Ebola Doctors Are Divided on IV Therapy in Africa

A nurse gave an Ebola patient intravenous fluids at the Red Cross treatment center in Kenema, Sierra Leone, in November. Credit Francisco Leong/Agence France-Presse — Getty Images

Medical experts seeking to stem the Ebola epidemic are sharply divided over whether most patients in West Africa should, or can, be given intravenous hydration, a therapy that is standard in developed countries. Some argue that more aggressive treatment with IV fluids is medically possible and a moral obligation. But others counsel caution, saying that pushing too hard would put overworked doctors and nurses in danger and that the treatment, if given carelessly, could even kill patients.

The debate comes at a crucial time in the outbreak. New infections are flattening out in most places, better-equipped field hospitals are opening, and more trained professionals are arriving, opening up the possibility of saving many lives in Africa, rather than a few patients flown to intensive care units thousands of miles away.

The World Health Organization sees intravenous rehydration, along with constant measuring of blood chemistry, as the main reason that almost all Ebola patients treated in American and European hospitals have survived, while about 70 percent of those treated in West Africa have died.

 

A Doctors Without Borders treatment center in Kailahun, Sierra Leone. The group’s physicians have reservations about IV rehydration in the field. Credit Daniel Berehulak for The New York Times

Every hospital there should have “early, liberal use of intravenous fluid and electrolyte replacement,” said Dr. Robert A. Fowler, a Canadian critical care specialist who leads a W.H.O. Ebola team. Anything less, he said, is “not medically justified and will result in continued high case-fatality rates.”

Experts who favor aggressive rehydration point to several hospitals that claim unusually low death rates as evidence that it is effective. Skeptics say other factors may be at work.

Even two of the most admired medical charities have squared off over the issue. Partners in Health, which has worked in Haiti and Rwanda but is just beginning to treat Ebola patients in West Africa, supports the aggressive treatment. Its officials say the more measured approach taken by Doctors Without Borders is overly cautious.

“M.S.F. is not doing enough,” said Dr. Paul Farmer, one of the founders of Partners in Health, using the French initials for Doctors Without Borders, whose staff members have worked on the front lines of Ebola outbreaks for years. “What if the fatality rate isn’t the virulence of disease but the mediocrity of the medical delivery?”

Doctors Without Borders representatives strongly disagreed, saying that Dr. Farmer’s assumptions about Ebola were incorrect, that intensive rehydration would probably not save as many patients as he believes, and that the W.H.O.’s position has not been proved.

The group’s overwhelmed doctors do what they can, officials said, but it is hard to insert needles while wearing three pairs of gloves and foggy goggles. IVs must be monitored, drawing virus-laden blood for tests is dangerous, and patients yank needles out — sometimes in delirium, sometimes just to go to the toilet when no nurse is around.

Ebola patients lose up to five quarts of fluid a day through diarrhea and vomiting. In that fluid are electrolytes like potassium, magnesium, sodium and calcium, and proteins like albumin. Electrolyte loss can stop the heart; protein loss can cause fatal internal swelling.

Rehydrating patients and replacing those elements “is the antidote to the idea that everybody’s going to die,” Dr. Farmer said.

Every Ebola hospital, he argued, should have a team that specializes in inserting IVs — or, better yet, peripherally inserted central catheters, or PICC lines. These are thin plastic tubes, inserted in the arm or chest and threaded through a vein, that can be left in place for days and the needle discarded.

Along with doctors at the London School of Hygiene and Tropical Medicine, who published an article on rehydration in The Lancet on Dec. 4, Dr. Farmer has also called for the use of thick needles driven into bone marrow with surgical “guns.” This procedure, known as intraosseous infusion, is slow, but it reinflates veins too shrunken to admit an intravenous line, and the needles are much harder for agitated patients to pull out.

However, not all doctors know how to use PICC lines or bone needles, or how to inject fluids into empty abdominal spaces, another technique endorsed in the Lancet article. (The article was accompanied by a video in which Dr. Ian Roberts, the chief author, had some of those techniques demonstrated on himself. He used minimal anesthesia, he said, to imitate field conditions in West Africa.)

Doctors Without Borders normally puts IV lines in as many Ebola patients as it can manage, said Dr. Armand Sprecher, an Ebola expert with the organization. That practice was temporarily stopped in September, when the disease was spreading so fast that doctors had only one minute per patient during the one hour they could work in their sweltering protective suits.

The fatality rate across the group’s six Ebola treatment centers in West Africa was about 60 percent then, and is now 40 to 50 percent, Dr. Sprecher said. He disputed Dr. Farmer’s contention that rehydration could bring it down to 10 percent.

“It would probably push it down some, but I’d be surprised if it were dramatic,” Dr. Sprecher said.

Dr. Farmer cited the treatment given at a unit in Hastings, Sierra Leone, as an example of the kind of care he endorses.

In a Dec. 24 letter to The New England Journal of Medicine, the Sierra Leonean doctors running that center with Western advisers said they had had a 48 percent fatality rate when they opened in September and had since reduced it to 24 percent.

Each of the 581 patients the center has treated immediately received IV fluids with electrolytes, they wrote. Even without lab tests, each patient also received an antibiotic, an anti-parasitic drug, an antimalarial drug, an anti-vomiting drug, pain pills, vitamins, zinc and a nutrition supplement.

“That’s effective case management,” Dr. Farmer said. “We’re cheering them on.”

The fatality rate at the unit Partners in Health runs in Port Loko, Sierra Leone, is 35 to 40 percent, its director, Dr. Corrado Cancedda, estimated.