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Saving lives without new drugs

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Science  21 Nov 2014:
Vol. 346, Issue 6212, pp. 911
DOI: 10.1126/science.346.6212.911

A room reserved for Ebola patients at the University Medical Center Groningen in the Netherlands.

PHOTO: REMKO DE WAAL/AFP/GETTY IMAGES

When people from the United States and Europe working in West Africa have developed Ebola, time and again the first thing they wanted to take was not an experimental drug. It was an airplane that would cart them home.

Care for Ebola patients in Liberia, Sierra Leone, and Guinea varies greatly at different clinics, but it never matches what wealthy countries provide. This partly explains why the Ebola epidemic has had a case fatality rate (CFR) of 70%, according to World Health Organization calculations. Too few Ebola patients have been treated outside Africa to make scientifically valid comparisons—and they may have been healthier before falling ill—but only five out of 20 to date have died, a CFR of 25%.

Now, there's a push to improve care in West Africa. Just a handful of basic interventions to fight the killer effects of Ebola, including dehydration and secondary infections, could dramatically lower the CFR there, says Michael Callahan, an infectious disease specialist at Massachusetts General Hospital in Boston. A case in point appeared online on 5 November in The New England Journal of Medicine (NEJM): Relatively intensive care in Conakry led to a CFR of 43%.

With so much room for improvement in supportive care, the current international focus on drugs is “misguided,” says Callahan, who has recently worked in Monrovia and provided care in four previous Ebola outbreaks. “While we wait for months for forthcoming experimental therapies, many lives can be saved, certainly hundreds and possibly thousands, using inexpensive and simple therapies,” he says.

Callahan is helping an international team develop guidelines dubbed Maximum Use of Supportive Therapy (MUST), aimed at keeping more patients alive. It includes intravenous (IV) drips to replace massive fluid loss from diarrhea and vomiting, a risk factor for shock; balancing of electrolytes such as calcium or potassium, which prevents kidney and heart failure; nasogastric tubes for feeding; and testing and treatment of secondary infections such as malaria. Introducing MUST will also make it easier to study new treatments, Callahan says: Randomized controlled trials—ethically fraught because only some patients get the novel treatment (see main story, p. 908)—will be much more acceptable if everyone receives high-level care. In addition, MUST might reveal side effects of new drugs that would otherwise be masked by Ebola symptoms, and it could reduce the rate of complications that might be incorrectly blamed on a drug.

It's an important proposal, but Ebola clinics will need more resources to offer MUST, says John Fankhauser, an American clinician who has worked at the ELWA hospital in Monrovia since before the outbreak surfaced. Overwhelmed by patients and logistical challenges, many clinics have provided minimal supportive care. “We are able to give IV hydration, but the testing is limited to malaria and Ebola,” Fankhauser says. Tests for electrolytes and other types of monitoring MUST calls for are simply beyond reach, he says. Callahan says the additional measures cost less than $600 extra per patient at a Monrovia clinic in August.

Armand Sprecher of Doctors Without Borders (MSF) in Brussels, who co-authored the NEJM report, concedes that the standard of care dropped when Ebola exploded this summer. But Sprecher, who is “very supportive of supportive care,” says MSF clinics have corrected several problems and now doubts that MUST can save many more lives. “I'm less optimistic than some people about how much of an effect we're going to have,” he says. “I hope I'm wrong.”

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