Lessons learned in the ‘Hot Zone’

“The most difficult part for a clinician is when you don’t know if the patient has Ebola or not,” said Dr. Frederique Jacquerioz at the recent American Society of Tropical Medicine and Hygiene Meeting in New Orleans. Despite the title of her presentation ‘from the ‘Hot Zone’: A Clinician’s Perspective on Confronting Ebola Virus in West Africa’, she said that only about 10% of Ebola patients in West Africa present with any sign of bleeding.

Dr. Jacquerioz has been the Director of the Tulane Clinical Training Program in Sierra Leone and Guinea since 2003 and since May she’s been working on developing training materials and technical support for the World Health Organization (WHO) on Ebola. She was in Guéckédou, Guinea in May, in Sierra Leone in September and a few days after her presentation would be on her way to Liberia.

“Guéckédou is probably the poorest part of Guinea, and Guinea is one of the poorest countries in the world,” she said. This is part of the reason why the outbreak occurred there, and why help had to be brought in from the outside to deal with it, including Médecins sans Frontières (who were there from the very start — see related article). Eventually, WHO’s The Global Outbreak Alert and Response Network arrived to coordinate a network of organizations and institutions with expertise (one if which is Tulane) and increase the capacity to respond.

Dr. Jacquerioz described some of the elements of that response and some of her findings and challenges of working in the field.

Elements of the response:

Every morning started with a meeting usually led by WHO or the Ministry of Health.

“It is a very important meeting, you learn what has happened in the past twenty-four hours; what has to be done in terms of contact tracing; how many beds are available,” she said.

All the various partners ‘MSF, members from the CDC, the Red Cross, WHO (and now many others — are gathered at the table, together with the religious and local community leaders — to inform the community about whatever was happening, explain the various interventions, to negotiate with them and earn their trust and support.

“Once you arrive there, as a clinician, you have to learn how to stay safe – this is really the motto to stay safe. You have to be very careful all of the time, there is no no-risk zone; even outside the treatment center you have to really wash your hands,” she said. Most of the infections among health care workers are believed to occur outside of the clinic setting.

The Ebola treatment center is divided into different risk zones – the low-risk zone and the high-risk zone (where the patients are, where the corpses are prepared before burial or cremation and where the assorted waste is managed. The zones are very well demarcated but with low fences.

“Transparency is really very important – you have rumors in that region that people fear we will take their loved ones, steal their organs and kill them,” she said. The low fences allow the family members to see and talk with their loved one, especially the stable ones that are outside the tents. They also train some family members to come in and help take care of their loved ones.

“The main thing that you have to learn is putting on the personal protection equipment (PPE). It’s not something you can learn in twenty minutes. It is really a skill and you need many days of practice,” said Dr. Jacquerioz. “We spend a lot of time training people.”

At the very beginning of the illness the patient will present with high fever, usually the onset is acute, with headache and fatigue but that could be so many other common febrile illnesses in that region. So each unit has a suspect ward housing some patients that end up not having Ebola. In order to prevent Ebola transmission in the unit, the beds are very far apart, with surfaces that can be easily cleaned.

She presented the following data from a case series published that week in the New England Journal of Medicine.

Characteristics, Symptoms, Vital Signs, and Time Course of Clinical

Progression of 37 Patients with Confirmed Ebola Virus Disease (EVD).*

Variable	Value
Median age (IQR) — year	38 (28–46)
Male sex — no. (%)	24 (65)
Health care worker — no. (%)
Yes	14 (38)
No	23 (62)
Known mechanism of contact — no./total no. (%)†
Health care	12/34 (35)
Household	23/37 (62)
Funeral	6/37 (16)
Known coexisting medical condition — no. (%)
Hypertension	2 (5)
Human immunodeficiency virus	2 (5)
Diabetes	1 (3)
Renal insufficiency	1 (3)
Tuberculosis	1 (3)
Malaria at presentation — no. (%)	4 (11)
Symptoms — no./total no. (%)
Fever	31/37 (84)
Fatigue	24/37 (65)
Diarrhea	23/37 (62)
Headache	12/21 (57)
Vomiting	21/37 (57)
Anorexia	16/37 (43)
Vital signs at admission
Temperature — °C	38.6±1
Heart rate — beats/min	93±14
Systolic blood pressure — mm Hg	125±25
Median interval from onset of symptoms (IQR) — days
To hospital admission	5 (3-7)
To death	8 (7-11)

* Plus–minus values are means ±SD. IQR denotes interquartile range.

