Baby on board–in a BSL4 lab

I’m happy to welcome Dr. Heather Lander to the blogosphere and Twitterverse. She’s a virologist who has done work with some of the world’s deadliest pathogens in a high-security biosafety level 4 laboratory. This is the type of lab where one must wear “space suits” to work with organisms. You’ve probably seen in dramatized in various movies and TV shows (such as The Walking Dead). Heather describes what it’s really like to work in one–even while pregnant.

Heather 9 months pregnant in BSL4
Dr. Lander, 9 months pregnant in a BSL4 lab


TS: Can you tell readers a bit about your background and research? How did you get interested in studying viruses, especially some of the deadliest on earth that require BSL4 containment?

HL: I began my college career as a music major but I also loved science so I enrolled in many science classes, weighing my options. When I took a molecular cell bio class I was hooked. I changed majors and didn’t look any farther ahead than my Bachelor’s degree. But then the news exploded with tale of deadly virus outbreaks, and books and movies started coming out. I was fascinated, as are most people, so with permission from the professor I enrolled in a graduate level molecular virology course. Turns out viruses are beyond interesting. They blew my mind: microscopic, consist of hardly anything and can take us down in a matter of days. I wanted to know what was going on. At this point I thought all viruses were insanely interesting, but I found myself drawn to those that cause hemorrhagic fevers (HFV), and not only because of the media attention. I started reading the literature and these viruses were pretty different than the more familiar ones. They were confounding and I wanted to help figure them out.

Because I hadn’t planned ahead, I wasn’t ready to apply to grad school. So to improve my chances of working with these viruses, I got a job as a technician in a very highly regarded lab that worked on angiogenesis; basically the biology of blood vessels. Because HFVs either damage blood vessels or make them leaky, I thought it would be a good knowledge base. From there I got into the University of Texas Medical Branch as a PhD student and ended up working with CJ Peters, one of the premier experts in HFVs. Our interests aligned and he was great at listening to and encouraging the ideas of a neophyte.

We wanted to investigate viral infection of the cells that line the blood vessels, endothelial cells, and UTMB was getting ready to open their new BSL4 facility – The Robert E. Shope, MD Laboratory – the first of its kind at a U.S. university. In deciding which virus to work with, we took Ebola off the table because it was pretty clear that Ebola caused blood vessel leakiness through overt damage. Other HFVs did not, so the mechanisms of vessel leakiness were still unknown. Of these viruses, the arenaviruses were good options for me. One in particular, Junín virus, which causes Argentine hemorrhagic fever,  was a nice model because we had access to virulent and attenuated strains. I could work with the attenuated BSL2 virus, to get my model and systems up and working, and then repeat the experiments with the virulent BSL4 virus. So I researched the effects of  Junín virus infection on human endothelial cells.

TS: For readers who aren’t familiar with what working in a BSL4 entails, can you describe what it’s like to work in such a laboratory? 

HL: Working in a BSL4 lab adds a lot of steps to any lab work so everything takes longer. Before you can even go inside you are required to have extensive training, health and psychological assessments and be granted Department of Justice security clearance – many BSL4 organisms are Select Agents. After training at all other levels: BSL2 and 3, you are required to complete 100 hours of mentored, supervised BSL4 training, and assessment by the mentor, before being granted independent access. So, BSL4 research is only done if you can’t answer the scientific questions another way. Now, UTMB has the Galveston National Lab, a second BSL4 lab that is much larger, but the Shope lab is relatively small, only a few people can be in there at the same time. This means you have to plan ahead and schedule. Do you have all the supplies you need? You can only carry so much in at one time and you can’t go in and out, it’s too time consuming. So you have to make sure you know what you’ll need and I would often go in a day ahead of time, just to take supplies and make sure I would be ready to go.

