Abstract
In November 2014, the World health Organization (WHO), in collaboration with United Nations Children's Fund (UNICEF), and the World Food Programme, produced interim guidelines (iGL) on providing nutritional support to patients in Ebola treatment units (ETUs). They have been translated into French and issued by the Ministry of Health, UNICEF and WHO in adapted versions to be used in the current outbreak in the Democratic Republic of the Congo (DRC). This paper evaluates the use and usefulness of the 2014 iGL in the West Africa and current DRC Ebola virus disease (EVD) outbreaks and identifies experiences and lessons learned from practitioners on the operational aspects of nutritional care and support in ETUs.
Key-informants (n=26), from 12 organizations (Non-Governmental Organizations, United Nations, Red Cross Red Crescent Movement) were interviewed who were actively engaged in the nutritional and/or clinical care of EVD patients.
There was a consensus among key-informants that the 2014 iGL initially served a guiding purpose. However, the vast amount of learning from the 2014-2016 and current EVD outbreaks indicates that the interim guidelines need to be revised. Practitioners struggled to find operational solutions for nutritional care, and the challenges were plentiful, especially regarding 1) the different perceptions of the importance of nutritional care among ETU staff; 2) the difficulties around food preparation and distribution for EVD patients; 3) how to take into account the patients dietary preferences; 4) the nutritional care needed in relation to specific EVD symptoms; 5) who assumed roles in nutritional care in ETUs; 6) if and how feeding support was organized; 7) whether malnutrition needed to be addressed and how; and 8) whether the intake of specific nutrients could contribute to improved treatment outcomes. Information from the key-informants interviews resulted in numerous lessons learned and recommendations for nutritional support during current and future outbreaks.
This investigation underscored the importance of documenting experiences of practitioners on nutritional care in emerging infectious diseases for which limited scientific evidence exists and for which interim guidelines are produced to fill in knowledge gaps. It also emphasized the importance of nutritional care in ETUs during treatment.
Author Contributions
Copyright© 2019
Ververs Mija, et al.
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests The authors have declared that no competing interests exist.
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Discussion
This investigation is the first attempt to better understand how nutritional support was managed in ETUs and the operational challenges faced by practitioners during the 2014-2016 outbreak in West Africa, as well as in the current outbreak in DRC. Practitioners struggled to find operational solutions for nutritional care, and the challenges were plentiful. Though released just after the peak of the outbreak, the 2014 iGL served a guiding purpose in the few months following its publication. However, the vast amount of learning from the 2014-2016 and current EVD outbreaks indicates that the interim guidelines need to be revised. Very few studies have described the actual nutritional care provided in ETUs and the experiences Trehan et al. described the nutritional care in detail for pediatric patients based on his experience in ETUs. However, this was aimed for a minority of the caseload in ETUs and had a significant focus on the use of specialized products, generally used for the treatment of severe acute malnutrition While waiting for more scientific evidence to be generated on what nutritional support should be provided, there is a need for continuous monitoring of practice and generation of lessons learned. What may work in DRC may not translate to other outbreaks. However, from this investigation, it is clear that some nutritional care practices are universal and relate more to the disease than the geographical locations (e.g., preference for local foods by adults, the importance of feeding support). Additionally, it is essential to obtain information on the perspectives of EVD patients themselves on the nutritional care they receive or have received. If future research findings are able to inform metabolically optimal nutritional care protocols, but the patients themselves do not consume what is recommended, treatment outcomes might be negatively impacted. A step for the near future would be to share the recommendations expressed by the practitioners with a broader audience and assess the support and feasibility of their implementation. While good nutrition cannot cure EVD, it is believed that maintaining the nutritional status of the people affected could improve their response to the treatment.