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At the epicentre

Virologists from the Robert Koch Institute diagnose Ebola virus infections in the European Mobile Laboratory

Andreas Kurth’s team being trained on the European Mobile Laboratory in Guéckédou. Source: Andreas Kurth/RKI

It's hot in the tent. Temperatures of 30° C prevail in Guéckédou in June. Andreas Kurth is covered in protective clothing from head to toe. There is sweat in his safety goggles, he tilts his head slightly backwards to prevent it from getting in his eyes. The twins lie in one bed together, two tiny, ema­cia­ted bodies. They are just six months old and completely dehydrated. Time and again, the nurses try to infuse them with water and electrolytes, but to no avail. The children are going to die. “They had no chance,” Andreas says.

The Doctors Without Borders treatment centre in Guéckédou, Guinea. On the left, patients are sitting under an umbrella. Clothing of doctors and nurses are drying on the right side. Source: Andreas Kurth/RKI The Doctors Without Borders treatment centre in Guéckédou, Guinea. On the left, patients are sitting under an umbrella. Clothing of doctors and nurses are drying on the right side.

In June 2014, Guéckédou, Guinea, was the epicentre of the Ebola virus disease (EVD) outbreak in West Africa. The patient visit is an exception. Andreas needs to install an instrument for measuring blood pa­ra­me­ters. Here at the treat­ment centre of Doctors Without Borders, he and his team normally are responsible for diagnostics. They test the blood from suspected EVD cases in the European Mobile Laboratory, a kind of high-security laboratory in a 20-square-meter tent. Here is decided which patients will have to stay at the treatment centre, and who may go.

Andreas Kurth is a virologist. He runs the new BSL4 laboratory at the Robert Koch Institute (RKI), a laboratory with the highest level of security. When they asked him whether he would provide support for the European Mobile Labo­ra­tory in Guinea, he didn’t hesitate for a second. “We know the pathogen. We know how to handle the samples. Who else is going to do the job, if not us?”

A European project

The European Mobile Laboratory, or EMLab, is a special laboratory for highly pathogenic agents that can be set up and operated in an outbreak area at light­ning speed. The mobile laboratories themselves − there are a total of three − were conceived of by the Institute for Microbiology of the German Bundeswehr in Munich. The Hamburg-based Bernhard Nocht Institute for Tropical Medicine coor­di­nates the deployments. The project is funded by the European Commission. Partners from all over Europe are involved, in­clu­ding: Public Health England, the Laboratoire P4 INSERM Jean Merieux in France and since 2014, the Robert Koch Institute.

The EMLab was deployed in Guéckédou at the end of March 2014, shortly after the first cases of EVD were officially confirmed by the World Health Organization (WHO). Five scientists always work here for four weeks. After­wards, they are replaced by the next team. Curtailing the outbreak depends on a reliable diagnostics on-site. Infected people have to be quickly isolated from others to prevent further spread of the disease.

Andreas Kurth begins his service in Guéckédou at the end of May 2014, along with a col­league from Marburg, a Scot, a French col­league and an Italian. The days are always the same. Around 8:30 a.m., the ventilation system is turned on and the laboratory is opened. The fresh blood samples first arrive in the glovebox, a trans­pa­rent box with in­te­gra­ted gloves in which the virologists can safely pro­cess the infectious material. The sample is tested for malaria and chemi­cal­ly deactivated, i.e. any Ebola virus that may be present is killed. Then, the sample is examined outside the glovebox in order to determine whether it actually contains traces of Ebola virus.

Andreas Kurth analyzes blood samples from suspected Ebola virus disease cases. Source: Gordian Schudt/University of Marburg Andreas Kurth analyzes blood samples from suspected Ebola virus disease cases.

The steps are similar to those in a biosafety level 3 laboratory at the Robert Koch Institute. And yet, wor­king in the outbreak area is completely different. This is not only due to the simple conditions in the tent which make every step in pro­ces­sing and disinfection lon­ger. When Andreas looks out the window of the tent in Guéckédou, he can see the patients over the red barrier fence. He sees people who are vomiting. He sees how a woman collapses dead. He sees children without parents wandering about the camp. “There is a face for every sample,” he says.

The first week of June is something like a turning point in Guéckédou. The epidemic picks up its speed, the number of cases suddenly shoot through the roof. His team processes 20 samples from patients suspected of having EVD per day. Almost all of them are positive.