During training you do a lot of practice. One of the most important things to practice initially is how to safely hold and open cryovials while wearing bulky rubber gloves. You also learn all safety and decontamination protocols as well as some practical things like moving around the lab safely. Seems silly, but in the lab, you are connected to an air supply through a hose that is attached to the air supply system on the ceiling. Those hoses don’t move with you. They stretch only so far and then you have to disconnect, move to where you need to be and connect a hose at that location. The suits are positive pressure with a constant inflow of air, with ports for air exhaust, otherwise they’d pop like a balloon. The air-flow is wonderful. The suits are cool and relatively comfortable, much more so than the stuff you wear for BSL3. Another important thing to learn and practice is how to enter and exit the lab. Seems simple but there are many steps involved. Here’s a description of what is is like to enter and exit the UTMB Shope Lab. Other labs are different, so this description isn’t meant to apply to all BSL4 labs in general, although the principles would be the same.

One of the best things about working in BSL4 is that, once you’re inside no one bothers you, no one interrupts you. There is a phone, but you don’t use it unless you have to.  So there are no annoying deliveries, phone calls or bored people stopping by to chat. It’s great. Though there was one very important thing I learned early: if you’re disconnect from the air hose, don’t bend over! When you do, you force the air that’s in the suit, out through the exhaust valves, so when you stand back up, the suit is sucked to you like a vacuum sealed bag with no air. Yeah, I did it. They laughed. It only happened once.

TS: Did you or your husband have any reservations about you continuing to work while pregnant? What convinced you that it was safe?

HL: We never had any reservations, and I’ll explain why. When I started working in the BSL4, I made sure I explained the work and the risks, to my family and my husband. So when I got pregnant, I had been working in the lab for a couple of years and he was very familiar with what I did. We had many long conversations about it and, as a couple, sat down with CJ and also our environmental health safety officer, the go-to person at UTMB for Select Agent biosafety, and member of the ASBA council. CJ had been head of USAMRIID’s containment lab and then he was Chief of Special Pathogens at the CDC. CJ and out EHS officer both know their stuff and were very helpful. I never felt pressured to continue working in the BSL4. It was my decision, with input from my husband of course, but he let me make the call. He trusted me and knew I wouldn’t be foolish. Aside from the obvious, the concern with Junín virus is that the case fatality rate is much higher than normal for pregnant women and fetuses, so it was not a cavalier decision by any means.

The bottom line, was that the entire time I worked in the BSL4, I valued my life and I was exacting and followed protocols to the letter. BSL4 protocols are designed to prevent any chance of contamination or infection and if they are followed, then the lab is clean. It’s the cleanest lab I’ve ever been in. I think a big misconception is that there are viruses floating around everywhere in the BSL4 and that’s why you wear the suit, but that’s just not true. The BSL4 protocols prevent contamination and infection. The suits are back-up – meant more to prevent exposure in the event of an accident than as a first line of defense. If someone in the BSL4 goes into cardiac arrest, we would remove the suit and administer first aid. This of course depends completely on each scientist adhering to protocols, and they do. And they are watched to make sure they do. The director’s office has cameras so he can see who is working and what they are doing. Every action is documented. And the people working in there are highly trained. I trusted those people and I trusted myself. I never deviated from the protocols, and I knew that. I was already being as careful and exacting as I could be, so there was no way for me to be more careful because I was pregnant. In addition, I wasn’t working with animals at that point, so the risks were lower. I was never worried and neither was my husband.

TS: How did your superiors take it when you first met with them to discuss continuing to do such work while pregnant? Was there anything you had to sell them on to allow you to work in there during your pregnancy?

HL: This was hard. I was terrified that they would make me stop working. No pregnant woman had ever been knowingly allowed to work in a BSL4 lab in the U.S. prior to this. I say “knowingly” because CJ pointed out that it’s possible that there were women at the CDC or USAMRIID who went into the BSL4 while pregnant and either didn’t know it yet, or they knew but waited as long as they thought they could before telling their supervisor, because they knew they would be told to stop. And here I was, a student at a university.

