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Investigative work in the outbreak area

Epidemiologists from the Robert Koch Institute help the World Health Organization and others contain Ebola virus disease in West Africa

A work of art for educating about Ebola virus disease emerges on the wall at a sports field in Monrovia, paid for by the Liberian Ministry of Health and Social Welfare. Source: Esther Hamblion/WHO

For many, the Redemption Hospital in New Kru Town, a suburb of Mon­ro­via, ap­pears to be the last hope. It is a reception ward for suspected Ebola cases for which there is no place in a treatment centre. Families have trans­por­ted their ai­ling loved ones here on the back of motorcycles; one woman is even lying in a wheelbarrow. The hospital, however, is already overcrowded. Police and security personnel have sealed the entrances. People are angry and desperate and Na­dine Zeitlmann is right in the middle of it. She and her team were actually here with their local assistants for an appointment with the Liberian Ministry of Health, but the crowds force them back into their car. Through the windshield, she wat­ches as the woman in the wheelbarrow dies. “The whole situation was shocking.”

Nadine normally works at the Bayerische Landesamt für Gesundheit und Le­bens­mittel­sicher­heit (Bavarian State Agency for Health and Food Safe­ty) in Ober­schleiß­heim, Germany, where she primarily concentrates on gastrointestinal pathogens such as typhoid, EHEC-HUS, hepatitis, and Salmonella. The biologist is currently completing her post-graduate training for applied epidemiology (PAE) at the Robert Koch Institute (RKI). This training programme is unique in Germany. She and her fellow participants, mostly physicians as well as scientists from other fields, principally learn epidemiological field work. They investigate disease outbreaks and estab­lish their own research projects, either in the Department for Infectious Disease Epidemiology at the RKI or, like Nadine, in a governmental health agency. Parallel to this, they attend lectures throughout Europe: The German programme is closely associated with the European Programme for Intervention Epidemiology Training (EPIET), which is coordinated by the European Centre for Disease Prevention and Control (ECDC).

In search of possible contacts: A case finding team in Monrovia interviews the head of the family of a deceased Ebola patient. Source: Nadine Zeitlmann/RKI. In search of possible contacts: A case finding team in Monrovia interviews the head of the family of a deceased Ebola patient.

In July 2014, the ECDC sends a request to the EPIET mailing list. In West Africa, Ebo­la is raging. The World Health Or­ga­ni­za­tion’s Global Outbreak Alert and Response Net­work (GOARN), which for years has successfully fought disease outbreaks all over the world, is desperately seeking epi­de­mi­o­lo­gists to help curb the epidemic on the ground. “It was a great op­por­tu­ni­ty to do something useful my­self”, recalls Nadine. She submits her application. Her supervisors at the RKI and in Oberschleißheim are supportive: they organise her examination in Munich to determine her fitness for service in the tropics, clarify the details for the business travel request. At the end of August 2014, Nadine flies to Monrovia, the capital of Liberia, for five weeks.

From Oberschleißheim to one of the epicentres of the Ebola epidemic

At that time, Mon­ro­via is one of the epi­centres of the Ebo­la virus di­sease (EVD) epidemic. Approxi­mately 200 people are infected with the virus per week. “There was too little of eve­ry­thing,” she says. “There were only two teams for safe bu­rials. There was no ambulance, too few helpers and far too few beds in the treatment centres.” She and her colleagues check the data­base in the Liberian Health Ministry in which cases of EVD are re­cor­ded. They perform an initial ana­ly­sis: How is the outbreak deve­lo­ping in Monrovia? When will the greatest number of cases be ex­pec­ted and where? When residents call the national EVD telephone hot­line and report a suspected case, the local teams drive there, question the residents about pos­sib­le sources of infection and, if pos­sib­le, arrange for the afflicted patient to be taken to an EVD treatment centre. “Creating a list of people with whom the patient had come into contact, putting them under qua­ran­tine and checking on them regularly was impossible in the outbreak si­tu­a­tion in Monrovia at that time,” says Nadine.

Nadine Zeitlmann and her colleague in the health agency of Margibi, a neighbouring county of Montserrado in Liberia. The experts identify cases of infected health care workers in the Ebola database. Source: Nadine Zeitlmann/RKI. Nadine Zeitlmann and her colleague in the health agency of Margibi, a neighbouring county of Montserrado in Liberia. The experts identify cases of infected health care workers in the Ebola database.

