The predicament of patients with suspected Ebola
Authors: Robert Colebunders, Shevin T Jacob, Johan van Griensven
Journal: The Lancet Global Health (2017)

We appreciate Eugene Richardson and colleagues' framing of the Ebola suspect using the “Ebola suspect's dilemma” heuristic.1Richardson ET Barrie MB Nutt CT et al.The Ebola suspect's dilemma.Lancet Glob Health. 2017; 5: e254-e256Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar Nevertheless, we disagree with some data used to inform their argument. For instance, the authors (presumably facetiously) mention that “a rational decision might be to deliberately infect yourself with malaria” on the basis of data showing that patients with plasmodium parasitaemia and Ebola virus disease who received anti-malarial treatment had 20% increased survival compared with a group infected with Ebola virus disease only.2Rosenke K Adjemian J Munster VJ et al.Plasmodium parasitemia associated with increased survival in Ebola virus-infected patients.Clin Infect Dis. 2016; 63: 1026-1033Crossref PubMed Scopus (36) Google Scholar In an independent cohort of patients with Ebola virus disease, the inverse was found to be true—mortality was significantly higher in patients with malaria and Ebola virus disease co-infection (66%) compared with patients with Ebola virus disease alone (52%).3Waxman M Aluisio AR Rege S Levine AC Characteristics and survival of patients with Ebola virus infection, malaria, or both in Sierra Leone: a retrospective cohort study.Lancet Infect Dis. 2017; (published online Feb 28)http://dx.doi.org/10.1016/S1473-3099(17)30112-3PubMed Google Scholar Thus, the apparent survival benefit has not been reproduced and caution should be exercised when suggesting a potential benefit of malaria in patients with Ebola virus disease. Additionally, the 25% chance of nosocomial transmission of Ebola virus disease cited by the authors is a probable overestimate given that only 3·3% of discharged negative patients returned to Ebola Holding Units in Sierra Leone with Ebola virus disease.4Arkell P Youkee D Brown CS et al.Quantifying the risk of nosocomial infection within Ebola Holding Units: a retrospective cohort study of negative patients discharged from five Ebola Holding Units in Western Area, Sierra Leone.Trop Med Int Health. 2017; 22: 32-40Crossref PubMed Scopus (7) Google Scholar Finally, we fully agree with the emphasis of this Comment on the importance of administering intravenous fluid as part of the clinical management of Ebola virus disease. To clarify, fluid loss associated with diarrhoea or shock might occasionally need “injection of saline solutions in extraordinary quantities”,1Richardson ET Barrie MB Nutt CT et al.The Ebola suspect's dilemma.Lancet Glob Health. 2017; 5: e254-e256Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar as required for some cholera patients. However, as has now been seen in some patients with Ebola virus disease to whom such aggressive fluid resuscitation has been administered, the risk of fluid overload is high, so such risks should be weighed against the potential benefits to appropriately tailor the therapy of a patient with Ebola virus disease.5Uyeki TM Mehta AK Davey Jr, RT et al.Working Group of the U.S.–European Clinical Network on Clinical Management of Ebola Virus Disease Patients in the U.S. and EuropeClinical management of Ebola virus disease in the United States and Europe.N Engl J Med. 2016; 374: 636-646Crossref PubMed Scopus (255) Google Scholar JvG was coordinating investigator of the European Union-funded Ebola-Tx trial evaluating the use of convalescent plasma as Ebola treatment in Guinea, supported by the Union's Horizon 2020 Research and Innovation Program (under grant agreement 666094). All other authors declare no competing interests. The Ebola suspect's dilemmaIn 1950, Merrill Flood and Melvin Dresher of the RAND Corporation developed a theoretical model of cooperation and conflict, which was later formalised by Albert W Tucker as the prisoner's dilemma.1 This model represents a situation in which two prisoners each have the option to confess or not, but their sentencing outcomes depend crucially on the simultaneous choice of the other (figure).1 Fittingly, it has become the paradigmatic example of individual versus group rationality and is an often used heuristic when conveying introductory social theory to students. Full-Text PDF Open AccessThe predicament of patients with suspected Ebola – Authors' replyWe thank Thomas Mayrhofer and colleagues for offering their threshold model as an explanation for patients' aversion to accessing Ebola facilities during the recent Ebola outbreak in west Africa. We agree that this threshold model provides a rational and more elegant explanation of patients' avoidance of ill-equipped and poorly sanitised holding centres; however, such an explanation was not the goal of our Comment.1 Instead, we aimed to produce a reductio ad absurdum2 of rationalist approaches to understanding behaviour during the Ebola outbreak. Full-Text PDF Open Access