ERADICATING EBOLA
Fifty years after the identification of Ebola, the most effective treatment is yet to be discovered.
What's the best way to treat Ebola?
October 28, 2014 -- Updated 1141 GMT (1941 HKT)
Kaci Hickox,
a nurse who recently returned to the United States after working in
Ebola-ravaged West Africa, sent CNN this image of the tent where she was
being isolated for Ebola monitoring Sunday, October 26, in New Jersey.
Hospital officials told CNN the indoor tent is in a climate-controlled
extended-care facility adjacent to a hospital. Hickox has twice tested
negative for Ebola.
HIDE CAPTION
The Ebola epidemic
STORY HIGHLIGHTS
- Blaser: 50 years after identification of Ebola virus, we still don't know which treatment is best
- He says the only way to find out is a randomized clinical trial of alternative treatments
- Blaser says this approach would allow doctors to continually improve quality of treatment
Editor's note: Martin
J. Blaser M.D. is professor of medicine at NYU Langone Medical Center, a
past president of the Infectious Diseases Society of America, and
author of "Missing Microbes." The opinions expressed in this commentary are his.
(CNN) -- Ebola virus has landed several times in the United States and at least twice has spread to health care workers.
Given the terrible and
extensive spread of Ebola in West Africa, more cases in travelers or
health workers would not be surprising. Disease has spread in this
manner since the times of plague, and sadly there will be more cases.
Martin Blaser
Despite the
identification of Ebola and related viruses nearly 50 years ago, we
doctors still don't know the best therapies for people who have been
infected. But with disease raging, we urgently need to learn the most
effective ways to quickly treat critically ill people, not only to stem
the tide of disease in the United States, but on behalf of the whole
world.
In any epidemic, there
are early cases and late cases. Let's learn from the early cases so that
if things get worse, we will have a better idea about what to do. Three
years ago, cases of very severe E. coli infections began to appear in Germany.
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By the time the epidemic
was over, hundreds had become ill, and at least 50 people died. By
studying this huge cluster of cases we could have learned much about
which treatments were optimal; instead, the epidemic ended with us
having learned nothing about how to treat the next outbreak.
Why? Because every doctor
treated his or her patients according to their best individual
judgment, given the information available to them. But judgment varies.
Thus treatment varied and so did outcomes. Since so little was learned,
when future E. coli outbreaks occur, we—and our patients—risk finding
ourselves in the same sub-optimal position again. That's where we are
with Ebola.
There is a solution to
this problem. Medical research has advanced greatly through controlled
clinical trials: ill persons are randomized to receive one treatment or
another, and then outcomes compared.
From such randomized
clinical trials has come the knowledge that has improved chemotherapy
for nearly all cancers, as well as treatments for HIV infections. The
randomized clinical trial minimizes the bias of personal judgment and
permits a head-to-head comparison of whether treatment A or B is better.
That's what we need for
Ebola, and for the next epidemic—whatever it is and whenever it comes,
which it will. But regulatory processes are slow and essentially too
time-consuming to be able to establish a randomized clinical trial in
real time as an epidemic is unfolding. Thus, I have a modest proposal:
Our health authorities
should pre-design a generic randomized clinical trial for acute
infectious diseases. The trial design should be well-vetted, and blessed
by the Centers for Disease Control and Prevention, the Food and Drug
Administration, the National Institutes of Health, and appropriate
ethics committees. When a possible outbreak appears on the horizon, the
President, via the Surgeon General, would be empowered to call a public
emergency, and the pre-approved generic trial would be launched.
All that would need to
be decided at that point is what treatment should constitute A and what
should be B. For nailing down treatment approaches, a panel of known
experts—say in Ebola virus—should be convened to provide their best
judgments. Thus when cases arrive, patients would be immediately offered
the possibility of enrollment in the randomized clinical trial.
Since the treatment
choices would be the best available, presumably few would refuse, and as
data is gathered over time it would become clear which treatment is
more effective, A or B. If it turns out to be B, the panel then asks: Is
there a reasonable treatment C? The next trial would then compare B and
C, and so on.
This approach would
allow us to be continuously learning what works and what does not, and
continuously improving treatment. Such a protocol would demonstrate an
orderly approach to handling an epidemic, an approach that could be
exported to other countries as well. And, of course, anticipation and
order are important antidotes to fear.
Let's start now, with
Ebola, though rest assured that there will be another epidemic coming
our way before too long. And another after that. Let's prepare.
copiado http://edition.cnn.com/
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