for managing sick patients – for example some gave intravenous fluids, some did not.

When I turned to the scientific literature for help, I discovered little research had been done on Ebola given most previous outbreaks had been small, sporadic and in remote settings. Whilst the World Health Organization’s pocket guide to viral haemorrhagic fevers was excellently written and very useful, much of the guidance was based on anecdotal experience and expert opinion. Much was written about experimental treatments such as ZMapp and clinical trials of new antivirals, but I wouldn’t have access to any of these in West Africa. My reading left me with more questions than answers.

I was posted to the Kerry Town Ebola Treatment Unit outside Freetown, run by Save the Children International and funded by DFID. The Kerry Town care team was a mix of Sierra Leone Ministry of Health staff, the Cuban Medical Brigade, NHS, and Save the Children International staff and volunteers. The unit shared a site with the UK Defence Medical Services treatment facility for healthcare workers. Fortunately, they had spare lab capacity to process blood tests (full blood counts and blood electrolyte levels) which enabled us to test blood on most patients as soon as they were admitted to Kerry Town. Very quickly we realised not only was the information from the blood tests incredibly useful when making clinical decisions about managing our patients, it was also answering some of my questions.

Half our patients had kidney failure when they were admitted. When we combined the blood test data with routinely collected information on patients’ clinical presentation and survival, we found that kidney failure didn’t only occur in patients who were dehydrated from severe vomiting and diarrhoea as was previously thought. Patients with mild symptoms could also have kidney failure which put them at higher risk of dying. One in three patients also had abnormal potassium levels, either too high or too low. Whilst liver inflammation was very common, liver failure was rare.

Our findings shed light on the clinical course of Ebola and clinical management. With basic supportive treatment including intravenous fluids and electrolyte replacement, more patients with kidney failure survived. This supports the use of intravenous fluids for Ebola patients, which remains controversial. Abnormal potassium can be fatal but can be managed with simple interventions, so our results support testing potassium levels. We hope this research, along with other studies emerging from the West African Ebola epidemic, can be used to develop effective and practical protocols for the basic clinical management of Ebola patients for future outbreak responses.

Publication:

• Luke Hunt, Ankur Gupta-Wright, Victoria Simms, Fayia Tamba, Victoria Knott, Kongoneh Tamba, Saidu Heisenberg-Mansaray, Emmanuel Tamba, Alpha Sheriff, Sulaiman Conteh, Tom Smith, Shelagh Tobin, Tim Brooks, Catherine Houlihan, Rachael Cummings, Tom Fletcher, Clinical presentation, biochemical, and haematological parameters and their association with outcome in patients with Ebola virus disease: an observational cohort study, The Lancet Infectious Diseases, DOI: 10.1016/S1473-3099(15)00144-9

Image: Drip stands at the Kerry Town Ebola treatment centre. Credit: Ankur Gupta-Wright