We conducted a literature search using the MEDLINE database (through PubMed and OVID search engines), Global Health, and Scopus, and used Google Scholar to search gray literature. Medical Subject Headings terms used included “hemorrhagic fever, Ebola,” “Ebola virus,” and “nutrition.” We also searched on the following terms: diet, vitamin, malnutrition, breastfeed, nutrients, fortified, micronutrient, caloric, calories, soup, porridge, cereal, legume, sugar, and dextrose. The search identified articles relating to Ebola virus and nutrition published from January 1, 2014, through August 30, 2019. We did not apply language restrictions, and for search engines that allowed it, we included only articles about studies with human subjects. We screened only the first 120 results from Google Scholar because of decreasing relevance of articles. We downloaded and managed articles through EndNote X9 (Clarivate Analytics, https://endnote.com).

Figure

Figure. Flowchart summarizing literature search and selection process for review of nutritional care for patients with Ebola virus disease.

We identified a total of 429 articles (Figure); 268 articles remained after deduplication. We excluded 240 articles after screening for information on nutrition or feeding during care for Ebola patients; content that caused exclusion included animal and bushmeat consumption in relation to Ebola transmission, testing and safety of breast milk in seropositive patients, food availability, malnutrition, agricultural stability before and during Ebola outbreaks, pharmacologic experiments for Ebola treatment, and molecular studies on the pathogenesis of Ebola virus. We completed full-text review on the remaining 28 articles. We excluded 5 non-English articles and added 1 more article identified from gray literature, resulting in review of 24 articles.

Most of the articles (n = 14) on nutritional support during Ebola treatment were case studies, cohort studies, or management recommendations focused on the clinical features, care provided, and outcomes observed (2–15). Four articles focused solely on patient care provided in the United States and Europe (5,6,8,14). Six described patients in West Africa during the 2014 outbreak: 3 in Sierra Leone (3,4,11), 1 in the Democratic Republic of the Congo (9), 1 in Liberia (2), and 1 in both Liberia and Sierra Leone (15). One particular study was a prospective cohort study on the effects of supplemental vitamin A on disease mortality rate (15). Two articles were field manuals, one an emergency interim country guidance for clinical management (16) and the other a list of essential medications for Ebola patient care (17). One article provided evidence-based guidelines for patient care using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology (18). One was a systematic review of current trends of Ebola virus management (19). Two articles were analyses of policies and programming regarding infant feeding (20) and nutrition (21). An editorial on nutritional management of patients with Ebola virus disease (22) and a comment published on the overall changes in care for Ebola virus disease (23) were included, as well as a personal report of a nurse’s experience in the field while working in an ETU (24). The final item was a letter from a nutrition advisor during the Ebola outbreak (25), which we identified from gray literature.

Despite the initially large number of papers with the key search term “nutrition” related to EVD case management, few explicitly described the details of the delivered nutritional support. Most clinical management papers delineated supportive care for dehydration and electrolytes through oral rehydration solutions (ORS) or intravenous fluid administration and did not refer to nutrition. Two studies and a retrospective review concluded that dehydration was associated with worse outcomes and increased mortality rates in patients (7,9,11). Both Leligdowicz et al. (7) and Smit et al. (11) included electrolyte imbalance as an additional risk factor for poor outcomes. Smit et al. found that poor nutritional status was also associated with increased mortality (11). The systematic review by Sivanandy et al. noted that nutritional care should include a “good amount of protein supplements” but did not specify a recommended amount or type of protein (19).

The evidence-based recommendations produced by Lamontagne et al. supported the importance of hydration in supportive care and monitoring serum biochemistry for electrolyte repletion (23). In creating the recommendations, a multidisciplinary panel met to analyze data on supportive care and voted to create a list of evidence-based guidelines. The panel strongly recommended administering ORS in an adequate amount, rather than using nonstandardized rehydration. The panel also strongly recommended that serum biochemistry (e.g., testing of electrolytes, glucose) should be made available, but the group did not produce any statements on nutrition (18).

In this literature review, we summarize existing practices and research findings on nutritional care for EVD patients. A wealth of literature exists on the clinical management and supportive care, but our review found only a limited number of publications on specific nutritional care, and they often lacked detailed descriptions of the actual nutritional care provided. The results could lead to the conclusion that the role of nutritional care in ETUs is perceived to have limited importance. However, the importance of good nutrition in fighting infection is widely known, and several researchers emphasized the need for good nutritional care for EVD patients (11–14,17,21,22). In addition, it is well established that adequate nutrition is essential in the management of critical illness or sepsis (26,27). Our review showed that nutritional care is poorly described and therefore the optimal composition and implementation of care remains unknown. One noticeable finding was the use of total parenteral nutrition (TPN) only in high-resource settings. It is unclear whether TPN is preferred over enteral nutrition and whether the role of enteral nutrition for patients’ survival is different in high- or low-resource settings.

We intended to compare actual nutritional care in ETUs with the 2014 WHO/UNICEF/WFP interim guidelines. However, various care descriptions from our literature review preceded the availability of these guidelines (2,3,5,6,8,9,14,17,22,24). This restricted our ability to compare recommended and actual practices. Only 3 works published after November 2014 commented on using the guidelines or reported any successes or challenges with attempting to follow them (12,13,21).

WHO recommends that EVD patients should be provided with a minimum recommended daily allowance (RDA) of nutrients through normal traditional or fortified foods (1,16) or micronutrient powders (28). It also states that, until further evidence is available, excess use of any micronutrient for EVD patients is not recommended, unless correcting for a specific micronutrient loss (e.g., treating hypokalemia). However, in many EVD-affected countries in sub-Saharan Africa, malnutrition, including micronutrient deficiencies, is widely prevalent (29,30), and 1 RDA of, for example, vitamins would not sufficiently address existing suboptimal levels in EVD patients.

To improve nutritional care for EVD patients, more documentation is needed on nutritional care in ETUs. We recommend that researchers and practitioners share specific and practical details of their experiences in providing nutritional support within ETUs to further facilitate the scientific base and ultimately improve the nutritional care for an increasingly prevalent patient population. In addition, research is necessary to determine whether specific macronutrients or micronutrients improve treatment outcomes in ETUs and elucidate their mechanism of action. For instance, the roles of albumin (14), selenium (31,32), and electrolytes (33,34) deserve further exploration, and the recognized importance of vitamin A in mounting an immune response to infectious diseases urgently merits further studies. It is also worth investigating whether anthropometric changes in patients admitted to ETUs relate to outcomes of illness and death. In addition, we see a need to examine whether the recommendation of providing 1 RDA is sufficient for managing patients with nutrient losses secondary to EVD-induced enteropathy, complicated by an underlying suboptimal nutritional status. We further underline the need for immediate research on breast milk and transmissibility of EVD (35). Last, we propose to not only examine whether specific nutritional care can raise patient survival rates, but to assess how it may contribute to symptom relief in the critically ill. Although adequate nutrition cannot cure patients with EVD, maintaining an optimal nutritional status could improve their response to treatment.