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What should be the nutritional support to adult patients with Ebola Virus Disease (EVD) in treatment centres in West Africa?

This question was posted the Prevention and treatment of moderate acute malnutrition forum area and has 23 replies. You can also reply via email – be sure to leave the subject unchanged.

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Mija Ververs

Normal user

30 Aug 2014, 07:53

Dear experts, I would appreciate your help in this. I drafted the following text but you might have ideas and other suggestions. Please help me on this one...

This question refers to patients infected with EVD who are not malnourished.

Before suggestions could be listed we need to look at a few questions:
1. Are there specific symptoms that would hinder normal food?
2. What are the clinical treatment priorities?
3. Are there specific nutritional needs?
4. Are the specific circumstances in the treatment centre that impact nutritional care?

1. Are there specific symptoms that would hinder normal food?

Symptoms in patients with EVD that could interfere with nutrition (ref1,ref2):
Most patients suffer from:
- Lack of appetite
- Stomach pain
- Diarrhoea
- Vomiting
- Nausea
- General malaise
- Fever
Some patients suffer from:
- Difficulties in swallowing
- Bleeding (external, internal)
- (note: bleeding in <50% of confirmed cases; mostly in later stage of diseases)

Anti-emetic medications may provide some relief and facilitate oral rehydration is nausea and vomiting are common (ref1).
If swallowing is difficult risk of aspiration is high and food should not be given orally.


2. What are the clinical treatment priorities?

Standard treatment for Ebola HF is still limited to supportive therapy. This consists of:
• balancing the patient’s fluids and electrolytes
• maintaining their oxygen status and blood pressure
• treating them for any complicating infections


3. Are there specific nutritional and food needs?

Like most infectious diseases patients with EVD need sufficient energy (kcal), proteins and especially lots of fluid (and electrolytes) to compensate for losses through diarrhea, vomiting, and fever.
Patients should be provided with food if they are conscious and can swallow. As most patients lose their appetite soft foods and fluids are easier to tolerate (ref1). Small frequent meals often are tolerated better.


4. Are the specific circumstances in the treatment centre that impact nutritional care?

The following description refers to the crises areas at present in West-Africa. In most cases, once diagnosed, the patients with EVD are in a hospital/special treatment centre. The current reality on the ground is as follows:
- There is limited access to staff (or visitors) being able to help to feed the patients
- Health care has NO extra time for feeding patients
- There is limited time for inserting and monitoring naso-gastric tubes by health staff
- Eating utensils (as well as food) can be a source of transmission
For logistical reasons food that is offered should ideally be appropriate to ALL infected patients.


WHAT FOOD COULD BE OFFERED?
The features of food and how to should be offered can be summarised:
1. Food should be offered in disposable materials (for single use only) that should be burned after use (plastic, polystyrene, straws, wooden/paper/plastic spoons, foil).
2. Food should be easy to ingest whilst lying down or in half-sitting position (semi-solid or liquid: mashed, porridge or completely liquid)
3. Food should be sufficient in calories and protein (electrolytes are corrected through other means, e.g. ORS)
4. Food should be attractive to the patient as he/she suffers from anorexia and general malaise.
Note: for all those that have difficulties to swallow or are too sick naso-gastric feeding should be offered
IMPORTANT: Whenever possible an assessment should be done on what patients themselves indicate what they can and prefer to eat in order to bridge that what is nutritionally needed is similar to what patients with EVD want.

Food to be considered for in-patient treatment of Ebola:

o PlumpyNut: Hygienic, individual portions, easy to eat; Does not need preparation and can be positioned at bedside
Comments: Rather dry and plenty of liquid should be offered separately; Problematic in patients with minor swallowing difficulties

o BP 100: Can be made into a porridge with adding water; Does not need preparation if used as dry biscuit and can be positioned at bedside
Comments: If offered as biscuit, plenty of water should be offered separately

o CSB: Offered as porridge
Comments: Requires preparation in a kitchen and regular distribution

o F100: Offered as liquid drink (through straw), easy to ingest and contributes to fluid intake; (Can be made into yoghurt…?)
Comments: Risk for those with lactose intolerance?


o Others? IDEAS????

or COMMENTS ON PREVIOUS TEXT?

