Critical Appraisal Of The Literature
Critical Appraisal Of The Literature
A literature review was performed in the PubMed and Ovid MEDLINE® databases using the search terms: Ebola, Ebola virus, hemorrhagic fever, Ebola virus disease, and Ebola vaccines with limits to humans. Given the limited literature available on pediatric patients with EVD, studies involving adults were included. The search resulted in 108 articles, predominantly from the adult literature. Literature searches were also conducted using Google scholar, MDConsult, and Medscape eMedicine using the key terms: Ebola, Ebola virus, hemorrhagic fever, and Ebola virus disease. Referenced sources from these articles were also reviewed.
Unfortunately, there is scant high-grade evidence regarding EVD in children, with only 14 articles noted on MEDLINE®. A search of the Cochrane Database of Systematic Reviews resulted in 6 publications relating to Ebola virus. One publication was a technological assessment investigating the cause of current epidemics not limited to Ebola. The only review involving EVD in pediatric patients examined routes of achieving parenteral access in patients with EVD. The other 4 articles were trials looking at genomics, vaccines, and novel therapies in nonhumans. No randomized controlled trials examining the management of EVD exist, making class I evidence for management recommendations not feasible.
The WHO and the Centers for Disease Control and Prevention (CDC) both maintain robust database information on EVD and provide extensive guidelines for healthcare workers. Additional guidelines are available from the Public Health Agency of Canada (http://www.canadiancriticalcare.org/_assets/Ebola Clinical Care Guidelines_ENG.pdf)11 and the Infectious Diseases Society of America (IDSA) (http://www.idsociety.org/2014_ebola/). The IDSA primarily focuses on the adult population, but information may be extrapolated to pediatrics.12 While the American Academy of Pediatrics (AAP) website Healthy Children (www.healthychildren.org) has a patient education sheet, a further search of the AAP (http://www.aap.org/) and the Canadian Pediatric Society (http://www.cps.ca/) sites revealed no guidelines or clinical algorithms. The European Commission Public Health Task Force published guidelines in 2004, known as the Bichat Guidelines, which outline the clinical management of hemorrhagic fever viruses, especially in the context of bioterrorism.13 A recent article written by a group of critical care clinicians serves as an excellent guide for the care of children with EVD in resource-rich areas.14 Most of the literature involving humans consists of case reports and case series, with the majority being retrospective in nature and not pediatric-focused. A large body of data on the pathogenesis of Ebola virus is from laboratory experiments employ-ing nonhuman primates, mice, and guinea pigs.15,16
Following the EVD epidemic that started in Guinea, Africa in late 2013, there has been a significant increase in the literature regarding the recognition, evaluation, and management of patients with EVD. This epidemic also resulted in a greater understanding of the pathology of EVD and methods to improve survival.6 The CDC has released numerous statements since the start of the West African outbreak, including a clinical evaluation algorithm (See the Clinical Pathway For Evaluation Of Patients With Possible Ebola Virus Disease). Currently, additional algorithms are available regarding reduction of exposure to the virus and prevention of transmission, but gaps regarding practical application remain.17 It is difficult to establish large randomized studies given how rapidly patients with EVD deteriorate, the ethics associated with treatment, the scarce number of “treatments” available, and the high morbidity/mortality rate. New scientific research seeks to develop novel vaccines and treatments to eradicate Ebola.
Marlie Dulaurier, MD;Katherine Moyer, DO;Rebecca Wallihan, MD
July 2, 2016
August 2, 2019
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Pharmacology CME credits