|
Ebola Virus Infection, What Nigerians Should Know By Professor Stephen .K. Odaibo
Animals in the wild act as host for Ebola related viruses. Though virulent they reach a state of anergy in which they live in symbiotic relationship. When the immunity of an animal is compromised by Trauma infection or cancer, the organism turns virulent and kills the host. Humans are infected inadvertently and once this happens, the virus acts like a pyrogen or sheds pyrogens as in a host versus graft disease as the victim tries to eject the organism from his body. The pyrogens induce fever in the victim heralding the first and early signs of Ebola or any other viral infection. Other symptoms include headache , nausea, weakness and progressive prostration. This may be followed by vomiting and diarrhea and ultimately internal and external bleeding. Any fever rising above 370C should be viewed with a high index of suspicion in the absence of a tender abdomen. However, these symptoms are similar to those of Q fever, Cholera, blackwater fever of Malaria and other fevers. None the less, all that glitters is not Ebola. Ebola virus replicates very rapidly in a hostile environment of human. It induces in the new host a systemic inflammatory response syndrome (SIRS). As the virus replicates in man, it moves to cause multiple organ failure. Two organ failure is worrisome, while three organ failure is a nightmare Ebola, virus causes three, four and even five organ failures in man, demanding a comprehensive life support. The prognosis of the infection is good if arrested at the pyretic stage. In its worst scenario, the virus affect the heamopoietic system, lungs, cardiovascular, kidneys and the gastro-intestinal system causing them to fail. There is consumptive coagulopathy (DIC) causing clotting factors to be depleted leading to bleeding from sources, where capillaries have been damaged.
The victim may develop vomiting and diarrhea. The vomiting is the result of gastric irritation and inflammation, while the diarrhea is due to the movement of large volume of fluid into the gut as a result of damage and sloughing of intestinal villi. This leads to loss of fluids, chloride, potassium and sodium, thereby inducing, hyponatreamic, hypokalaemic, alkalosis with paradoxical aciduria. This cannot be treated by drinking brine or salt solution nor by oral rehydration therapy. The virus causes a reduction in surfactant of the lungs with damage to the alveolar capillary membrane, leading to pulmonary congestion causing productive rusty or bloody sputum. Damage to the kidneys results from hypovolaemia from vomiting and diarrhea or papillary necrosis leading to bloody urine. When the blood pressure falls below 60mm Hg systolic, the kidneys shuts down and goes into an acute failure which requires urgent fluid or blood replacement. If the fluid depletion persists, myonecrosis sets in. There is cerebral hypoperfusion resulting in loss of blood- brain barrier which rapidly results in death from compounding sick cell syndrome.
Ebola virus is a filamentous rna virus causing zoonotic disease in man. Zoonotic disease is shared by man and animal while psittacosis is that shared with birds. Leptospirosis , bubonic plague and Lassa fever are diseases carried by rats and mice and homes must always be reed of them.
The first symptom of any viral infection be it, influenza, hepatitis, cholera or Ebola is malaise and fever due to the virus acting as pyrogen in suspect, , hence serological test( ELISA) must be carried out to confirm, the presence of Ebola infection in the suspect. The fever must be brought under control, with the use of antipyretic and anti-inflammatory agent, such as aspirin or indocid in the dose of aspirin 75mgs to 150mgs daily and indocid in the dose of 12.5mgs to 25mgs daily for as long as the fever can be controlled, while looking out for other signs and symptoms, of the disease .Once Ebola infection has set in the use of vaccine is not helpful. Vaccine use stimulates immunity in those not yet affected by the virus. Vaccine is deployed mostly in the unaffected population for prophylaxis. Once the infection has set in the immune response of the patient can only be boosted with the use of hyperimmune human globulin (IGg) in the dose of 250mgs daily, but it is expensive. Alternatively, immunity of the sick patient can be boosted with serum of a patient recovering from Ebola infection.
In a hospital, isolation ward is usually located some distance from the rest of the wards. Today only those with open tuberculosis are found in these wards. Patients with Ebola infection need isolation with strict barrier nursing with no visitors allowed. Single use disposable items must be deployed such as disposable paper gowns, masks, caps, plastic gloves, aprons and shoe covers. All discarded items used for the patient must be incinerated at the end of the day. The same set of nurses are allocated to the same patients to recovery. It is expensive to treat a patient with Ebola infection to recovery. It could cost between $40 thousand to $60 thousand dollars (USD).