If visitors in protective gear are allowed to regularly stay with patients with EVD other (normal/mashed) food can be offered. Visitors can then be requested to support the feeding process with offering regularly small portions of food and drinks.

Mija-tesse VERVERS
30 August 2014

Ref 1. Clinical Management of Patients with Viral Haemorrhagic Fever: A Pocket Guide for the Front-line Health Worker 13 April 2014 Interim emergency guidance-generic draft for West African adaptation. World Health Organization.
Ref 2. Ebola hemorrhagic Fever. Fact Sheet,Centers of Disease Control CDC, (2014). National Center for Emerging and Zoonotic Infectious Diseases Division of High-Consequence Pathogens and Pathology (DHCPP)

Tamsin Walters

en-net moderator

Forum moderator

5 Nov 2014, 09:39

Dear all,

Further to my previous message, I would like to add the following additional detail:

WHO, UNICEF and WFP are pleased to share the interim guideline on nutritional care of children and adults with Ebola virus disease in treatment centers:

http://www.who.int/nutrition/publications/guidelines/nutritionalcare_with_ebolavirus/en/

The guideline underwent an additional external review and some additions have been made in terms of research questions and process outline in relation to version 15, however the core guidance remains the same. While the guidance applies to Ebola Treatment Units, the nutritional principles apply to anyone with Ebola virus disease.

The update will include additional research and input from technical and operational experts. It is anticipated that the update will be made within 6 months’ time. In the meantime, comments and queries should be shared with nutrition@who.int and nutrition@unicef.org . Feedback on those comments and queries will be shared as the volume of queries dictates.

Best wishes,
Tamsin

Tamsin Walters

en-net moderator

Forum moderator

2 Sep 2014, 20:39

Dear all,

Mija has updated her question to include some new information from the field. However she is very keen to hear more from people out there about their experiences and opinions. The question remains the same: what is the most appropriate nutritional support we can provide to adult patients with ebola virus disease in treatment centres in West Africa?

This question refers to patients infected with EVD who are not malnourished, with the aim of promoting their recovery.

***The full updated working document has been removed as it has now evolved to official WHO/UNICEF/WFP interim guidelines. See below ***

While there is much ongoing discussion between agencies with the intention of putting together some clear agreed guidance, further inputs from those in the field would be welcomed to share what you are doing, what your experience is and what you consider is needed. Suggestions, ideas and experiences - what has worked, what has not - can all be shared. Mija welcomes comments or critiques of the document attached, with the aim of working together towards developing the best available guidance.

Many thanks,
Tamsin

Tamsin Walters

en-net moderator

Forum moderator

3 Sep 2014, 20:42

Dear all,

UNICEF and WHO have been in consultation with Professor Michael Golden and his advice regarding convalescent feeding is copied below:

I was asked by UN agencies to comment on two aspects of the present Ebola outbreak. First, breast feeding advice and second convalescent feeding of recovering patients. Here I am addressing convalescent feeding only.

I have preached for a long time that we as physicians, when we treat sick patients, should not only give ORS or Amoxycillin etc to attack the main disease agent - but we should also be taking care of convalescence to bring the patients back to their pre-illness state of health. Indeed, I have been advocating at government level and with NGOs that this should be a major program in order to break the link between disease and malnutrition and it would be one of the most effective programs to prevent stunting of children. The only team that seems to have taken this advocacy seriously is MSF-Holland. They did a study with convalescent malarious patients (van der Kam, S et al. Ready-to-use therapeutic food for catch-up growth in children after an episode of Plasmodium falciparum malaria: an open randomised controlled trial. PLoS.ONE. 7[4], e35006. 2012). It would appear that WHO has already addressed this question to a very limited extent in document WSH9204 (page 19) with respect to diarrhoea:
“When a child recovers he or she will need extra food to regain lost weight.
“Give the same foods after the diarrhoea stops, and give an extra meal each day for the next two weeks.”

This is unlikely to happen with the quality of diet that would lead to meaningful physiological recovery given the high prevalence of stunting and other nutrition related conditions that we find in most developing countries. The alternative is for the medical services to "take care of convalescence" and to give for a short time a nutrient dense supplement.

