Behind the Scenes in an Outbreak

This post does not have any relevance to my own experiences. It comes out of my uttermost respect for all scientists, doctors, and investigators who work in the field during disease outbreaks around the world. They are the individuals that work very hard behind the scenes to save lives.

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In 1976,  scientists at the Centers for Disease Control and Prevention (CDC), USA were informed about an outbreak of an unknown hemorrhagic fever virus (a disease caused by a virus with symptoms of fever and bleeding) in Zaire (now known as the Democratic Republic of Congo). A team of epidemiologists was sent out to the area in order to investigate the source and cause of the disease as well as to find out how it was transmitted and to prevent further spreading. They worked in remote areas of Central Africa where basic supplies such as syringes, rubber gloves, and tubes, or even fuel were hard to find. They traveled from village to village on muddy tracks and convinced locals to cooperate and help find the victims of this dangerous virus. It was during this time that they named the new virus after a river which ran near where it was first reported: Ebola 1

With a fatality rate of 88% in 1976, the Zaire ebolavirus strain is the most lethal of the five Ebolavirus strains identified so far 2 (see my previous post for a description of virus strains). Later, Zaire ebolavirus caused 15 more outbreaks in Africa, including the latest West African outbreak in 2014-2015. Although there are no vaccines or proven treatments, containing an Ebola outbreak is, in theory, not so hard. That is because the virus is not very efficient in human-to-human transmission. Yet, with thousands of victims, the recent West Africa one was the most complex and severe Ebola outbreak in the disease’s known history. Why?

Because the complexity and severity of an outbreak are not just due to the characteristics of a virus. Local circumstances, including the state of medical facilities and even cultural elements, also play their role.

CDC Epidemic Intelligence Officer Dr. Leisha Nolen, a doctor and scientist by training, was out there in the field during the 2014-2015 West African outbreak. I asked about her personal experience with the difficulties of containing this outbreak:

What was your responsibility in the field during the Ebola outbreak in Sierra Leone?

I was deployed to both Sierra Leone and Liberia as part of the Centers for Disease Control and Prevention (CDC) Ebola response in 2014. I went on three different deployments, at three very different times in the outbreak and because of that, I did very different things during each of those deployments. The first deployment was right after the first cases of Ebola were detected in Liberia. The country was not familiar with the disease; so was unprepared. A large part of my job at that time was educating healthcare workers about Ebola and what to look for in people who had the disease. I also helped set up a reporting system, a tracking system, and helped train health workers on protecting themselves. That month was actually rather calm; the country was not yet overwhelmed.

plane

Nolen is taking a plane to go to the rural part of Liberia.

When I deployed to Sierra Leone two months later, the situation was completely different. I arrived in the beginning of August when the disease was really starting to spread and people were starting to be affected throughout the country. The country and its health system were overwhelmed. I spent the next month and a bit working with the ministry of health to create a plan to deal with the outbreak. Sierra Leone (and Liberia and Guinea) did not have the experience or resources to control the outbreak. During that deployment, it was nearly impossible to get sick patients out of their homes for treatment and prevent the spread Ebola to the community – there simply were not enough ambulances or isolation wards available. It was a very hard month and the few of us who were there at that time were also completely overwhelmed by the disaster that was occurring.

By the time I returned to Sierra Leone in November, things had started to change. The World Health Organization and international non-governmental organizations brought in materials and people to support the response. For 6 weeks, I went to a small, rural area of Sierra Leone and worked with that region’s community as an epidemiologist, communication expert, and infection control expert. One of my proudest achievements was creating a picture book campaign that was used to educate the community members about the dangers of Ebola and how to protect themselves against it. We created teams of community teachers who went house-to-house showing people these books and teaching them how to stop the infection.

picture booksNolen is showing community teachers how to use the picture books.

Why do you think the Ebola virus spread so effectively in West Africa?

There are a number of reasons Ebola spread so extensively in West Africa. One factor that contributed to the spread of Ebola is traditional burial practices. One of the most important funeral traditions in West Africa is to wash the body of the dead. This was something that the family would all do together, and if the person was a chief of the village, then the whole village would do this together. This is also one of the most dangerous things you can do during an Ebola outbreak because the body and body fluids of someone who has died from Ebola are very infectious. Another factor that contributed to the spread of Ebola was the lack of resources – it was hard to tell people not to share utensils and use proper infection control practices such as using disposable gloves when these things weren’t readily available.

How did you experience the outbreak influenced local people’s, particularly families’, lives?

Life both changed and did not change. Mid-way through the outbreak, most schools were closed and community gatherings were forbidden. However, it was remarkable how people continued to live and work. West Africa society is very social and it was apparent that traditional beliefs were of the utmost importance in West African culture. Even after traditional burials were forbidden because of the risk of disease transmission, people continued to hold these in secret. The belief that they had to prepare their loved ones for the afterlife was more important to them than stopping themselves from getting sick.

How much did you observe the local people knew about the Ebola disease?

There were a lot of rumors about Ebola in the beginning of the outbreak.  People were not familiar with the disease and did not always trust the guidelines and recommendations that were distributed by the government and outsiders. Overcoming the communities’ disbelief and distrust was one of the biggest hurdles to stopping the outbreak.  There was a lot of work done to craft communication messages that were accurate and could be understood and accepted by the community.

teacherA community teacher is using the picture book to teach a family how to protect themselves from Ebola.

As a scientist and doctor, what do you think are the challenges of containing a viral outbreak?

Unlucky for us, viruses are very adaptable. There is no doubt we will continue to face new and dangerous viral outbreaks. As horrible as it was, the Ebola outbreak taught me a lot about how to respond to emergencies like this. This experience has taught me that it is not always the biology of the virus that is the biggest challenge, it is the way we respond and communicate. A coordinated response and the effective communication of information to the community will go a long way in addressing the next epidemic.

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Unfortunately, viruses and other pathogens continue to cause outbreaks around the world all the time. Zika virus outbreak in South America is the most recent example. Thanks to the work of people like Dr. Nolen, help is provided to those in need. Hopefully in the future, more and more resources will be available to projects investigating ways of disease prevention and treatment.

Betul

References

1 Joseph B. McCormick and Susan Fisher-Hoch. 1999. [Level 4] Virus Hunters of the CDC: Tracking Ebola and the World’s Deadliest Viruses. Sterling Publishing: New York

2 de La Vega, M.A., Stein, D. and Kobinger, G.P., 2015. Ebolavirus evolution: past and present. PLoS Pathog11(11). Pubmed: 26562671

Featured image: © Mrfiza | Dreamstime.com

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