The diarrhea and vomiting can be managed with rapid fluid replacement, replacing sodium, potassium and bicarbonate with darrows solution, bicarbonate and potassium chloride along with strict monitoring of intake and output chart. The treatment of Ebola virus infected patient requires total intensive care management with daily monitoring of Hb, PCV,CT, BT, ,PT,, PTT, APTT, LFT,serum albumin , arterial blood gasses, electrolytes and urea, urinary FDP. intake and output chart, daily weighing of patient using the bed scale. and four hourly monitoring of vital signs as required are carried out. Serum albumin below 3grms% requires transfusion with 100mls to300mls of 5% human albumin to enhance prognosis. A throat swab is mandatory. Patients blood must be typed ready for emergency transfusion with fresh blood and not stored blood.
The vomiting and diarrhea can be palliated by administering metoclopramide and motilium..Daily use of heparin in the dose of 250 units subcutaneously will prevent DIC. However, if bleeding starts, Heparin dose is doubled or tripled and fresh blood transfused to replace the consumed clotting factors ..Fibrin degradative product (FDP) will increase in the urine at this time.
Hyperalimentation may be employed if vomiting stops, otherwise total parenteral nutrition (TPN) must be instituted. If cough is productive, isolates from the sputum may require the use of antibiotics as opportunistic organisms may rear their heads.
Pain is a factor in very sick patients and contributes to the low blood pressure. Administration of morphine, 1mg every 2hours IV, relieves pain, decongests the lungs and opens up the airways. Oxygen may be administered intermittently to obviate risk of myonecrosis and cerebral hypoxia. Radiograph of the chest is advisable to recognize in a patient, pulmonary congestion or consolidation. For very sick patients, hyperimmune human globulin (IGg) is essential. Known antiviral agents, like acyclovir may be tried in double or triple doses to slow down rapid replication of the virus. ZMapp is a current trial drug and its efficacy is being awaited. Administration of Interferon may be usefull.
Ebola virus infection is a contagious disease that is acquired by droplet spread to the lungs, by faeco- oral ingestion or by inadvertent intravascular inoculation. It is not a communicable diseases like HIV, gonorrohea or syphilis. Ebola infection is best treated by barrier nursing and contact tracing for which Epidemiologist, are best known and their services employed.
Patients are nursed in strict isolation with no visitors allowed. Patient,s bed sheets, gowns and clothing must be washed and autoclaved daily. Matresses and pillows must be drapped with impermeable MacIntosh rubber sheets. Nurses must wear single use disposable plastic aprons , gloves, and shoe covers. All disposed items must be incinerated daily. The use of latex rubber surgical gloves are not allowed in an epidemic , however sterile ones may be used once for procedures like urethral catheterization. A sluice room for the disposal of patients waste is required with bed pan and urinary washer and autoclave. The floor is mopped daily, swipped with antiseptics. Patients is given daily bed bath, oral toilet, four hourly vital signs.When a patient dies, the room is fumigated with 10% formalin and locked out for 6 to 12 hours.The bed mattress is sterilized in a bed autoclave and the bed disinfected by swipping with 10% formalin.. A central clearing point where the results of daily investigations of patients for review, interpretation and treatment are sent, is mandatory. It is important to note any co -morbid condition of the patient that requires investigation and treatment. The staffs offering treatment must be well trained and highly remunerated and must be insured.
Ebola infection rapidly causes death from multiple organ failure which requires intensive care management with daily monitoring of vital signs, electrolyte and urea, arterial blood gases, urinary FDP, PCV, CT, BT, PT, PTT, and APTT. Patients blood is typed and ready for eventual transfusion with one pint of fresh blood. Intake and output chart with adequate volume replacement must be strictly adhered to and if possible the blood volume is determined in a volumetron. Intermetent oxygen must be desirable to alleviate respiratory distress and improve muscle and brain perfusion.
On the long run, improving personal hygiene and that of the nation is mandatory. Refuse heaps in townships must be cleared, along with adequate sewage disposal will limit the spread of the disease. Hand washing with soap and water which is basic must be habitual especially among food handlers. Vaccinating the unaffected population with ebola virus vaccine should be the ultimate goal. Ebola virus has the propensity to become a pandemic infection like the bubonic plague of the 14th century that killed nearly 200 million people in Europe. Nigeria must rapidly transform from third to first world after the order of Lee KuanYew of Singapore. Nigeria must increase her health budget allocation to 15% of the National Annual budget according to WHO recommendation otherwise ebola infection will remain a sporadic infection in the subsahara Africa for a very long time to come.
Long Live Nigeria
This Article is Written For Every Nigerian Including Doctors, Nurses and Clinical Students |