And of course the Zinc administration advice is, I contend, a particular intervention that has proven benefit that should be generalised to 1) all nutrients needed for recovery and not just zinc - zinc is often the limiting type II nutrient and that is why it works - now we need to add all the others - K,Mg,PO4 etc - and 2) all other diseases that result in major weight loss/ inappetance.

At any rate, that is where I am coming from - there is limited literature but the theory is sound and what literature that there is would strongly support this approach. The question then arises as to what would be the best supplement to give?

I would argue that there needs to be a RCT now to compare RUTF with Supercereal for convalescent feeding. But using the principle of primum non nocare we should give the supplement which has been shown to be most effective as the routine treatment outside of any trial – therefore the first choice would be RUTF and the trial would be an equivalence trial.

Although the present interest in the Ebola epidemic gives us the opportunity to have this practice accepted as standard care for this particular condition and to test which supplement would be superior for convalescent feeding it should NOT be restricted to Ebola patients. Convalescent feeding of patients that have been extremely ill should be generally recognized as best standard medical practice and applied to all such conditions and patients of all! To restrict it to ex-Ebola patients and deny those other patients who have been so ill that they have lost considerable amounts of weight would be unethical.

I would give one sachet per day of lipid based spread type RUTF (eg Plumpy’nut®) to children less than 5 years and either two sachets or, preferably, the equivalent amount of BP100 (also an RUTF) per day to children above 5 years and to adults. I would give this when their appetite returns and continue for two weeks and reassess the patients at that stage to determine if a further two week supplementation period is warranted.

In future, we should have another product with exactly the same composition, but a different packaging and name (for convalescent feeding) to differentiate it from the products used to treat severe malnutrition. Ready-to-Use-Convalescent Food –RUCF.

Michael Golden

Marie McGrath

ENN

Forum moderator

4 Sep 2014, 20:12

Dear all
Mija-tesse Ververs, following consultation with many experts and practitioners, has updated the guidance for nutritional support in treatment centres in West Africa.

She is very keen for feedback from the en-net audience. Your experiences and opinions are very welcome.

Marie McGrath

ENN

Forum moderator

5 Sep 2014, 12:49

Dear Mija,
Many thanks for this very useful document and process. I have some suggestions/observations. They stem from experience in clinical dietetics and nutrition support in adults and paediatrics the UK context, and having worked in Sierra Leone in the past. In no particular order:

1) Is full fat animal milk (e.g. packaged UHT milk) available? Are eggs available? Both are nutritious 'normal' foods that are practical (e.g. boiled eggs) and may be particularly useful in convalescence. Milk will be especially valuable for children over six months that are not breastfed.

2) My experience with NG feeding and use of liquidised food, is that it is highly problematic. You would need wide bore NG tubes that are particularly uncomfortable for the patient. They are likely to get blocked and are difficult to keep clean, so become an infection risk. It is much easier to use and maintain tubes where liquid is used. Given the context, has F75 and F100 been considered as an option, especially in the early days of nutrition support where appetite will be low, and likely only liquids tolerated. It might be useful to compare the nutrition profile of existing enteral feeding products used in clinical settings (there are many), with the nutrient profile of F75 and F100 and see how close they are. Perhaps a nutrition/dietietic department in a university would be able to support such analysis?

3) Children, specifically considering the needs of 6-23 months of age, may or may not have access to breast milk, depending on if the mother is also infected and under treatment/alive. For breastfed fed infants, maintaining breastfeeding will be important and support for this,. For non-breastfed infants over 6 months, full fat animal milk and fortified complementary food will be the way to go. More frequent feeding of children would be better, e.g. three porridges a day if that were possible - or at least an additional fortified biscuit. We are working on an update to the infant feeding and ebola guidance on another discussion stream on en-net and we will then review your guidance and see what specific direction we can give.

4) My experience with sick adults is that when very ill, they tolerate and can manage liquids better than solids, and insipid foods that are not strong tasting or smelling. I suspect that adults may have difficulty in accepting and consuming Plumpy'nut and that F100/F75 would be better accepted. Also, appetite is not an indicator of when to start to support nutrition intake - most nutrition support in clinical settings is about how to achieve a decent nutrition intake when the patient has no appetite. "Little and often" helps build intake.

