Faith, medicine or ZMapp?
For Ebola survivors Dr. Kent Brantly and Nancy Writebol, the answer is clear.
“I would say the Lord. His merciful, gracious hand saved me in a way that used people and medication and a drug that had not been released. I think all of those things have played into our recovery,” Writebol told NBC News in an exclusive interview for the Friday NBC News Special "Saving Dr. Brantly: The Inside Story of a Medical Miracle.”
The doctors who treated them have another idea and they think what they’ve learned can save Ebola patients in Africa. What almost killed Brantly, they say, were irregular heart rhythms caused by what’s called electrolyte imbalance — the loss of minerals because of his constant, unending diarrhea.
“The closest infectious disease we can compare it to is cholera,” Dr. Bruce Ribner, who heads the special containment unit at Emory University Hospital in Atlanta where Writebol and Brantly were treated, told NBC News.
As with cholera, the constant vomiting and diarrhea pull all the fluids from the body, and with them sodium, potassium, magnesium and calcium — the so-called electrolytes that help the cells in organs such as the heart, brain and kidneys to function.
Brantly was losing five to seven quarts a day of fluid, Ribner said.
“The first night each time he got out of bed to go to the bathroom, he was getting weaker and weaker,” said Crystal Johnson, one of the nurses who cared to Brantly and Writebol. “He was febrile. He could barely stand. Every hour was tedious. We could not leave the room. We had to stay in our Tyvek suits and stay in the room.”
“It was water. It was just water coming out of him,” added infectious diseases specialist Dr. Aneesh Mehta, another member of Emory’s Ebola team.
And with every bout of diarrhea, Brantly was losing the electrolytes that make the heart beat regularly. “He was having rhythm problems because his electrolytes were so out of balance,” Ribner said.
Ebola horrifies people because it kills so quickly and takes so many of its victims — up to 90 percent in some outbreaks, and fully half in this current epidemic. And it’s a hemorrhagic fever, one that causes internal and external bleeding. It’s this especially horrific aspect of the illness that captures the imagination.
But after weeks of treating Writebol and Brantly under first-world conditions — in a sterile hospital room, with the facility to take regular blood draws and watch hour by hour what their bodies were doing, the doctors at Emory have some new ideas about what’s killing Ebola patients. It’s not the scary stuff so much as the fluid loss.
Doctors knew this to some extent. Medecins Sans Frontieres (MSF or Doctors Without Borders) says its teams have found that if people get saline treatment early on in the course of infection, the survival rate goes up to as high as 75 percent.
But Dr. Colleen Kraft, an infectious disease specialist at Emory, says replacing fluids is not enough.
“Over there, they don’t have a way to monitor those electrolytes,” she said. Yes, you could give patients an “electrolyte replacer” such as Pedialyte or Gatorade. “But you need to replace it in a very monitored and aggressive way,” she said.
In fact, it’s important to measure each electrolyte individually and replace it in a precise fashion, said Mehta. “The magnesium, potassium, each one is important in its own way,” he said.
“The laboratory testing, I think, would have a significant impact in improving their outcomes.”
Such monitoring is something that can only be done in specially equipped facilities, however. “That was just about impossible in Liberia,” Brantly said. For one thing, it’s dangerous to take blood from a patient with Ebola — it’s loaded with virus and highly infectious. One mistake — an injury called a needlestick — and the doctor, nurse or technician can become infected.
“He said he remembered patients sitting up and clutching their chests and then, essentially, falling over dead."
Kraft remembers something Brantly told her as they discussed treating Ebola patients in Liberia. “He said he remembered patients sitting up and clutching their chests and then, essentially, falling over dead,” she said. “I wonder if some of these individuals were basically dying of electrolyte abnormalities.”
Dr. Marshall Lyon, another member of the Ebola team at Emory, thinks it may be possible to improve matters a bit with better saline replacement solututions. “Probably a lot more success would be from making good IV solutions and making those available in West Africa,” he said.