I broke the news in a committee meeting, my last powerpoint slide was an ultrasound photo. The reactions were mixed, to say the least, but CJ was my advisor so they deferred to him. I didn’t have to sell it to CJ, or to our EHS officer. They were very supportive and seemed to welcome the opportunity to advance the rights of pregnant women in biosafety, in a safe way. We discussed the risks and my work and when my husband and I decided to go ahead and push for me to be allowed to keep working, consulting with the Director of the Shope Lab, and the safety experts at USAMRIID and the CDC.

We also involved my physician, who really advocates to prevent unneeded limitations of pregnant women. It took about 3 months for these negotiations, during which time, I did not go into the BSL4. With the help of my doctor we came up with a plan that would allow me to work in the BSL4, with limitations designed specifically to mitigate any difficulties that the pregnancy itself might cause. We drafted a contract and everyone signed it and it went into my UTMB file along with my OBGYN medical records.

Because sometimes unexpected things can happen during pregnancy, some limitations imposed included that I would not be allowed to go into the BSL4 alone. We also decided I would not stay in the lab for more than 3 hours at a time. This was to prevent me from getting both too tired, or dehydrated.  Turns out this one really didn’t need to be written down, my bladder was always screaming at me before the three hours were up and that meant exiting the lab. I also couldn’t work with animals, which wasn’t something I was doing anyway. When all was said and done, USAMRIID, the CDC, my Physician and UTMB were all on board and I went back in. After I paved the way, others have done it. You’re welcome. 😉

Heather in BSL4 with first successful Junin Romero plaque assay!
Dr. Lander displays her Junin Romero plaque assay.


TS: How was it, logistically, working in there while pregnant? I know I always felt huge and clumsy while pregnant and I wasn’t working with anything above BSL2 level and wearing a normal lab coat.

HL: Because the suits are cool, it was still pretty comfortable. It slowed me down for sure, especially the last couple of months. Moving with deliberation was already ingrained in me so that didn’t change, but I definitely moved more slowly. And I was huge, and the suit was definitely cumbersome. My belly pushed against the suit near the end but it wasn’t painful or even uncomfortable, I just had to give myself enough clearance when moving around tables and things. I also had to ask for help when doing normal everyday housekeeping kinds of things in the lab like emptying a trash bin or lifting autoclave pans. Everyone I worked with was very helpful and kind, so it was not a problem. I had the normal aches and tiredness, but if I ever felt too tired to go in, and there were a few times I did, I would cancel my time for that day and reschedule. I knew my limits and respected them.

TS: Any good stories?

Oh boy do I. Unfortunately I can’t share the best ones. When I was still in the 100-hours-of-mentored-training segment of my BSL4 experience, I was in the lab with a professor and we were working with Rift Valley Fever inmice. We had finished the work and had already put the animals away and cleaned up. We were just getting ready to exit the animal room, to go into the main section of the lab, and the air hose connection valve on my suit broke. Without the air hose, there’s no air, not to mention the suit had a hole in it. The professor realized what happened before I did and grabbed the air hose and shoved it against the broken valve, allowing air to get inside the suit. He and I took turns holding air hoses in place while we showered and exited. Because of the incident we had to fill out paperwork and I had to go to the university hospital’s BSL4 exposure unit for a potential exposure. Because we hadn’t been working with anything when the valve broke, I wasn’t actually exposed to anything, but it was standard protocol. I was released fairly quickly and have a story to tell. The experience taught me a lot about how to handle those situations and even though those kinds of things are REALLY rare, the BSL4 director made changes to specifically prevent anything like that from ever happening again, and it hasn’t happened since.

TS:  What are you working on now and what are your longer-term career goals?

HL: I want to put my expertise to good use and I’ve come to realize that I love writing so I’m hoping to find something that can incorporate that. In the meantime, I have a really interesting job doing grant development for faculty at UTMB. This involves high-level assessment of the science, grantsmanship and presentation/writing of proposals, in an effort to help make faculty more competitive. To get my pathogen fix and dispel some emerging disease misconceptions, I recently started the blog and I’m really enjoying it. I also have ideas for a novel (don’t we all?), so…who knows?