Best regards
Marie

Jessica Bourdaire

Normal user

8 Sep 2014, 18:00

Dear Mija,

I have tried to give some answers to your main questions:

1) Are there specific symptoms that would hinder normal food? And 2) what are the clinical treatment priorities?

I see 2 kinds of patients by their condition:
a) Those that can eat
b) Those that can’t

Can eat:
I would provide high energy nutrient dense food especially when appetite is poor and when nausea is present as higher amounts of nutrients are contained per gram. When appetite starts becoming normal, nausea is gone and large amounts of food can be tolerated, I would consider other options.

Can’t eat:
Nasogastric tubes mostly allows liquids, thicker solutions might block the tubes even the larger ones. Patients experiencing important internal bleeding, profuse vomiting or unconscious, might not tolerate NGT. I would say that commonly priority for those severe cases in acute phase focuses on IV fluids and oxygen when parenteral nutrition is unavailable.

3) Are there specific nutritional needs?
I think there is not enough evidence to determine this but given that Infection reduces appetite and increases nutrients requirement, diarrhoea contributes to electrolyte imbalance and is linked to malabsorption, bleeding reduces circulating blood and induces anaemia, all type of nutrients must be somehow concerned. Ration of normal or low energy nutrient dense food providing 2100kcal/day is unlikely to be consumed by a patient with poor appetite or nausea, therefore, I would consider RUTF as first option.

4) Are the specific circumstances in the treatment centre that impact nutritional care?
Time and staff to prepare and provide food, availability of nutritious food, potable water supply, decontamination of utensils, NGT surveillance is time consuming, etc.

Broadly speaking, I think RUTF tick most of the boxes in terms of Nutrition and Practicability. I would prefer to give plenty water along with but not added to the RUTF not only because contamination but also because dilution of nutrients (except BP100). When RUTF is not available, I would consider other options (high calorie/nutrients food as much as possible). Delivering food in treatment centres should not open a new window for contamination so I personally think that we should try to keep it as simple as possible.

Jessica Bourdaire

Mija Ververs

Normal user

10 Sep 2014, 09:43

Hi Jessica
Thanks very much for your reply. Just one reminder, NG feeding and IV are currently NOT an option. NG feeding is apparently not possible because of throat problems and, needless to say, both NG and IV have high contamination risks for staff.
We will wait for more reactions and update v7 into a version 8 when we have sufficient new information and replies like yours. Keep on thinking with us!
Mija

Marie McGrath

ENN

Forum moderator

19 Sep 2014, 17:16

Updated guidance on infant feeding in the context of Ebola has been posted on the en-net discussion thread. It is relevant to (and cross-references) the draft guidance on nutrition support to adults and children with EVD.
Best regards
Marie

Mija Ververs

Normal user

19 Sep 2014, 17:24

Dear all
For those that would like to have more information on the nutritional care protocols for patients with EVD, we can inform you that we are intensively working with various implementing organisations as well as UN agencies to draft interim guidelines for adult patients and children >6 months). We hope to post these guidelines early next week. The guidelines will be a more updated and refined version of the previously posted guidance (v7).
Mija Ververs

Jessica Bourdaire

Normal user

20 Sep 2014, 16:06

Hi Mija,

I am looking forward to reading the protocols, especially the revision on the amount of food that could possibly be eaten by convalescent patients considering the various symptoms affecting eating/digestion/absorption.Thanks.

Jess

Zelalem Tafese

Hawassa University

Normal user

21 Sep 2014, 12:54

Is there any research initiative targeted on finding the best micronutrient to be suplemeted for patient with Ebola, as anutritional suport.

Mija Ververs

Normal user

22 Sep 2014, 12:50

Thanks for your question. For the moment there is limited research available on micronutrients nor macronutrients and Ebola Virus Disease. We know that potassium is important to replenish losses through diarrhea and vomiting.

