Nutritional Care for Patients with Ebola Virus Disease in Ebola Treatment Units – Past and Current Experiences from Practitioners

Half of the organizations providing food to EVD patients, prepared in onsite kitchens run by the organizations responsible for ETUs; the other half contracted local catering companies. One organization initially ran a kitchen and then transitioned to catering, while a second organization reversed this pattern. Both options had advantages and disadvantages, see Table 2.

Most KIs had experienced challenges in the provision of foods in West Africa and DRC:

KIs noted that foods were transported to the patients in the ETU ward with confirmed EVD patients (Red Zone) through slides, hatches, or staff entrances. Food was primarily provided on hard plastic plates or polystyrene compartment trays. Additionally, plastic cups, sippy cups, bowls, small plastic bags, or mineral bottles were used. Spoons were typically the only utensil provided. However, KIs noted the usefulness of straws, which were less frequently used. Hard plastic materials were disinfected after use or burned, and all other materials and leftover food were disposed of as hazardous materials. Foods were individually packaged; some ETUs labeled commodities with patient numbers, patient names, or just the composition of the meal. Food was placed on tables or chairs at the bedside or in communal areas for those who could eat at a table. Various challenges were reported:

KIs agreed that the provision of meals and snacks evolved over time with much trial and error. There was little standardization across organizations and menus and approaches varied. Some organizations were limited on the types of foods available, which led to the use of specialized products (RUTF, High Energy Biscuits, therapeutic milks, ready-to-use supplementary foods (RUSF), and/or CSB). The ease of use of the products by staff was also a factor in their selection. All organizations attempted to provide a balanced diet through the aid of specialized products. These specialized products were generally the recommended commodities in the 2014 iGL. KIs mentioned that the rationale behind the use of RUTF and therapeutic milks was the nutrient density of the products, easier consumption for patients with difficulty swallowing, and consumption without utensils.

Overall, three meals and 2 to 3 snacks were provided in most ETUs. Meals were provided in different consistencies: standard, soft/semi-solid, and liquid. Typical meals were as follows:

Breakfast: porridges (often made from CSB), RUTF, therapeutic milks, fruits/juices, bread, local doughnuts, eggs

Lunch: often of a standard ‘family’ meal made from staple foods and meat/fish/chicken, sauce, beans, oil, local soup

Dinner: similar to lunch or breakfast

Snacks were provided upon request or followed fixed schedules and included bread, fruits, biscuits, RUTF, RUSF, crisps, sweets, etc. Liquid diets for very sick and young children were mainly therapeutic milks, soups, or RUTF diluted with water. Semi-solid/soft foods mainly consisted of mashed regular meals (listed above), RUTF, RUSF, porridges, or soups.

The majority of adult patients in ETUs covered by the KIs did not prefer specialized products. Reasons given for the dislike of the products included the monotony of diet and lack of palatability. Similar experiences were captured in both West Africa and DRC. This resulted in patients not consuming the supplied foods, but also significant wastage in the Red Zone, which created a health hazard. KIs mentioned numerous challenges:

Many KIs were torn between what they thought was best in the given context and the reality of the refusal of foods by adults. Some organizations shifted to a more patient-centered approach, taking into account the patients’ preferences for local foods. However, other organizations continued to provide only standard menus with limited flexibility to meet patient preferences. As one KI stated: ‘Not eating by patients was a big problem; that was less a problem later when we gave them what they wanted. We had to individualize care because some were not eating, and many were dying from hypoglycemia.’

Liquid diets were problematic for some patients. This was likely a combination of the commodity (therapeutic milks) and the patients’ weakness, lack of appetite, and the monotonous diet. Providing sufficient nutrition to critically ill patients was a significant issue. Nausea, vomiting, anorexia, weakness, and hiccups led to difficulty in consuming foods, which resulted in weight loss in some cases. KIs stated that once patients began to recover, and their appetite returned, patients could consume large amounts of food.