Training session at the German Bundeswehr and rules of conduct for the deployment

Ebola has been raging in West Africa for more than one and a half years. According to the WHO, more than 27,000 people have been infected with EVD since March 2014, more than 11,000 have died. It is the worst outbreak in history. The European Mobile Laboratory project has long since deployed all three of their mobile laboratories in West Africa. So far, 17 RKI employees have supported the EMLab on-site, some even twice. “On ave­rage, we pro­vide two col­leagues eve­ry month,” says Andreas Nitsche. He leads the Department for Highly Pathogenic Viruses at the Robert Koch Institute and organizes the missions.

He says that anyone who wishes to work in the EMLab should be proficient in the diagnosis of viruses and, as far as possible, already experienced with African countries. The candidates get a five-day training course by the Ger­man Bundes­wehr in Munich, online safety training for UN staff, a full range of examinations, vaccinations, and rules of conduct for the deployment: avoid crowds, don’t spend time outside the hotel or laboratory. Andreas Nitsche says the participants come from a wide range of fields. Even an influenza researcher is among them. “There are many young scientists who are ready to take on this big responsibility.” He is proud of his colleagues.

Coping with the fear

The deployment in the EMLab is very demanding. The staff stands in the laboratory for many hours, continuously for four weeks. It's cramped, it's hot. Some teams process up to 70 samples a day. “Then there are the group dynamics to consider,” says Andreas Kurth. The five team members are cobbled together from all over Europe. For the next four weeks, they spend almost every minute together. “At some point it is getting difficult.” He could barely communicate with two team members because they didn’t speak English well. In the team of his RKI colleague, Constanze Yue, there was even some tension from the outset.

Constanze works in the Department for Highly Pathogenic Viruses for the German Partnership Program for Excellence in Biological and Health Se­cu­ri­ty of the Federal Foreign Office which in part is located at the RKI. She helps African partner countries like Morocco or Tunisia expand their diagnostic capabilities. When the request came from the EMLab in June 2014, her friends said: "Don’t go." She went anyway. “I didn’t have any time to really think about it much. I simply did it.”

It was a drastic experience, she now says. The individual team members didn’t get along well with each other. One colleague was completely over­whelmed by the outbreak situation. “He refused to handle the samples. His face was pale as if turned to stone. He was suffering severely.” He didn’t want to break off the deployment. His fear, however, was so great that Cons­tanze processed all the infectious samples in the glovebox by herself. The colleague only handled material which had already been deactivated.

The underlying threat of Ebola made it difficult for her, too. News of phy­si­ci­ans from Doctors Without Borders or WHO em­plo­yees who were infected de­spite taking all safe­ty pre­caut­ions spread like wild-fire among the helpers. When she sat in her hotel room alone in the evening, she called her colleague at the RKI at home in Berlin. “She gave me courage.”

Her experiences in Guéckédou have not scared her off. In November, Constanze concludes yet a second deployment in the EMLab − this time in Foya, Liberia, together with a colleague from the RKI. “My condition was that there had to be one member in the team that I knew,” she says.

Two employees per month for the EMLab

When employees participate in the EMLab, they are absent from the Robert Koch Institute for six weeks, including the preparation time and one week of recovery at the end. This also means that tasks remain unfinished or col­lea­gues in Berlin must take over. “Management has said from the start: anyone who wants to go to the out­break may go. We’ll compensate for that here,” says Andreas Nitsche. The RKI will support the European Mobile Laboratory Project as long as the outbreak lasts. The RKI coordinator says there are enough candidates: “Most of those who already have been want to go again.”

Andreas Kurth and Constanze Yue greatly benefit from their deployments. They feel that they have done something really useful. They learned that even under hard conditions, highly pathogenic agents can be handled safely. They take their hats off to the helpers from Doctors Without Borders, who sacrificially care for the patients − ”and to the resilience of the patients,” says Andreas.

For every now and then, there are moments of happiness. The pregnant woman, for example, who defeats the Ebola virus infection, or the 15-year-old boy who, severely weakened by the infection, leads fitness exercises daily and jogs back and forth in front of the treatment tent. There are moments when no more trace of the virus is found in the blood sample of an EVD patient, when even the second one, the confirmation test, is negative the next day. When the patient finally goes home.

Date: 13.08.2015