Writebol and Johnson are the first two Americans to catch and survive Ebola in the raging epidemic that’s taken more than 2,000 lives in West Africa. Their colleague Dr. Rick Sacra is the third victim, and he’s now being treated at a special hospital unit in Omaha, Nebraska.
They’re all medical missionaries, sharing their faith as much a part of their goal as providing medical care to people in need of it — in their cases, in Liberia. Brantly works for Samaritan’s Purse, whose chairman and president is Franklin Graham, son of the evangelist Billy Graham. Writebol is an employee of SIM USA, an even older missionary organization whose workers and volunteers also spread word of their faith along with more worldly charity. Sacra, a faculty member at the University of Massachusetts medical school, also worked for SIM in Liberia.
Brantly and Writebol got an experimental treatment called ZMapp. It’s a combination of engineered antibodies called monoclonal antibodies that are designed to home in on Ebola virus and inactivate it. Brantly told his colleagues in Liberia to give the single three-dose course of the drug to Writebol. They only had one treatment course and she was older and sicker, he argued.
Then, “My condition deteriorated,” he said. “My doctors were very concerned I was going to die.” He’d been shaking and gasping for breath. He took the first course, and the results were almost immediate.
“It was after that infusion that the shaking became violent,” Brantly said. It lasted about 30 minutes and it’s a standard reaction for people given monoclonal antibodies. “Initially, I felt worse. They gave me some more Benadryl.” The antihistamine can calm the body’s response to the antibody treatment.
“It was after that infusion that the shaking became violent."
After another half-hour, the shaking had stopped, and an hour later, his rash started to disappear. “I was able to get up and walk to the bathroom, which I hadn’t been able to do in a day and a half,” Brantly said.
But to him, it’s not at all obvious that ZMapp was responsible. To Brantly, a man of deep faith who prays openly and frequently, who quotes scripture as a matter of course during conversation, it’s clear that something else was.
“The people in the room taking care of me, they began praying over me,” Brantly said. “What I didn’t know at the time was that there were also people outside my house praying for me," he added, speaking with queit precision. “There were thousands of people, including my teammates there in Liberia who were begging the Lord to save my life.”
His wife Amber called and e-mailed friends and family, asking them to pray, also. For the Brantlys, this was reason enough to explain the sudden change.
“I am not saying that ZMapp was inffective,” Brantly said. “I think God uses people and drugs and events and circumstances all the time to work his miracles.”
And, he points out, two of the people who got ZMapp — a Spanish doctor and a Liberian doctor — died anyway.
“I would caution everybody — yes our two patients have survived but there are two other patients that got this product that did not survive," Ribner agreed. “In fact, it may impede people’s survival and response.”
Brantly doesn’t discount the efforts of everyone who worked to save his life — from his colleagues in Liberia, to the efforts to get him on a specially equipped jet and into the unit at Emory, where doctors, nurses and technicians gave up vacation time and volunteered for the potentially hazardous and certainly strenuous duty to help him.
“I think God worked through those people to save me,” Brantly said.
Nancy and David Writebol agree.
“Every step of the way there was a piece of equipment, there was some person who had a skill that was needed at the moment, there was plane that had been specially built and equipped for Nancy and for Dr. Brantly,” David Writebol told NBC News. “There was a hospital. Then there were countless, countless people out there praying for Nancy and for Dr. Brantly.”
"Why were we saved and not others? I don’t know we can ever answer that question."
“We don’t understand the way that the Lord works,” Nancy said, looking at her husband and caressing his hand. “Why did God allow us to receive treatment? Why were we saved and not others? I don’t know we can ever answer that question.”
Johnson knows when that moment of salvation came — whether it came through science or something more mysterious.
“For me, it was when they asked to take a shower," she said, laughing. “That was it. I knew it then. They had the will. They had the strength and I knew it then.”