The new england journal of medicine

correspondence

Ebola Virus Disease in West — The First 9 Months

To the Editor: The World Organization spreading Ebola. Likewise, neglecting to rapidly (WHO) Ebola Response Team (Oct. 16 issue)1 control this in Ghana could predicted that the current Ebola epidemic would have unpredictable yet potentially devastating claim a dreadful 20,000 combined cases by early consequences. November 2014, assuming no change in the con- Stanislas Rebaudet, M.D., Ph.D. trol measures applied in West Africa. The threat Assistance Publique–Hôpitaux de that Ebola poses to national public health and Marseille, social, economic, and security foundations may Sandra Moore, M.S., M.P.H. worsen if a secondary epidemic eventually ex- Renaud Piarroux, M.D., Ph.D. plodes in the region. Since June 2014, nearby Aix–Marseille University Ghana has been affected by a serious cholera Marseille, France epidemic that was responsible for 12,622 cases as [email protected] 2 No potential conflict of interest relevant to this letter was re- of September 6. Current cholera and Ebola zones ported. are separated by , a frequent crossing 1. WHO Ebola Response Team. Ebola virus disease in West point for commuters traversing West Africa. To Africa — the first 9 months of the epidemic and forward projec- effectively control cholera , specialized tions. N Engl J Med 2014;371:1481-95. treatment centers, access to potable water, sani- 2. Cholera outbreak in the West and Central Africa: regional update, 2014 (week 35). New York: UNICEF (http://www.unicef tation, and community hygiene awareness are .org/cholera/files/Cholera_regional_update_W35_2014_West_ critical. However, in Ebola-affected areas, quaran- and_Central_Africa.pdf). tine units are overwhelmed, many health facili- DOI: 10.1056/NEJMc1413884 ties are dysfunctional after the desertion by staff members who fear viral contamination, and it has become increasingly dangerous to conduct To the Editor: The WHO Ebola Response Team awareness campaigns owing to violence against describes the of Ebola virus dis- health and humanitarian workers accused of ease (EVD) in West Africa using anonymized pa- tient-level data generated from EVD surveillance this week’s letters in multiple countries. These data document the demographic profile of patients with EVD, their 188 Ebola Virus Disease in West Africa — risk factors, and the course of their illness. We The First 9 Months regret that the WHO neither makes this data set publicly available nor provides an interface to ex- 189 Goal-Directed Resuscitation in Septic Shock tract customized tabulations. Such data sharing could accelerate the discovery of key factors in 191 Malpractice Reform and Emergency the epidemic and could yield insight into the eco- Department Care nomic and demographic drivers of the outbreak. 193 Physiological Approach to Acid–Base It would also permit a better assessment of pos- Disturbances sible control scenarios. Current models of EVD transmission1,2 are parameterized with the use 196 Inefficacy of Platelet Transfusion to Reverse of outdated data from much smaller Central Afri- Ticagrelor can outbreaks, which limits their applicability to West Africa. Some patient-level data sets collect-

188 n engl j med 372;2 nejm.org january 8, 2015 The New England Journal of Medicine Downloaded from nejm.org at UC SHARED JOURNAL COLLECTION on January 11, 2015. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved. correspondence

ed during the West African outbreak are already tential and challenge of mobile network data. PLOS Currents Outbreaks 2014 September 29 (Epub ahead of print). publicly available,3 and some mobile telephone DOI: 10.1056/NEJMc1413884 providers have released call-data records to help predict the spread of EVD.4 We encourage the WHO to adopt these practices and share this The Author Replies: The WHO receives patient- data set with all researchers who wish to lend level data on EVD from the ministries of health their skills to help stop this tragedy. of the affected countries, which own the data. Stéphane Helleringer, Ph.D. After discussion with external research groups, Mailman School of Public Health, Columbia University and under specific conditions, the WHO shares New York, NY these data in order to carry out epidemiologic [email protected] analysis, as well as the evaluation of interven- Karen A. Grépin, Ph.D. tions. The results of these joint analyses are con- New York University solidated by the WHO into recommendations to New York, NY member states for action in the field. In addition Andrew Noymer, Ph.D. to sharing patient-level data with collaborating University of California, Irvine institutions, the WHO publishes aggregated Irvine, CA data, such as cases reported according to the No potential conflict of interest relevant to this letter was re- week and district in , Liberia, and Sierra ported. Leone, which are made publicly available in regu- 1. Rivers CM, Lofgren ET, Marathe M, Eubank S, Lewis BL. lar situation reports. Modeling the impact of interventions on an epidemic of Ebola in Sierra Leone and Liberia. PLOS Currents Outbreaks 2014 Octo- Christopher Dye, D.Phil. ber 16 (Epub ahead of print). World Health Organization 2. Estimating the future number of cases in the Ebola epidemic Geneva, Switzerland — Liberia and Sierra Leone, 2014–2015. MMWR Surveill Summ [email protected] 2014;63:Suppl 3:1-14. 3. Gire SK, Goba A, Andersen KG, et al. Genomic surveillance for the WHO Ebola Response Team elucidates Ebola virus origin and during the 2014 Since publication of his article, the author reports no further outbreak. Science 2014;345:1369-72. potential conflict of interest. 4. Wesolowski A, Buckee CO, Bengtsson L, Wetter E, Lu X, Tatem A. Commentary: containing the Ebola outbreak: the po- DOI: 10.1056/NEJMc1413884

Goal-Directed Resuscitation in Septic Shock

To the Editor: The Australasian Resuscitation mortality.4 Since the exact nature of fluid therapy in Sepsis Evaluation (ARISE) Investigators and is crucial in EGDT, can the authors provide data the Australian and New Zealand Intensive Care on the specific fluids that patients received both Society (ANZICS) Clinical Trials Group (Oct. 16 before and after randomization? issue)1 report that early goal-directed therapy Hans-Joachim Priebe, M.D. (EGDT) did not reduce mortality at 90 days University Hospital Freiburg among patients with early septic shock. During the Freiburg, Germany 72 hours after randomization, both groups in the [email protected] No potential conflict of interest relevant to this letter was re- study received a mean of approximately 6500 ml ported. (70 to 75 ml per kilogram of body weight) of 1. ARISE Investigators, ANZICS Clinical Trials Group. Goal- combined crystalloids and colloids (see Table S5 directed resuscitation for patients with early septic shock. N Engl in the Supplementary Appendix of the article, J Med 2014;371:1496-506. available at NEJM.org). A footnote in Table S5 2. Prough DS, Bidani A. Hyperchloremic metabolic acidosis is a predictable consequence of intraoperative infusion of 0.9% saline. suggests that 0.9% saline was often used as crystal- Anesthesiology 1999;90:1247-9. loid; rapid isotonic saline infusion predictably 3. Handy JM, Soni N. Physiological effects of hyperchloraemia results in hyperchloremic acidosis.2 Hyperchlore- and acidosis. Br J Anaesth 2008;101:141-50. 4. Silva Junior JM, Neves EF, Santana TC, Ferreira UP, Marti YN, mia can be associated with reduced gastric muco- Silva JMC. The importance of intraoperative hyperchloremia. sal perfusion, renal vasoconstriction, a reduced Rev Bras Anestesiol 2009;59:304-13. glomerular filtration rate,3 and even increased DOI: 10.1056/NEJMc1413936

n engl j med 372;2 nejm.org january 8, 2015 189 The New England Journal of Medicine Downloaded from nejm.org at UC SHARED JOURNAL COLLECTION on January 11, 2015. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved.