What's it like to work an Ebola outbreak?

As another Ebola outbreak simmers in Uganda (and appears to be increasing), I recently was in touch with Zoe Young, a water and sanitation expert with Médecins Sans Frontières (MSF*, known in the US as Doctors without Borders), who was working in the Democratic Republic of Congo during the DRC Ebola outbreak earlier this fall (and blogging it!)

Regular readers know of my interest in this virus, but I'm obviously geographically removed from any of the outbreaks. As such, Zoe and her colleague, physician Armand Sprecher, were generous enough to answer my questions about their work with MSF and the Ebola outbreak in particular; our conversation is after the jump.

First, just a bit of background on Zoe and Armand. Armand is a native of Philadelphia, and received his Bachelor's degree in cognitive science from Brown University. He followed that with his MD from Jefferson Medical College, then headed west for a residence in emergency medicine at the University of Missouri Kansas City, then back to the east coast for a degree in public health from Johns Hopkins. He's worked in the field with the International Medical Corps (IMC) in Bosnia, and with MSF in Sri Lanka, East Timor, Uganda, and Burindi. He's been working in the headquarters of MSF's Operational Center of Brussels (OCB) as the medical department's public health support person since 2004.

From 1997 to 2001, while not in the field, he worked in emergency rooms in Wisconsin, Nebraska, New Jersey, and Wyoming.

Zoe is London born and bred. She graduated from the University of Manchester with a BSc in Biology and Geology and received an MSc from Edinburgh in Environmental Protection and Management. She has extensive field experience, having worked for Action Against Hunger (ACF) in Sierra Leone in 1996-7 and in Burma from 1997-98. She worked with Oxfam in Sierra Leone 1999 and in Eritrea 2000; with International Federation of Red Cross and Red Crescent Societies (IFRC) in El Salvador in 2001, and with International Rescue Committee in East Timor in 2002. She started work with MSF headquarters in the medical department as part of the water, hygiene and sanitation unit in 2004.

Zoe also worked elsewhere when she wasn't in the field, including stints with Interact Worldwide, a sexual and reproductive health organization in London. She also helps to run a web-based fair trade business importing recycled items and silver.

I asked them first how they both ended up working with MSF, and in the DRC on Ebola:

Armand: During my emergency medicine residency, I spent my elective time in Bosnia with IMC. The medical coordinator there was a former MSF expat and his recommendation led me to volunteer when I finished my residency. As for the DRC, it was both a matter of assignment and choice (as are most MSF postings). I had experience and interest in filovirus outbreaks, and MSF needed me there.

Zoe: A friend of mine sent me the link to the job when it was advertised and I applied - never really thinking that I would get it and move to Brussels! A few months after I started I took over as the focal point for haemorrhagic fever from one of my watsan (water and sanitation) unit colleagues when he left - he had made it all sound very interesting and challenging.

Can you describe your previous experience with outbreaks of this type?

Armand: I worked with MSF in the Ebola-Sudan outbreak in Gulu in 2000 as their isolation ward physician. This is where I met my wife, who was the field coordinator at the time. She went to the Gabon outbreak in 2002 while I was at Hopkins, and the problems with that outbreak led me to do my masters thesis on health communication in Ebola outbreaks. Once in headquarters, I went to the Marburg outbreak in Angola in 2005 as medical coordinator. Since then, I have been working on, among other things, revision of MSF's filovirus outbreak management manual.

Zoe: I went to join the team in Angola for the Marburg outbreak. I was lucky as there were several watsans there including my former colleague, so I got a very good job briefing. Then in July this year I went to Uganda to help do some training for a very small Marburg outbreak, which was a good refresher for the DRC Ebola outbreak in September.

What was the situation like when you arrived in the DRC?

Armand: I arrived in the first week of October, so things were almost over by then. The last patient was hospitalized shortly before my arrival (though of course we did not know that then). Many of the people who had been there from the beginning were ready to leave. The project coordinator was tired, so I replaced her in addition to being the medical coordinator for the ensuing two and a half weeks. The community was happy with our presence and the general feeling was that things had improved. Though there was still fear of the disease, this was not interfering with outbreak control.

Zoe: I arrived about a week after the first teams had got there. Basic isolation was in place with disinfection procedures, but it was a bit chaotic. As more medical staff were arriving, it needed to be improved because otherwise with all these new people moving about, it would have been difficult to ensure correct procedures. It was good that there was something in place to build on because it made it much easier to make big improvements very quickly. Also, we were lucky in that there was plenty of space and the local administrator was happy for us to extend the perimeter of the isolation to make a better flow.

What was a "typical" day like (if there was one?) How long were each of you there?

Armand: I was there for two and a half weeks. These interventions are many-headed hydras, and coordinating means spending the day touching base with everyone to make sure that they know what needs to be done and provide any necessary support. It also means keeping in touch with the other organizations (MoH, WHO, CDC, Public Health Agency of Canada, Médecins du Monde, etc.). In practice, this means sitting down with team members or people from other agencies individually, or collectively in MSF team meetings or WHO coordination meetings (quite the change from Gulu, where I spent all day in personal protective gear with patients in the isolation ward). It is fascinating though. It requires that one have a good understanding of epidemiology, clinical medicine, infection control, health promotion, medical anthropology, etc.