If any of you have research ideas (apart from the obvious e.g. to investigate what the impact is of nutritional care support to patients with EVD on their survival), please let us all know. We are very interested in good suggestions.
Thanks so much, mija

Mija Ververs

Normal user

23 Sep 2014, 13:27

Dear All
Currently we are working around the clock on Interim Guidelines for Nutritional Care Support in Adults and Children infected with Ebola Virus Disease in Treatment Centres . This is done by a group of experts from all kind of organisations (UN, academics, NGOs, ICRC, etc). As there is a new round of comments amongst those experts on Wednesday and Thursday, we can ensure you that a draft version will be posted this Friday for you all to comment on . Sorry for the delay, I had sincerely hoped I was able to post it by at latest tomorrow....
Meanwhile, if you have ideas or suggestions based on experience in the field with treating patients with EVD on the nutritional care, I encourage to send me these asap.
Thanks for all you patience.
Mija
PS The guidelines are drafted for adults and children >6 months.

Tamsin Walters

en-net moderator

Forum moderator

26 Sep 2014, 12:38

From Mija-tesse Ververs:

Dear all

After intensive consultation with various implementing organisations, academics and UN agencies we have drafted a new version of the Nutritional Care in Adults and Children infected with Ebola Virus Disease in Treatment Centres. It has a new numbering now: after version 7 that was posted on EN-NET recently, this is the latest (now called version 0.4 Interim Guideline).

As most of us have not had experience with patients with EVD, we are aware that some parts in this document might need changes in the near future. After all, this is a living document for the time being and we will learn by trial and error. We encourage you to give feedback on this guideline, especially organisations that are currently implementing programmes for patients with EVD. We highly value your experiences.

If you feel the document needs changes, please submit concrete suggestions for the text marking why and how you would see it being adjusted. The deadline for changes (or comments) is Tuesday 30 September 16.00 Geneva time. Feel free to send suggestions for changes to me (mijaververs@hotmail.com) or use the EN-NET forum if you want an open forum discussion.

I hope that together we can make a difference in the care and survival of patients with EVD. And thanks to all who already have contributed so much and with so much passion!

My warmest regards, Mija-tesse Ververs

Anonymous 1455

Normal user

26 Sep 2014, 12:56

I think it is needful to mention breastfeeding by recovered mothers (and breastfeeding of children with EVD) even though we do not have the full understanding of the issue.

Mija Ververs

Normal user

2 Oct 2014, 15:29

Update on Nutritional care and EVD patients

Dear all
After an intensive process of drafting, revising, re-drafting and re-revising of an initial guidance for nutritional support to patients with EVD we are now getting closer to a better, more accurate and appropriate version. The time of commenting on the latest version 0.4 is over. Most likely by tomorrow there will be a new draft version 0.5 that addresses all concerns that were raised in formal and informal forums. This version will be reviewed by a group of experts including NGOs, UN agencies, academics, and ICRC.
WHO and UNICEF will consequently process the Interim Guidelines and make it ready for internal clearance. I was informed that this will be done shortly due to the urgency of the matter. These Guidelines will be a first formal attempt to give guidance to practitioners on nutritional care for adults and children with EVD.

Once again I want to thank everybody for their contributions that were most of all very constructive and helped tremendously to make the writing of the draft version of the Guidelines possible.

As soon the Interim Guidelines have been made official they will surely be posted on EN-NET.

Note: Please do not use any of the older draft versions that may be circulating since changes have been made.

Thanks to you all, Mija

Marie McGrath

MAMI Special Interest Group Coordinator

Frequent user

13 Oct 2014, 21:25

Dear All
On October 8th, the Ebola Communication Network (ECN), was launched. The ECN is an online collection of Ebola resources, materials and tools from and for the global health community. Access and share resources at: http://ebolacommunicationnetwork.org/

Tamsin Walters

en-net moderator

Forum moderator

22 Oct 2014, 11:11

Dear all,

Please find here a new WHO/UNICEF/WFP Interim Guideline: Nutritional Care in Adults and Children infected with Ebola Virus Disease in Treatment Centres that can be widely shared.

***Please note: The link above now directs you to the new, revised version of the guideline***

Although the document is still labelled draft version, it has been cleared by UNICEF, WFP and WHO in terms of content. Version 1 will be released in the coming days once editing and formatting has been completed; these processes are currently ongoing. The content of the documents will not differ between v 0.15 draft and final version.