† Some patients had more than one exposure.

She noted that a particularly high percentage of health care workers had contracted Ebola in the early days of the epidemic — when there was not enough protective equipment or training available.

In the study, age was found to be a risk factor for mortality. The median age (interquartile range) years: 29 (26–37) among the survivors, and 45 (40–47) among those who died, (p-value 0.005). In addition, the people that had the highest viral loads upon admission were the ones that were most likely to die.

“The ones that die never develop an immune response, and the ones that survive are the ones that have the ability to develop an immune response,” she said. This would not appear to bode well for people living with HIV (there were two in this study) or other coinfections that could impair immunity. At present there was not enough data to know whether HIV increases susceptibility to Ebola — there has been little laboratory support to routinely monitor for coinfections or comorbidities — however, she expected that would change with the increased research capacity being introduced over the coming months.

Clinical management is supportive and has to be aggressive.

• Restore Fluid loss from diarrhea and vomiting
• Electrolyte abnormalities
• Septic shock physiology
• Symptomatic management of nausea, vomiting, diarrhea, seizures, myalgia, pain
  • Quantify input and output
  • Administer fluids aggressively to keep up with losses
  • Monitor with iSTAT
  • Eg., glucose, potassium
  • Can cause morbidity or death (arrhythmia, cardiac arrest, seizures)
  • Aggressive fluids but monitor for shock, overload, pulmonary edema

“You also treat for malaria especially in kids. In Guinea, it was the beginning of the rainy season and there were many cases of malaria,” she said

What are the challenges in taking care of these patients?

Working with the PPE limits the time healthcare workers can spend inside the treatment unit — one to three hours depending on the kind of PPE.

“That is not much time to take care of all of the patients so you have to be very focused on what you will be doing inside. You have to really know where are the patients that are very seriously ill. It is very important to know exactly what you will be doing before entering,” she said. “Also, you always enter in pairs — this is another safety measure — so if anything happens inside that person can help you to get outside.”

Another challenge was getting patient data out of the unit — since nothing can really go outside without being sterilized. “It gets quite messy,” she said.

Another issue was keeping track of the patient’s fluid loss. Since patients are often too weak to go to the restroom, they installed buckets to collect the vomit and diarrhea. Sometimes the cleaners or someone else would empty the buckets of waste collecting the vomit and diarrhea without recording it on a white board established for the purpose.

Monitoring electrolytes was also quite difficult without basic laboratory capacity. They tried to use iSTAT point of care monitoring device but it was very sensitive to the heat and humidity. They went to great lengths to try to keep the device dry and cool, in Styrofoam with rice, salt and dry ice.

Thousands of healthcare workers are needed to man the Ebola treatment units.

“In May, in those centers we never had more than twenty patients at a time. When I went back in September, it was a different picture and there were hundreds of patients,” she said. “Sometimes in Sierra Leone, there were two doctors, one hundred patients and the nurses on strike and so it was very, very challenging.”

Twenty-four to twenty-five new treatment centers are being built both in Liberia and in Sierra Leone. Each one hundred-bed treatment center requires a clinical team of two hundred to two hundred and fifty people, plus a one hundred person support team to clean the center. Still others are needed to transport patients or to bury the dead.

In addition to recruiting and training so many healthcare workers, transportation is a major challenge not just getting to the region, but around within it.

“One of the barriers that we had is that many commercial flights stopped and in September there was only ‘Air-Morocco’ going to Freetown and Monrovia. It took me more than forty-three hours to go from Kenema to Freetown, so it’s a very long trip and sometimes you have to wait many days to go back. And now, as you know we have another barrier for those of us returning to the United States. I’m really hoping that the travel ban ends in the coming weeks because we really need more people now in the field,” she concluded.

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Global Health Strategies generously supported Theo Smart’s attendance at the 63rd Annual American Society of Tropical Medicine and Hygiene Conference in New Orleans.

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