In autumn 2014, the first priority for the local and in­ter­na­tio­nal aid wor­kers from WHO was to get the si­tu­a­tion in the out­break areas under con­trol. Making sure that infected people were treated and that the deceased were safely buried, that sufficient personal protective equip­ment and dis­in­fec­tant were on-hand, and that, in some cases, the exponential increase in the num­ber of cases was stemmed. Only then the path would be clear for the second phase of the battle. WHO calls it “Getting down to ze­ro.” With tight infection control measures, the virus is to be curtailed.

Nets with gaps

This means that whenever people fall ill with EVD, the field epidemiologists have to disclose how they became infected and who they may have infected. They have to track down all contacts, place them under quarantine at home for 21 days and check their health daily. Anyone who develops a fever is taken to a treatment centre. Ideally, all confirmed cases, suspected cases and contacts will come together in a seamless net, each one of them being monitored. Thus, additional infections are prevented.

In the field, however, things never work that well. The epi­de­mio­lo­gists have to do real in­ves­ti­ga­tive work. Ne­ver­the­less, there are still gaps in the net. Many ca­ses only come to light after the af­fec­ted person has died. Then, sources of infection and contacts can hardly be re­con­struc­ted. Sometimes not all parties concerned pass on all in­for­ma­tion immediately. “Obtaining precise information is a big problem,” says Maja George. The post-doctorate biologist currently works in the Rhine­land-Palatinate State Agency for Consumer and Health Protection in Landau. She will soon conclude the postgraduate training for applied epi­de­mio­lo­gy at the RKI.

For WHO, she was deployed in Kambia, a rural district in northwestern Sierra Leone from the beginning of March to the middle of April 2015. There were only a few Ebola cases at that time, but the risk was great that more would spill over from neighbouring Guinea. Maja led her surveillance team of international and local staff over bumpy roads in the remotest areas for hours in order to carry out investigative work in villages, find cases or contacts. It was anything but easy. “People tended to be coy and incommunicative,” she says. Often, the team lost valuable time.

The fear of being quarantined

Aid workers are lead into the bush where the bags of clothing from a deceased Ebola patient have been stashed. Source: Maja George/RKI. Aid workers are lead into the bush where the bags of clothing from a deceased Ebola patient have been stashed.

In one village, says the epi­de­mio­lo­gist, a man had died of EVD. His highly infectious clothing had been picked up by a friend from a neigh­bou­ring village, it was said, on a mo­tor­cyc­le. But the people in the neigh­bou­ring village remained si­lent. “We had to drive there three times before we found the motor­cyc­list,” says Maja. The team then gradually learned that no­bo­dy had wanted the clothing of the de­cea­sed man. The motor­cyc­list had left it in a plastic bag in the bush. “The residents of the village had in­tui­ti­ve­ly done the right thing.” A de­con­ta­mi­na­tion team then retrieved the clothing from the bush and disinfected it. The motorcyclist was quarantined. He was lucky: He wasn’t infected with the Ebola virus.

In Sierra Leone, quarantines are established by the government. A temporary barrier is placed in front of the house. Unarmed soldiers ensure that nobody walks in or out for the next three weeks. Every day, the residents’ tempe­ra­tures are taken. The affected families are pro­vided with food and necessities for that time. Never­the­less, some­times entire villages conspire to evade the quarantine.

Maja George also experienced that people already quarantined denied symptoms of the disease − be­cause they were afraid they would be taken away and never return, or simply be­cause they had nobody to take care of their children. For security reasons, the actions of the epi­de­mio­lo­gists are li­mi­ted: In order to protect themselves from being infected, they are not allowed to enter the houses. They speak with fa­mi­ly members in front of the house and have to rely on the information they are given.

A safe burial of a deceased patient in Kambia District, Sierra Leone. As a safety precaution, all deceased persons are buried this way in the Ebola outbreak area. Source: Maja George/RKI. A safe burial of a deceased patient in Kambia District, Sierra Leone. As a safety precaution, all deceased persons are buried this way in the Ebola outbreak area.

One time, Maja and her team weren’t aware that a man who was under quarantine with his wife and seven children was actually infected with EVD. He had probably suppressed the early symptoms with medications; his wife had said nothing to the team. The man and six children died. “You just stand there powerless and can’t really do anything,” she says. She knows that experiences like these are part of the job.