The West Africa outbreak identified two local foods which were preferred and consumed by adults, including extremely ill patients: pepper soup and coconut water. In West Africa, various KIs mentioned that pepper soup was the preference of very sick patients, with fever, in a catabolic state, anorectic, and/or unwilling to eat. One KI stated: ‘As they were sick, nothing worked so we changed the whole menu to pepper soup because the patients did not want anything else’.

One KI who oversaw a relatively large ETUs stated: ‘It was in hospital X where it began, by accident. The hospital had a certain moment no access to potable water, they were buying water in plastic bags, but patients weren’t able to hold plastic bags. One family brought coconuts and patients were able to drink the coconut water and hold the coconut. The flesh was soft and culturally accepted. We started to buy between 200-300 coconuts each day. We hired someone to cut coconuts for patients. However, coconuts were only in season until November, and we got through the urgent phase before November. By December we ran out of coconuts. Coconuts were burned (after use), the husks helped to burn the other plastics and waste. I think it had a positive impact on mortality, but I don’t have enough detail to publish.’/…/ ‘We worked with one of the WHO experts on the use of coconuts and diarrhea. Coconut water as a replacement for ORS. I didn’t see that it had an impact until the change in the case fatality rate. There was no way to identify the coconuts were having an impact. Self-administering of fluids was important and beneficial. Patients were taking in much more fluid, so I feel the consumption of coconuts had a tangible difference. Keeping patients hydrated seemed to be having them recover quickly’.

Some KIs mentioned that there was an unwritten rule that the first 7-10 days after admission to ETUs were crucial. Regarding nutritional support, one KI stated, ‘If they survive the first week and especially the first few days,nutritional support is very important for survival. Exactly then we need to listen and give them what they want.’

In the West Africa outbreak, anorexia, vomiting, and diarrhea were particularly severe⁷. As one KI indicated: ‘Symptoms of diarrhea and vomiting was what was killing them. We saw that (once the patient was admitted in the ETU) we needed to intervene earlier before the vomiting/diarrhea would start. We stopped waiting for the transition phase with foods/drinks. We didn’t wait until the critical stage to start with foods/drinks/fluids. Once diarrhea or vomiting is present, it is difficult to reverse it. Once the patients got critically ill, then dehydration went so fast…. There were four men, still walking into the clinic but diagnosed with EVD, then the vomiting and diarrhea started; then all died at day 3…. I learned to put in foods/drinks/fluids before diarrhea began. I cannot directly link to outcomes, but I felt it was working’. KIs stated that the use of intravenous (IV) fluids was hotly debated. KIs had specific opinions on the use of ORS, IV fluid, and the use of foods during rehydration:

Some KIs worked diligently to improve oral fluid intake by EVD patients. As one KI stated: ’Patients would take ORS, but would come to ask for soda and coconuts (which we gave). The self-administration, acceptance, and willingness to take in fluids were important!’ Some organizations ensured that there was cold water, especially in the context of the hot climate of West Africa: ’Plastic packets of water, we stuffed the fridges full of those. We threw them over the fence for people to drink. They were nice and cold and appreciated.’ Others organized to have ice for patients with sore throats.

The use of sodas was discouraged in the 2014 iGL. “Owing to the high osmolarity of sugary carbonated beverages or juices, it is important that they are not given to patients with diarrhea. These products are low in electrolytes and nearly all essential nutrients”². However, some KIs argued that they were useful, including for patients with diarrhea, frequently requested by patients, and helped to increase/maintain fluid intake. As one KI stated: ‘Fizzy drinks were used and received well. They cheered people up.’ At least half of the organizations in this investigation reported the use of soda.

Sip feeds, designed for specific medical purposes, were included as an option for liquid diets in the 2014 iGL. Sip feeds often have a low renal solute load, low osmolarity, and come in lactose-free options. However, no KIs reported having used these products in ETUs but some stated that it might have been a missed opportunity. Sip feeds, though not ideal, may be more acceptable to adult patients than therapeutic milks or RUTFs. Various reasons of non-use were reported: unavailability of product in organization supply catalogs, unfamiliarity with product, substantial lead time for ordering and receipt, customs issues, the expense of product, and limited shelf life.