The guidance will be hosted on en-net, available through the ENN resource library, and others are invited to repost the link to other webplatforms so that any subsequent updates will be clear. It will be a 'working' guidance in that WHO will look to update again in about 3 months as things are evolving so quickly and in order to respond to field experiences of implementation.

In order to streamline communication in terms of feedback on the guidance and additional queries, you are kindly invited to contact Zita at WHO and Diane at UNICEF (email contacts are provided within the guidance). Every couple of weeks, updates on emerging issues or feedback will be shared on en-net.

The infant feeding guidance in the context of Ebola is explicitly mentioned within this document. In 3 months time, the infant feeding guidance will also be updated based on experiences of implementation.

Best wishes
Tamsin

Tamsin Walters

en-net moderator

Forum moderator

5 Nov 2014, 09:22

Dear all,

The Interim Guideline on Nutritional Care in Children and Adults with EVD in Treatment Centres (Version 1.0) can now also be accessed at the following link:

http://www.who.int/nutrition/publications/guidelines/nutritionalcare_with_ebolavirus/en/

It is anticipated that it will be updated within 6 months, as needed, in light of increased field experience, ongoing research and data analysis.

Best wishes,
Tamsin

Tamsin Walters

en-net moderator

Forum moderator

13 Nov 2014, 20:33

From Rachel Fuli:

The interim guideline version 0.15 talked of nutritional care for children (under the age of five??) and adults but no mention about age group that fall between children and adults. Daily caloric intake is 100kcal/kg body weight for children and 35 kcal/kg body weight for adults. Where do older children and adolescents fall?

This question has been shared with the technical group

Marie McGrath

ENN

Forum moderator

22 Dec 2014, 10:17

In light of the Ebola outbreaks in Sierra Leone and Liberia, the Nutrition and Social Behaviour Change (SBC) Working Groups of the Core Group hosted a 1 hour webinar on Ebola and nutrition. A panel of speakers provided updates and activities related to programming adjustments, guidance notes and research needs and Social and Behavior Change Communication. A presentation on nutrition in the ebola response, with reference to the nutrition support guidance discussed here, was presented. You can access the recording online.

Stemming from this presentation, just a reminder that experiences in implementing the guidance is sought by UNICEF and WHO to inform an update in a few months time. Key areas where information is sought in particular are:
1. Food & nutrition in Ebola Treatment Units (ETUs)
a) Food & nutrition packages provided (per ETU)
b) Food & nutrition packages provided per patient (if different packages) – disaggregated by gender, age, severity of disease, etc. of the patients)

2. Food & nutrition intake by patients in ETUs
a) Kinds of foods best tolerated by EVD patients (disaggregated by gender, age, severity of disease, etc. of the patients)

3. Impact of nutritional status & support in ETUs
a) Number/percentage of patients with undernutrition (wasting) on admission and on discharge, disaggregated by gender and age
b) Number/percentage of patients with biochemical abnormalities and micronutrient deficiencies, disaggregated by gender and age
c) Recovery rate disaggregated by nutritional status, gender and age
d) Duration of recovery, disaggregated by nutritional status, gender and age

Please send feedback to: nutrition@who.int and nutrition@unicef.org

Marie McGrath

ENN

Forum moderator

30 Jan 2015, 09:06

The WHO/UNICEF/WFP guideline on nutritional care of children and adults with Ebola virus disease in treatment centres is now available in French.

Marie McGrath

ENN

Forum moderator

27 May 2015, 18:47

Dear en-net
The WHO and UNICEF are planning an update of the Interim Guideline on Nutritional Care in Children and Adults with EVD in Treatment Centres (Version 1.0). They are very keen for field experiences to inform the update.

Let us know if you have found the guidelines useful, have you encountered gaps, challenges or inconsistencies in implementing the recommendations, and is there anything you would like to see reflected in the next version. Examples of case management or programming situations you have worked in are incredibly valuable.

You can post your headline feedback and experiences on en-net and we can follow up with you directly for more details. If you prefer, contact me directly (marieATennonline.net).

The deadline for feedback is 20th June. Feedback is also sought regarding the infant feeding and ebola guidance.

Best regards, Marie

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