Ask the right questions

Post-doctorate infectious disease biologist and PAE participant Joana Haußig knew early on that she wanted to help in West Africa. “The work done by my colleagues there has impressed me,” she says. After having performed outbreak investigations in Germany, she learned that one thing is essential in the field: “You have to ask the right questions.”

One PAE learning module was particularly beneficial to her de­ploy­ment in West Africa: the par­ti­ci­pants learn to manage an acute outbreak event in a realistic exer­cise. They must obtain and in­ter­pret current information, with all the difficulties associated − time is short, some information must first be translated. “We learned how to work together effectively, even un­der great pressure,” says Joana. “And we also learned how to com­mu­ni­cate in such a situation.” Good communication is critical, especially in West Africa.

“Examination report? I have that in my head”

From early April until the middle of May 2015, Joana is deployed in Guinea, in a part of the capital Conakry and in Dubréka in the north. She and her team are mainly responsible for hospitals and private medical practices − in other words, locations where, sooner or later, suspected cases of EVD will emerge. They compile lists and determine where the greatest number of suspected cases might be ex­pec­ted. “The doctors in the emergency rooms, for example, are supposed to fill out a questionnaire about EVD symptoms for each patient, no matter why he or she came in,” says the epidemiologist. No case may be overlooked.

A doctor in Dubréka shows Joana Haußig and her colleague from the WHO patient data. Source: Carlos Carvalho/ARS Norte, IP. A doctor in Dubréka shows Joana Haußig and her colleague from the WHO patient data.

The speci­a­lists check the sur­veys and follow up. “There have been suspected cases every day. For­tu­na­te­ly, most turned out negative,” says Joana Haußig.

In Dubréka, the epidemiologists al­so visit 30 private medical prac­ti­ces, which in some cases consist of nothing more than a small back room. They provide the doctors with additional information and, if ne­ces­sa­ry, with soap, gloves and thermal scanners. “I liked this work. The doc­tors were very grateful,” she says.

Sometimes, however, she actually had to do a lot of persuading, for exam­ple, when it comes to the proper docu­men­ta­tion of patient data. “People in Guinea are accustomed to oral reports”, she says. When she asks a local doctor involved in case studies for the relevant docu­ments, he taps on his forehead and says: “I have every­thing in here!” – “And what do I do if there is a time when your head is not there?” she then asks back.

“The EVD out­break in Guinea has lasted more than one and a half years. The local doc­tors have their own way. They won’t change over­night,” she says. “All you can do is try to gently improve the system.”

Seven weeks later, at the end of July, a young man died again of Ebola virus disease in Liberia. Even after everything, countries must remain vigilant.

The outbreak is not yet over

 Employees of the Red Cross give a lecture on safe burials at a meeting in Dubréka, Guinea. Source: Joana Haußig/RKI. Employees of the Red Cross give a lecture on safe burials at a meeting in Dubréka, Guinea.

Nadine Zeitlmann, Joana Haußig and Maja George have gained much from their mis­sions to West Afri­ca. They admire the great com­mit­ment of the locals, who main­tain Ebola hotlines with their private cell phones and do dangerous work such as burials despite low pay. They learned the importance of good communication skills. Some­times, you are most likely to track down someone who might be in­fec­ted by speaking calmly with the women of the village rather than by threatening to call the police. You cannot always stubbornly insist on following rules, the three epidemiologists say, you have to reach com­pro­mises. An epi­de­mi­o­lo­gi­cal database with lots of variables may indeed provide the best in­for­ma­tion, but it isn’t feasible in such a situation. The deployment enriched their post­gra­duate training.

So far, nine PAE participants have supported the World Health Organization and Doctors Without Borders (MSF) in West Africa. For others, the journey to West Africa is still ahead. Although the number of cases in Guinea and Sierra Leone has diminished greatly in the last few months, the outbreak is not over yet.

And yet, there is hope. Liberia, which has been the most severely affected, was declared free of Ebola by the WHO on May 9 2015. To celebrate the day, Nadine opened a bottle of Liberian beer and ate ginger cookies which she had saved during her deployment for this very moment. “I was simply proud of the fact that Liberia has accomplished it.”

Seven weeks later, at the end of July 2015, a young man died again of Ebola virus disease in Liberia. Even after everything, countries must remain vigilant.

Date: 13.08.2015