Kate Johnson

September 11, 2014

WASHINGTON, DC — High-tech facilities are not essential for the safe treatment of a patient with Ebola infection, says one of the doctors at Atlanta's Emory University Hospital, where a third humanitarian aid worker begins treatment after being infected with the Ebola virus in Liberia.

Although Emory has a Serious Communicable Diseases Unit, complete with negative-pressure and dedicated laboratory facilities, Emory's Aneesh Mehta, MD, assured delegates here at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) that they will not need this level of technology should they need to treat patients with Ebola virus infection.

"We have the unit so we used it, and we used the negative pressure for the first day, but then turned it off," Dr. Mehta said, describing the successful treatment of the first 2 aid workers infected in Liberia who were airlifted in August to the Atlanta facility.

Staff in the Emory treatment unit initially used more extensive personal protective equipment (PPE) than is currently recommended by the Centers for Disease Control and Prevention (CDC) because the patients had particularly contagious symptoms on arrival, but that was temporary, he said.

The patients, Kent Brantly, MD, 33, and Nancy Writebol, 59, were treated with the experimental drug Zmapp (Mapp Biopharmaceutical Inc), supplies of which have now been depleted. But Dr. Mehta says simple supportive care, which is readily available in developed countries, also played a critical role in their recovery.

 
All hell broke loose, I think that's the best way to put it. Dr. Joseph Blondeau
 

"Both of our patients had very marked electrolyte abnormalities and detectable nutritional deficiencies, and we feel that our ability to have laboratory testing, particularly of the blood chemistries, was critical for administering patient-specific therapy," he told delegates here at the meeting.

"We found hypokalemia, hypocalcemia, and hyponatremia to varying degrees in both patients, and they required intravenous and oral replacement of electrolytes," said Dr. Mehta. "They also had significant potassium deficiencies for several days that required replacement."

Their care required 24/7 nursing support that allowed for rapid adjustments, he added.

But there were some unexpected roadblocks in delivering treatment. Some laboratory technicians were reluctant to handle patient samples that needed to be sent to the CDC, and commercial couriers, even when trained in category A handling, refused to pick up samples from Emory, he said.

Waste management also became an issue, with the hospital's waste management contractor refusing to pick up from the hospital for the first 6 days.

To date, 10 patients have been admitted to US hospitals under suspicion of Ebola infection, but all have tested negative, the CDC's Barbara Knust, DVM, MPH, said at the meeting. And there have been similar false alarms around the world.

One of those false alarms was at St. Paul's Hospital in Saskatoon, Saskatchewan, Canada, when a patient, recently back from Liberia, arrived at the hospital in critical condition. Joseph Blondeau, PhD, acting head of Pathology and Lab Medicine at the Saskatoon Health Region, said he felt suddenly unprepared.

"All hell broke loose, I think that's the best way to put it," said Dr. Blondeau, who presented his experience during a presentation at the meeting. "I can say with certainty that there were not many people in the province of Saskatchewan who fully understood what was about to happen should this patient have tested positive for Ebola."

 
The reality is we're only the next landing flight away from the first case. Dr. Joseph Blondeau
 

He told Medscape Medical News, "We were most fortunate to have had a highly suspected case that turned out not to be so that we could learn from it under extraordinary and extreme circumstances. I would say that we are much better prepared for the next suspected case should we have one."

Dr. Blondeau was also faced with an uncooperative courier service and the possibility that he himself would be forced to drive the patient's specimen 9 hours for confirmation. As the reality started sinking in, more issues arose.

"There were concerns about the patient's and his family's privacy from the media, and there was the potential for public panic as misinformation was spread," he explained.

"There was also tremendous fear and panic among the staff, with people concerned about their own exposure and the safety of their families. The World Health Organization actually complicated this case by reporting that the patient was positive for malaria," said Dr. Blondeau. "even though the data supporting a diagnosis of malaria was weak at best."

Plans were made for a mobile laboratory that would be dispatched by the federal government to provide critical-care testing, including blood gases, complete blood counts, and polymerase chain reaction–based technology for monitoring any exposed patients, he said.

And then, 24-hours later, lab results showed a negative result for Ebola and the patient's condition was confirmed: Staphylococcus aureus, a methicillin-susceptible strain.

"It was exciting and terrifying," said Dr. Blondeau. "It's an experience I never expected I would live through in my career."

Dr. Blondeau and his team were alerted again last month to another vomiting patient presumed to be on an inbound flight from Senegal. They were much better prepared this time around, "but we're not where we need to be," he stressed.

Dr. Blondeau called for a collaborative laboratory system shared by Canada and the United States. "We cannot do this on our own, and the cost of being prepared will be small compared to the cost of dealing with an outbreak. The reality is we're only the next landing flight away from the first case."

Dr. Mehta and Dr. Blondeau have disclosed no relevant financial relationships.

54th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). Abstract P1281. Presented September 8, 2014.

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