Odds were stacked against Dallas Ebola patient

Even in the best of circumstances, the odds were against Thomas Eric Duncan, the 42-year-old Liberian citizen who died of Ebola at a Texas hospital Wednesday, doctors say.

"Ebola, even with treatment, is a terrible disease," said Thomas Frieden, director of the Centers for Disease Control and Prevention, in discussing Duncan's case.

Ebola has an incubation period of 21 days, with many of those who are infected showing symptoms about halfway through this period. That means that now is the peak time for diagnosing any additional patients who may have been infected by Duncan, who was admitted to the hospital Sept. 28.

Frieden said all health care workers should "think Ebola" when they see any patient with a fever who has been to West Africa within the past 21 days.

About 70% of Ebola patients in West Africa are dying of the virus, including 60% of those who get to the hospital, said Robert Murphy, a professor of medicine and biomedical engineering at Northwestern University in Chicago.

"He may have been too far gone for even our best supportive care," says Amesh Adalja, infectious disease specialist at the University of Pittsburgh Medical Center.

Ebola mounts a rapid, full-scale attack on virtually every system of the body.

Unlike an infection such as tuberculosis, which primarily attacks the lungs, Ebola assaults many organs of the body at once, Adalja said. Massive diarrhea and vomiting can cause dehydration and disrupt the normal balance of electrolytes, such as sodium potassium, causing heart rhythm problems, he said. In Africa, patients often die of dehydration.

The virus can cause bleeding by making tiny holes in blood vessels and by damaging platelets, a type of blood cell that normally helps the blood to clot. Ebola can cause kidney failure, liver failure and respiratory failure. It can also prompt the immune system to overreact, further stressing the body. Many patients with Ebola die of septic shock, also known as a bloodstream infection, Adalja said.

At least 8,033 people in West Africa have been infected with Ebola and 3,879 have died, according to the World Health Organization. The WHO notes that these figures underestimate the true scope of the outbreak, as overwhelmed responders fall behind in their ability to report cases. Health care workers also continue to fall ill: 232 of the 401 health workers stricken by Ebola in West Africa have died.

Murphy notes that Duncan's care was hardly ideal.

Duncan developed symptoms of Ebola Sept. 24, four days after arriving in the USA. He sought care at Texas Health Presbyterian Hospital, but doctors sent him home with antibiotics. He was not admitted to the hospital until Sept. 28.

Such delays can be deadly, Murphy said.

"The quicker we can get patients into care, the better their odds for survival," Adalja said.

Doctors may have had a more difficult time with Duncan than others, Adalja said. "We don't know his past medical history," such as whether he had any serious chronic diseases in addition to Ebola, Adalja said.

Dallas officials mishandled the situation at multiple points, Murphy said, including quarantining Duncan's family for days in a contaminated apartment.

"I hope other hospitals learn from this," Murphy said. "This guy probably would have done better if he had stayed in Liberia," where doctors are more familiar with Ebola. "The outcome couldn't have been any worse."

In the future, contacts of Ebola patients may be less likely to come forward if they think they will be treated the same way, with a police officer posted outside their door, said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

Public health officials should learn from the case, Osterholm said, and be prepared to temporarily relocate families such as these.

There are no proven treatments or vaccines for Ebola, but several Ebola patients treated in the USA and elsewhere have received experimental, unproven drugs for compassionate use. Two experimental vaccines are in the first phase of human studies, but won't be available for months, even if they work as hoped.

Murphy said he also wonders why Duncan didn't quickly get experimental treatments or blood transfusions given to other American Ebola patients. Officials announced Duncan was receiving brincidofovir, an experimental antiviral drug made by North Carolina-based Chimerix, more than one week after Duncan was admitted to the hospital.

Three Americans treated for Ebola — Kent Brantly, Nancy Writebol and Richard Sacra — were evacuated from Liberia to top-flight American hospitals with specialized biocontainment units developed to treat Ebola and other dangerous diseases. Brantly and Writebol were flown to Emory University Hospital in Atlanta. Sacra went to the Nebraska Medical Center in Omaha.

All three survived.

"We've gotten lucky with the airlifted cases that they were able to get good supportive care," Adalja said.

Officials at the National Institutes of Health have said it's impossible to know exactly what allowed the three to survive. All were treated in intensive care units, where doctors could replenish their fluids, monitor their heart rates and keep other vital functions stable. Each received an experimental medication.

Brantly and Writebol, who both contracted Ebola while working for missionary groups in Liberia, received a drug called ZMapp, which contains man-made antibodies against Ebola. That drug's manufacturer, Mapp Bio of San Diego, says there are no more supplies of ZMapp, which was made in small quantities during its early developmental phase.

Sacra, a physician, who also contracted Ebola with a missionary group in Liberia, received a different drug, TKM-Ebola. That drug is also experimental and made by the Canadian company Tekmira Pharmaceuticals.

Brantly and Sacra also received blood transfusions from Ebola survivors.

Brantly received the blood donation from a teenager before leaving Liberia. After he recovered, Brantly then donated blood to Sacra.

Officials at the Nebraska Medical Center also announced Wednesday that Brantly has donated blood to Ashoka Mukpo, a freelance cameraman who became sick while in Liberia, who is now being treated in Omaha.

Although there's no proven therapy or vaccine for Ebola, doctors hope that blood transfusions from survivors will provide current patients with antibodies that will help their immune systems fight off the virus.

Mukpo is also receiving brincidofovir, a broad-spectrum antiviral that has shown promise against Ebola in test tubes and is now being tested in animals, according to a statement from Texas Health Presbyterian Hospital.

It has not been tested against Ebola in humans, which has led researchers such as Thomas Geisbert, a professor at the University of Texas Medical Branch in Galveston, to question using it as the drug of choice.

But Anthony Fauci, director of the National Institutes of Allergy and Infectious Diseases, says that brincidofovir has a good safety record. It's been used in 1,000 people given the drug in clinical trials for diseases other than Ebola. There is also a good supply, with 3,000 patient doses available.

While TKM-Ebola has been very effective in monkeys, doctors still don't know whether it's safe in humans, Fauci said. With so many unknowns, doctors may opt for the more conservative approach, trying the drug with fewer known side effects.

Doctors abroad are trying other drugs.

A French female nurse infected with Ebola in Liberia, for example, has received a Japanese anti-influenza drug called Favipiravir. That drug is made by Toyama Chemical Co., a group firm of Fujifilm Corp.

Murphy says hospitals and public health officials haven't fared well in the first test of their ability to deal with Ebola.

He notes that a Spanish nurse was infected with Ebola while caring for a priest in Madrid. The nurse has been described as a sanitary technician, charged with changing the priest's diaper and removing his things after he died.

Murphy said it's risky to allow anyone to enter the room of an Ebola patient unless that person has had specialized training and advanced education.

Hospitals who aren't equipped to treat Ebola patients should quickly transfer them to more sophisticated medical centers, Murphy said.

Duncan's story underscores why the world needs to quickly control the Ebola outbreak in West Africa, said infectious disease specialist Jesse Goodman, professor of medicine at Georgetown University Medical Center and the former chief scientist at the Food and Drug Administration. The longer that outbreak rages out of control, the greater the odds that Ebola will spread to other countries.