Many thanks to Heather for participating! Be sure to check her out at Pathogen Perspectives or Twitter

New paper on Ebola–no primate-to-primate transmission seen

By the same lead author that published the pig Ebola transmission paper comes a new publication examining airborne transmission among primates. In these, Ebola did *not* spread between non-human primates (NHPs) via air. I sent an email to the PI to comment; will update the post if he responds, but in the meantime, some money quotes directly from the publication:

“One experiment reported contact free transmission between infected NHPs to one uninfected NHP although cross-contamination due to husbandry practices could not be ruled out with certainty26. Interestingly, EBOV infected swine transmitted the virus to naïve NHPs over a 0.3 meter buffer zone that prevented direct contact between the 2 species27. …However, airborne transmission in natural outbreaks cannot be a common occurrence and is possibly insignificant by the account of several reports49282930.”


“The presence of transmission in the pig-NHP experiment and not the NHP-NHP experiment, both performed under similar conditions and environments, could be explained by the fact that EBOV disease in pigs is respiratory in nature with high amounts of infectious particles present in the oro-nasal cavities in the symptomatic phase of the disease which provided an opportunity for release into the environment35. On the receiving end, NHPs are known to be susceptible to lethal EBOV infection through the respiratory tract242731 putting the onus of the transmission on the ability of the source to shed infectious particles.”

Translation: even though previous reports in primates had suggested the potential for airborne transmission, other factors couldn’t be ruled out, and epidemiologically, it’s insignificant. In the experiments they did, pigs just handle Ebola differently than primates (as I mentioned here), and so make them more likely to spread the virus via a respiratory route.

Significance: No airborne transmission between primates in this controlled experiment, strengthening the evidence that Zaire ebolavirus isn’t a risk in this manner. So Donald Trump, you can stop freaking out now.

A historical perspective on Ebola response and prevention

Yambuku, Zaire, 1976. A new disease was spreading through the population. Patients were overcome by headaches and bloody diarrhea. The disease was spreading through entire families and wiping them out.

Eight hundred and twenty-five kilometers to the northeast, a similar epidemic was reportedly raging across the border in Maridi, Sudan. Were these outbreaks connected? Despite enormous challenges trying to navigate both the logistics of crossing a landscape of unpaved and unmarked roads, as well as the political difficulties of an attempt to enter and collect samples in an area marked by recent civil strife, samples were finally collected and shipped to the World Health Organization for testing.

All told, these outbreaks caused 602 cases and 431 deaths. The Zaire outbreak wasn’t stopped until the hospital was closed, because 11 of its 17 workers (65%) had died of the disease. Investigators went door-to-door in 550 villages in the Yambuku area  to find and isolate new cases. Roadblocks were set up to restrict access to the area.

In Sudan, a number of cases were traced to workers in a cotton factory (probably due to bat exposure) and their families. The epidemic increased when one case went to the Maridi hospital, and the virus then was transmitted within that hospital. Note what the write-up describes:

“The hospital served as an efficient amplifier from which the virus was disseminated throughout the town. The number of cases gradually increased until mid-September and at the end of the month there was a large number of cases, particularly in hospital staff. The number of cases declined in early October, possibly as a result of the use of protective clothing. A considerable increase in the number of cases was observed in late October and early November, which may have been partly due to a lack of protective clothing when supplies ran out in mid-October.”

In Maridi, the doctor-in-charge, along with 61 members of the nursing staff came down with Ebola. Thirty-three of them died. Eight additional deaths occurred among the ancillary and cleaning staff. This outbreak was only contained because, again, the hospital was made safer via extensive training and the use of good personal protective equipment, and cases were identified in the town by going door-to-door. Buy-in from local officials was obtained, which is critical–while families may not trust outsiders, they more often will listen to local leaders. Cases were isolated in their homes or taken to the hospital. Eventually every village in a 30-mile radius from Maridi was screened, and the outbreak burned out.

Now imagine you’re looking at this in real time, via 24-hour news networks, from halfway across the world. You’re hearing news reports of cases spiking. Healthcare workers are contracting the disease. You don’t have all the information but you’re coming to your own conclusion that the virus must be mutating in Sudan.

