Dallas Hospital Responds To Criticisms of Ebola Patient's Treatment

Posted: 10/10/2014 3:01 pm EDT Updated: 10/10/2014 4:59 pm EDT

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After the death Wednesday of Thomas Eric Duncan, the first person to die of Ebola in the U.S., the hospital that cared for him has gone on the defensive.
In a statement released after Duncan's death, Texas Health Presbyterian Hospital Dallas spokesman Wendell Watson wrote that the hospital would like to "correct some misconceptions" about what occurred during Duncan's initial visit to its emergency room on Sept. 25. The statement specifically addressed allegations that the hospital didn't pay enough attention to Duncan because he was from another country and may not have had insurance.
"Our team provided Mr. Duncan with the same high level of attention and care that would be given any patient, regardless of nationality or ability to pay for care," a statement said Thursday. "We have a long history of treating a multicultural community in this area."

The hospital also announced Friday it had changed its patient intake process to improve its screening for Ebola, and that it would make its staff available to talk to other hospitals that may have such patients.
At a press conference held by Duncan's family on the day he died, Josephus Weeks, his nephew, raised questions about whether the hospital care for the Liberian man was on par with what American missionary workers Kent Brantly and Nancy Writebol received at Emory University. Both of them survived Ebola after being transported back to the U.S. for treatment, whereas Duncan had to be diagnosed by the Dallas hospital and died after battling symptoms for two weeks.
Weeks didn't elaborate on which aspects of Duncan's treatment the family believes were inadequate, ABC News reported. Texas Health Presbyterian Hospital has yet to explain why Duncan was initially discharged after his first visit on Sept. 25, which left him on his own to deal with worsening symptoms and widened the window of potential exposure to other members of the Dallas community.
Weeks' frustration is understandable, said Dr. Charles Chiu, an infectious diseases expert and the director of the Abbott Viral Diagnostics and Discovery Center at University of California, San Francisco. Chiu was not directly involved in the care of any of the Ebola patients, but he did comment on the details of Duncan's treatment as they have been reported in the media. He cautiously agreed that the delay in Duncan's care could have affected his outcome.
"Any sort of delay of supportive care in the hospital could potentially make a difference," Chiu told The Huffington Post. "Patients will do better if they get care earlier." On the other hand, Chiu said, "it's hard to tell whether it made a huge difference."
Health officials have offered explanations for several other significant differences between the treatment Duncan received and that received by other Ebola patients in the U.S., such as a course of the experimental drug ZMapp (given to Brantly and Writebol) or a blood transfusion from a recovered Ebola patient.
In the case of both treatments, officials cited factors beyond his doctors' control for determining why they were unavailable to Duncan. The hospital has said that Duncan did not receive a blood transfusion from a survivor because the available blood did not match Duncan's blood type.
"With someone already in critical condition, you wouldn't want to give them mismatched blood," explained Chiu. "It could lead to life-threatening transfusion reaction and endanger their life more."
As for why Duncan didn't receive ZMapp, the Centers for Disease Control and Prevention said that there are no doses of the treatment anywhere in the world, and the hospital said doses haven't been available since Aug. 12. Moreover, ZMapp has not been proven to work, and it's unclear whether it played a positive role in Brantly's and Writebol's recoveries.
One day after Duncan died, however, news broke of a Norwegian Ebola patient who is set to receive ZMapp, which has only increased the confusion as to exactly how much of the drug is available and to whom. British paper The Independent reports that the Norwegian patient contracted the virus in Sierra Leone and arrived in Oslo, Norway, on Thursday to begin treatment. A spokesman for Norwegian Medicines Agency told Dagens Medisin on Wednesday that ZMapp was being shipped from Canada.
Instead of ZMapp, Duncan received the experimental anti-viral drug brincidofovir, which prior to his treatment had only been tested against Ebola in a test tube and not in animals (as ZMapp had been).
The conflicting details about ZMapp are a curiosity, to say the least, and details are still emerging. But there are too many variables between Duncan and Brantly as patients to compare the respective courses of their disease, said Dr. A. Scott Lea, the Infectious Diseases Clinic director at University of Texas Medical Branch.
Like Chiu, Lea was also not involved in the direct care of any of the Ebola patients. He serves as clinician to Ebola researchers at UTMB's Galveston Laboratory, one of only a handful of Biosafety Level 4 laboratories in the U.S. As he put it, he's "the guy who worries what would happen if [Ebola researchers] expose themselves" to the virus.
Anything from a patient's upbringing to their state of health before infection can influence how a body responds to the disease, Lea explained to HuffPost. Brantly, who was born in Indiana, may have had biological advantages that come from being raised in a developed nation -- as opposed to Duncan, who grew up near a leper colony, spent years in different refugee camps as an adult and lived in an impoverished neighborhood in Monrovia, Liberia, before he flew to the U.S.
A patient's genetics could also play a role in how Ebola progresses, although research hasn't yet borne that out, Lea explained. For instance, compared with the general population, people from Equatorial Africa are more resistant to malaria, and people from Northern Europe are more resistant to tuberculosis, he said.
Even in the best of circumstances, Ebola has a terrifyingly high mortality rate -- up to 90 percent in some recorded outbreaks, according to the World Health Organization. The mortality rate for the current outbreak is estimated to be 48 percent, according to the latest figures from the CDC. Even people who have been treated with ZMapp in Liberia and Spain have died, demonstrating that even the most promising experimental drug has limitations.
Ebola still has no proven treatment. In fact, given the relatively small number of people who have been treated with experimental therapies like blood transfusions, ZMapp or brincidofovir, it's scientifically impossible to say if any of these treatments are better or worse than the others, since evidence is only anecdotal, said Chiu.
Both Chiu and Lee expressed sympathy for Duncan and his family. Chiu said Duncan's family's experience is "devastating" and it must have been difficult for them to be "unable to touch, hug or communicate with their loved one who is dying," for fear of infection.
Lea also said that his heart goes out to his family. "I'm just crushed that this man did not survive," he said. "I wanted American medicine to make him well."