Zoe: I think that the typical day changes during the outbreak. To begin with, it was much more about trying to get everything correct and safe in the isolation. Training of staff for burials, collecting patients, disinfection, etc. Sometimes training is a bit by osmosis because there just isn't time to talk to everyone about every aspect, or it is ad hoc, talking in the car to the drivers about procedure, etc. Then of course activities depend on the number of patients and whether they have died or not. Some days were a bit more fraught than others. There was one day with three burials that I mentioned in my blog (which was edited because it was so awful) where we were literally trying to match the body with coffin - get the body into the small coffin, then to the grave - perhaps not yet dug, back to pick up the next body, etc. Some days, there were reasonably healthy patients in the ward, so perhaps improvements in flow planned and then everything in the air because new patients coming in or people dying outside the isolation. I found the whole experience really tiring but very enjoyable and it certainly kept everyone on their toes.

During an outbreak like this, I know there are many responsibilities: patient care, education of both local people and your co-workers, contact tracing, diagnostics, scientific research, and I'm sure many others. I also know you wear many hats while you're there as well, doing everything from setting up isolation wards to burying the dead. I'm wondering about the logistics of all this--do you all work together, or is it more that everyone does their own thing?

Armand: So now you get to why coordination is important. Everyone has their principle domain of responsibility, but there needs to be communication within the group. If the epidemiologist doing case investigation finds a novel transmission method of importance (such as a local traditional medical practice), then this would need to be passed to the people doing health promotion. If the team in the isolation ward notes that the patients have been receiving little in the way of visits or inquiries from the patients' families, this bodes ill for the welcome that survivors may receive when discharged, and how they are treated may have an impact on the willingness of those who become ill to be detected and isolated themselves. This would be something to discuss with the mobile teams working in the community, that they may investigate further. Even PCR has false negatives, and interpretation of a negative result that should result in a patient's discharge from isolation needs to be interpreted in light of their clinical appearance and epidemiologic risk. These are just a few examples of how people need to work together. I have not been involved in another sort of intervention that had people so interested in each other's work. It is also the reason why poor coordination can be so detrimental to outbreak control (as, alas, it has been too frequently the case).

Zoe: Also every evening we had a kind of round up of the days' events, like hearing about the road making [a road between villages was built while they were there--TS] or meetings or what the CDC was planning to get a general overview, not just the specifics. It was a great team as well and as Armand says, everyone is very interested in the whole process, not just their speciality.

Ebola is a pathogen that's been so mythologized in the media and popular press. How does working during an actual epidemic like this contrast with what's been shown in movies such as "Outbreak?"

Armand: As for the disease, it is not as bloody and dramatic as in the movies or books. The patients mostly look sick and weak. If there is blood, it is not a lot, usually in the vomit or diarrhea, occasionally from the gums or nose. The transmission is rather ordinary, just contact with infected body fluids. It does not occur because of mere proximity or via an airborne route (as in Outbreak if I recall correctly). The outbreak control organizations in the movies have no problem implementing their solutions once these have been found. In reality, we know what needs to be done, the problem is getting it to happen. This is why community relations are such an issue, where they are not such a problem in the movies.

Zoe: As Armand says, there is not as much blood as you think there will be, although I also think that I have been lucky when I hear about some patients that colleagues have dealt with where there was more blood and horror. I haven't seen Outbreak; perhaps I will save that for viewing during the next outbreak as those sorts of films are great tension reliever and also useful educational tools (how not to..........).

I'd like to ask about a few quotes from your posts, Zoe. The first, from here, regarding workers' appearances in their protective gear:

"What really struck me was how un-human she looked, completely dressed up, making strange jerky movements and impossible to see her face. I saw, really for the first time, how we might be perceived by the patients."

How *do* you feel you were perceived by the people there, both patients and not? You mention in another post about a driver (I think it was a policeman) who no longer wanted to help once he saw you had a body under a sheet. Was that a common reaction?

Armand: I cannot say much about Zoe's experiences, but I will add what I can from my own. When I was in Gulu, the outfits were a bit different, but not too much so. It was important that people have their names written on their aprons, or we would have had a hard time recognizing each other. I can imagine what this meant for the patients. This is one of the reasons that maybe face shields would be better than goggles and masks, if the protection were similar.

In the community, we have made an effort to keep people from overusing protective gear so that we do not give the impression of mysterious invaders from another planet coming to take people away as we spray chlorine solution everywhere.

Zoe: In fact it was a soldier who wanted a lift. There were quite often policemen and soldiers by the sides of the road who wanted to be dropped at the next guard post or town. The rule is that we don't pick up people that we don't know to take in the cars and certainly not someone from the army. So, we passed this guy without slowing down (we were going pretty slowly because of the road and because of the body in the back) so the driver spoke to him as we passed. A hundred yards or so further on there was a big pothole and one of the spray machines in the back tipped over so we stopped to get out and right it. The soldier thought we had stopped for him and came running up to jump in. More difficult now, since we had stopped, not to take him but luckily at the mention of the body under the plastic sheeting he backed right off.