You would, however, be wrong. These outbreaks were actually separate epidemics (and led to the identification of Zaire ebolavirus and Sudan ebolavirus, respectively), but collectively, that was a lot of Ebolavirus disease in 1976–the most deadly single year for Ebola until 2014, in fact. It took an enormous effort on the ground in these two areas to stop the outbreak.

Though not wholly analogous to today’s West African epidemic, there are lessons here to take away. There is a steep learning curve for dealing with Ebola. Besides the single case from the Ivory Coast, Ebola has not historically been a West African disease. Liberia, and Guinea and Sierra Leone in particular, do not have a great history of governmental stability, and are still recovering from civil wars, government coups, and a general lack of stable national leadership. Infrastructure is also substandard, as early reports on the main hospital in Conakry, Guinea noted. Each country seems to be dealing with this largely on their own without solid cross-border cooperation, and since the borders tend to be flexible in any case, patients and those incubating Ebola have been able to travel and move the virus into new areas. The public in general does not understand the disease, and in some cases keeping doctors out with knives and machetes, accusing physicians of murdering their loved ones and bringing Ebola to their villages.

It’s reasons like this–structural and sociological issues, by and large–that have led the WHO to declare the outbreak to be “out of control.” As far as has been reported, there is nothing particularly notable about the virus itself, which is very closely related to previous Zaire ebolavirus isolates. The infection rate in healthcare workers–about 60 out of 1300 total cases reported at the time–is actually quite low, given the conditions they’re working in and the lack of experience most of them would have had with Ebola. (Again, in Sudan, it was 61 out of 284 cases–so 21% of the total cases were doctors and nurses–versus about 5% in this outbreak).

The outbreaks in these countries are bad currently, but for the future, we can look at Uganda as a model. The first outbreak in that country, beginning in 2000, resulted in 425 cases and 224 deaths. The second outbreak in 2008 resulted in 149 cases and 37 deaths. In 2011, they had a single case with no secondary spread. In 2012, 11 cases and 4 deaths. 2012, 6 cases and 3 deaths. It’s probably impossible to stop Ebola from spilling over into the human population, but Uganda has done a great job responding. They are able to do early detection of suspected cases in their biosafety level 4 lab in Gulu. They alert local authorities if something is suspected, then send a task force to assist with containment. They communicate effectively with the public about what they can do, and how effective treatment in hospitals can lower the mortality rate. They work with community leaders when a quarantine needs to be put in place. These things can all be employed in West Africa as well, but it takes time and a lot of commitment to get such networks up and running. We need this cooperation as much as we need PPE and even more than we need “secret serums,” because it is only with prevention of new cases that this epidemic will finally die out.


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Are we *sure* Ebola isn’t airborne?

Since yesterday’s post, several people have asked me on various social media outlets about the airborne nature of Ebola. Didn’t I know about this paper (“Transmission of Ebola virus from pigs to non-human primates“), which clearly showed that Ebola could go airborne?

Indeed I do–I wrote about that paper two years ago, and it in no way changes my assertion that Ebola doesn’t spread between people in an airborne manner.

Let me back up. The paper in question was an experimental study done in the wake of the 2008 finding of the Reston Ebola virus in pigs and a previous study looking at the Zaire virus in pigs. In the air transmission study, they inoculated pigs with Ebola and examined transmission to macaques (who were not in direct contact with the infected pigs). They did find aerosolized Ebola in air samples, and some of the macaques did come down with symptoms of Ebola. So, it looked like pigs could spread Ebola through the air, which is something that had already been suggested by the epidemiology of the 2008 pig Ebola outbreak. It’s always nice when experimental data matches up with that observed during a real-life occurrence of the virus.

*However*, the kicker was not that Ebola is transmitted by air in human outbreaks, but rather that there may be something unique about pig physiology that allows them to generate more infectious aerosols as a general rule–so though aerosols aren’t a transmission route between primates (including humans, as well as non-human primates used experimentally), pigs may be a bigger threat as far as aerosols. Thus, this may be important for transmission of swine influenza and other viruses as well as Ebola.