Generally, clinical staff determined what was provided to patients, including the type and consistency of food. Most KIs noted that there was no recording of information on dietary needs or preferences, only verbal sharing of information.

In the West Africa outbreak, many organizations had nutritional staff. However, nutritionists were not always allowed in ETUs, which was perceived as an impediment to improving the nutritional care of patients. Feedback from patients and health staff to nutritional managers was minimal. Only two KIs stated that they were able to monitor the content and quantity of food consumed by patients through a recording chart they developed. Their system monitored improvement or decline in appetite and provided insight into patient status with regard to nutrition: ‘We knew who was deteriorating as they were not eating (anymore)’. Others tried but did not have the capacity for monitoring.

Some KIs also mentioned the clinical staff’s nationality/background resulted in different perceptions of nutritional care.

Some KIs resorted to training of staff on the basics of nutritional care. However, over time in DRC, various KIs mentioned that the role and importance of nutritionists have increased, sometimes because some clinical staff strongly advocated for nutritional care.

Three KIs estimated that at any time during the height of the outbreak in West Africa, an ETU would have approximately 40% severely ill, 20% moderately ill and 40% ambulatory patients. Feeding support provided to patients varied by ETU, as well as by organization. Patients in need of support were assisted by different types of staff:

nutritional support staff, nutritionists, nursing aides, community members, community health workers, general infection prevention and control staff and sometimes nurses, doctors as they had increased access to the patients. Patients also supported each other. Some KIs mentioned it was often a collaborative effort at the meal times. Whoever was present assisted. However, many KIs stated that in the beginning there was simply not enough staff to effectively provide support for feeding in light of the essential tasks to run the ETU. As the response matured, EVD survivors started to play a significant role in some ETUs as feeding support ‘staff’, often receiving a per diem. At least six out of the 12 organizations ‘employed’ EVD survivors to provide feeding support. While some EVD survivors found this role to be psychologically difficult, others appreciated the opportunity to be useful while delaying their return to their communities and the associated stigma. Two KIs described the construction of simple furniture, wooden triangle or ‘pillows’, which enabled patients to sit upright to help with the feeding process.

KIs stated that very few EVD patients were acutely malnourished upon admission. Some patients lost weight and possibly developed malnutrition during their stay. KIs stated that though most intended to perform anthropometric measurements at admission, this was infrequently implemented because of the ‘no touch policy’ or lack of time. At best, weight was measured. Some organizations only screened children at discharge for referral purposes or provision of food upon discharge. One organization only measured mid-upper arm circumference (MUAC) when children <5 years of age were suspected to be acutely malnourished. However, this was still limited by the need to sterilize tapes after each measurement. If needed, most organizations had the means to treat malnutrition as products used for the treatment of malnutrition were recommended for EVD patients in WHO’s 2014 iGL. Overall, KIs stated that malnutrition was not a significant issue; however, no prevalence data were available, as no data were collected.

One KI questioned the use of therapeutic milks, normally used for treatment of SAM, for non-malnourished children: ‘In DRC, every child is prescribed F75 or F100, we don’t find this is appropriate. If a child is not malnourished it can eat normal food, and they want that! …There is no reason to take these specific products from other sites where they need it, away from community management of acute malnutrition programmes.  Therapeutic milks are still limited in availability./…../ And children do not necessarily like these milks, they want real food: cassava leaves, rice, chicken/meat and fufu.’

Four KIs (3 medical doctors, 1 nurse/nutritional manager) expressed significant concerns on hypo-albuminemia in EVD patients. The following captures the concern of practitioners:

KIs mentioned the need for specific micronutrients, such as magnesium, potassium, zinc, and vitamins A and K. Concerning the 2018-19 DRC outbreak, 2 KIs reported that laboratory analyses are increasingly assisting in determining the dietary needs of patients.