I think that most people were happy that we were there. Quite often there were comments about that and of course for the staff it was the opportunity for work as well. But, of course the people didn't want to touch anything contaminated and even the drivers to begin with would be very careful about washing the whole surface of their cars, not just the back that had had the patient in it.

Because of the set up it was possible to see the patients and talk to them without all the protective gear on which was nice - of course they didn't necessarily realize that you had been the one in the space suit standing next to them 10 minutes before. But it did mean that they could see that they were being taken care of by (friendly) human beings.

Zoe, you wrote, regarding contact follow-up:

"When I went out this morning with the team one of the first houses we visited belonged to one of the patients that we buried last week. His wife was sitting there, looking extremely desolate. I asked how she was and she said, 'not sick'. Of course, I hadn't meant that. What was very difficult was that it wasn't really possible to touch her arm or take her hand to show a bit of empathy. She is a contact and has to be monitored."

Many of the stories you shared on your blog ended badly, with the death of the patient. But as you note, you stayed removed, even though it was difficult for you. These outbreaks must be hugely emotional--how do you cope?

Armand: When I was doing clinical care, I focused on treating what I could (i.e. other infections that resembled Ebola enough to get the patient isolated - dysentery, malaria, etc.), keeping the patients comfortable, keeping the staff safe, and making sure the survivors recovered well. That worked well enough, but that was Ebola-Sudan, so we had a few more survivors. Coordination removes one from the patients, so it is easier in that regard.

Zoe: In a way the openness of the structure made it all more difficult because all the time, even when inside, it was possible to look out and see the family members and see their sadness. Also, because we were at the end of the epidemic there were not that many patients there at any one time so you build up a bit of a relationship with them--especially the ones that come in earlier on in the disease, and who are talking and walking about. But there are plenty of things to think about and ways to improve what we are doing, so it is not possible to spend too long dwelling on things - and of course there were lots of fun and funny people working in the team so there was lots of laughter and joking as well.

Regarding local conditions and infrastructure, you wrote:

"The man in the isolation unit at the moment comes from Kalombayi. This is a village which has had no road access, just a track for bicycles and motorbikes. Martin has had hundreds of people clearing a path so that cars can pass and so that patients can be collected if necessary. He has also had to make three bridges."

You make it sound like building roads and bridges is old hat. How much of this has to be done in outbreaks such as these? How widely scattered were the cases you were dealing with?

Armand: I think Martin's road work impressed even the experienced MSF folks. That being said, we do what needs doing. Zoë didn't mention the airstrip that he did? The cases and their villages where we traced contacts were within a 1-1½ hour drive by Landcruiser (under 30 kilometers, I think).

Zoe: Yes, as Armand says Martins's road work was amazingly impressive and now that I read the paragraph I wrote again, I certainly didn't do him justice. I think that the total length of that particular road was 20km. He also improved the road to Luebo, which was a relief as there was a lot of to-ing and fro-ing for meetings and trainings. Although it was fun to be on such an excitingly precarious road on the first day, it is exhausting to travel like that every day. And of course Martin found a forgotten airstrip and remade it with waiting area and latrine, Kampungu International. All this work involved hundreds of labourers scraping and shoveling the road surface and cutting back trees and bushes, and Martin and his assistants would supervise all of it every day.

Finally, can you give the readers some information about where things stand now? You mention an overlapping outbreak of typhoid, which I also read about in the news; was that confirmed? Do they know anything about the subtype of virus (I assume Zaire strain...?)

Armand: It was Zaire. The typhoid was confirmed, as were some cases of Shigella. However, it is not clear that these were above their normal incidence, so I would hesitate to say there were parallel epidemics (as has been said). The outbreak was declared over on the 19th of November.

Zoe: Yes, that's over and the next one has begun!

The epidemic was confirmed rather late and was winding down when we arrived, so our impact may not have been great. However, it was a useful experience for us, as is each outbreak, in preparation for the next.

We had good relations with the community, which has not always been the case. It would be nice to know if it was something that we did, which could be repeated, or a result of contextual factors.

Many thanks to Zoe and Armand for taking the time to respond to my questions--and best of luck to them as risk life and limb taking on new epidemics.

*MSF has built considerable experience in previous outbreaks of hemorrhagic fever, especially caused by Ebola or Marburg: in Angola (2005), Gabon (1997 and 2002), Uganda (2001), Congo-Brazzaville (2003/2004), southern Sudan (2004). In DRC, MSF responded to a big Ebola outbreak in Kikwit, capital of the neighbouring province of Bandundu, in 1995. This epidemic killed 244 people between May and August 1995.

Image of 2007 DRC outbreak from http://a.abcnews.com/images/International/ap_congo_ebola_071003_ms.jpg