So unless you’re sitting next to an Ebola-infected pig, seriously, airborne transmission of Ebola viruses isn’t a big concern. (Perhaps this corollary should be added to this handy diagram examining your risk of Ebola).


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Ebola is already in the United States

It’s odd to see otherwise pretty rational folks getting nervous about the news that the American Ebola patients are being flown back to the United States for treatment. “What if Ebola gets out?” “What if it infects the doctors/pilots/nurses taking care of them?” “I don’t want Ebola in the US!”

Friends, I have news for you: Ebola is *already* in the US.

Ebola is a virus with no vaccine or cure. As such, any scientist who wants to work with the live virus needs to have biosafety level 4 facilities (the highest, most secure labs in existence–abbreviated BSL4) available to them. We have a number of those here in the United States, and people are working with many of the Ebola types here. Have you heard of any Ebola outbreaks occurring here in the US? Nope. These scientists are highly trained and very careful, just like people treating these Ebola patients and working out all the logistics of their arrival and transport will be.

Second, you might not know that we’ve already experienced patients coming into the US with deadly hemorrhagic fever infections. We’ve had more than one case of imported Lassa fever, another African hemorrhagic fever virus with a fairly high fatality rate in humans (though not rising to the level of Ebola outbreaks). One occurred in Pennsylvania; another in New York just this past April; a previous one in New Jersey a decade ago. All told, there have been at least 7  cases of Lassa fever imported into the United States–and those are just the ones we know about, who were sick enough to be hospitalized, and whose symptoms and travel history alerted doctors to take samples and contact the CDC. It’s not surprising this would show up occasionally in the US, as Lassa causes up to 300,000 infections per year in Africa.

How many secondary cases occurred from those importations? None. Like Ebola, Lassa is spread human to human via contact with blood and other body fluids. It’s not readily transmissible or easily airborne, so the risk to others in US hospitals (or on public transportation or other similar places) is quite low.

OK, you may say, but Lassa is an arenavirus, and Ebola is a filovirus–so am I comparing apples to oranges? How about, then, an imported case of Ebola’s cousin virus, Marburg? One of those was diagnosed in Colorado in 2008, in a woman who had traveled to Uganda and apparently was sickened by the virus there. Even though she wasn’t diagnosed until a full year after the infection (and then only because *she* requested that she be tested for Marburg antibodies after seeing a report of another Marburg death in a tourist who’d visited the same places she had in Uganda), no secondary cases were seen in that importation either.

And of course, who could forget the identification of a new strain of Ebola virus *within* the United States. Though the Reston virus is not harmful to humans, it certainly was concerning when it was discovered in a group of imported monkeys. So this will be far from our first tango with Ebola in this country.

Ebola is a terrible disease. It kills many that it infects. It *can* spread fairly rapidly when precautions are not carefully adhered to: when cultural practices such as ritual washing of bodies are continued despite warnings, or when needles are reused because of a lack of medical supplies, or when gloves and other protective gear are not available, or when patients are sharing beds because they are brought to hospitals lacking even such basics as enough beds or clean bedding for patients. But if all you know of Ebola is from The Hot Zone or Outbreak, well, that’s not really what Ebola looks like. I interviewed colleagues from Doctors without Borders a few years back on their experiences with an Ebola outbreak, and they noted:

“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.”

So, sure, be concerned. But be rational as well. Yes, we know all too well that our public health agencies can fuck up. I’m not saying there is zero chance of something going wrong. But it is low. As an infectious disease specialist (and one with an extreme interest in Ebola), I’m way more concerned about influenza or measles many other “ordinary” viruses than I am about Ebola. Ebola is exotic and its symptoms can be terrifying, but also much easier to contain by people who know their stuff.


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Repost: What’s it like to work an Ebola outbreak?

In the light of the current Ebola outbreak, I thought this post from 2007 was once again highly relevant. 

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.

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.


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