Fast forward 4 months. We had been waiting for Ebola for months without any cases. Samaritans Purse had provided our hospital with a plane-load of personal protective equipment and helped us transform our tuberculosis isolation building into an Ebola isolation ward. They had also helped train multiple doctors and nurses at our hospital and helped us set up a triage system. But no cases came—for months. We all started to suffer from what could perhaps be called “vigilance fatigue.” It was hard to remember that we needed to be asking every case where they came from. It was hard to take every fever case seriously as a potential Ebola case. What is really challenging is that Ebola presents exactly like malaria (and a lot of other diseases): fever, headache, diarrhea, muscle pain. The hemorrhagic signs come much later, if they come at all. Interestingly, one phenomenon that had been noted multiple times in the West Africa epidemic was that pregnant women have very atypical presentations of Ebola. Sometimes the only sign of Ebola was fetal demise (the death of the fetus prior to birth). Very often, pregnant women did not present with fever, resulting in them not being flagged by temperature screening, and thus increasing the risk that more people would be exposed before the disease was discovered.
The vast majority of Ebola outbreaks have occurred in the Democratic Republic of Congo. This outbreak started near Beni and for the most part has stayed 3 to 4 hours drive from us. In late September or early October, there were a couple of cases within an hour or two on both sides of us, and we feared that we would be next to receive a case. But these transmission chains died out and the outbreak went back to being about 4 hours from us. However, in early December, cases started multiplying about 60 kilometers from us, near Komanda. The possibility that a case would come to Nyankunde was again quite significant. I started talking with others at the hospital about how we could better communicate with the community about Ebola control efforts to avoid having Ebola patients flee care like they have been doing in the Beni area. We also discussed the importance of keeping our guard up.
On Friday the 21st a pregnant woman was brought to the hospital by her father-in-law, who happens to be our hospital’s chauffeur. She was very sick and was in fact bleeding from her mouth. The guards at the gate apparently initially refused entry because of the bleeding, which was concerning for Ebola, but her father-in-law convinced them that this was because she had fallen during a seizure. He emphasized she was pregnant and needed prenatal care. She was taken by two nurses (thankfully wearing gloves) to our maternity department, where again she was reportedly refused entry due to concern about possible Ebola. Again, they were convinced otherwise by the father-in-law. A pelvic exam suggested an infection. An ultrasound showed that the fetus was dead. As noted above, Ebola is notorious for causing intrauterine fetal demise; at the same time, many other things can cause this. She had no fever, which again is classic for Ebola in pregnancy, but she was hypoxic (her oxygen levels were low). At least one nurse was exposed to her blood while putting in an IV due to a torn glove. A training doctor performed the pelvic exam and also had high-risk exposure due to the patient’s agitation during this procedure. Due to her hypoxia, the decision was made to transfer her to the ICU. Despite two people thinking about Ebola at the Maternity, for some reason, no one informed the team that had been trained to deal with possible Ebola cases, nor was the ICU informed that the patient they were receiving was suspicious for Ebola. I was leaving the hospital when I heard that a hypoxic patient had been transferred from the Maternity to the ICU. I decided to stick my head in and check on her. Instinctually, despite wearing gloves with almost all my patients for the last 4 months (a policy we had instituted during the Ebola outbreak), I grabbed my stethoscope and started listening to her heart and lungs. I didn’t hear anything that explained why she was hypoxic.
I’m not sure what made me pull back and think, but after about 30 seconds, I thought, “I need to ask where this patient is from.” On asking, the patient’s companion said she was from a village on the other side of Komanda, right near the new cluster of Ebola cases. Immediately I realized that I might have touched an Ebola patient with bare hands. I washed my hands and my stethoscope thoroughly and made sure everyone was wearing gloves. Unfortunately, there were two family members with the patient, both without gloves. One of them was holding a piece of gauze over the site where they had attempted to place an IV, and this site was oozing blood. I called the head of our health zone, who is a doctor at our hospital, and informed him that we had a suspicious case. Then with gloves, I took a closer look at the patient. She was profoundly altered and disoriented, unable to answer any questions. Her hands and feet were cold, suggesting she was in shock. She was oozing from an IV site and had previously been bleeding from her mouth. Her uterus was clearly enlarged, consistent with pregnancy. And her eyes were injected with a reddish color. She looked like so many pictures of Ebola patients that I had seen. On the other hand, a dead fetus that is not removed can, even without Ebola, lead to profound illness, including bleeding problems in a pregnant woman.
The woman died just before an ambulance arrived to take her to an Ebola treatment center for testing. Thankfully they were able to get a blood sample, and the next morning the result came back: Positive. We had received our first Ebola case, and I had touched her with bare hands. Others had even been exposed to her blood.
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| The team that buried our Ebola patient |
Working in collaboration with the World Health Organization, the Congolese ministry of health arrived the same day to safely dispose of the body and to start vaccinating all the staff, as well as the family of staff that had been in close contact with the patient. To have a vaccine that can diminish the risk of contracting this infection is a game-changer! I received the vaccine the day after my exposure.
We decided that Anna, Luke and Miriam would move down to stay with our MAF pilot colleagues to avoid contact with me that might prevent them from being able to evacuate to Uganda with MAF. I was able to visit them, but I could not touch them and had to keep some distance. This was hard, but completely understandable. Anna and the kids flew out with MAF the day before Christmas. I would most likely not see them for the duration of my 21 day quarantine. It was sad to spend Christmas without them, though we opened presents and had a little celebration together on the 23rd. Suddenly I was home alone. Since my exposure was limited, I didn’t think it was likely that I would develop the disease. This made quarantine much easier psychologically. I made sure not to touch anyone, but I didn’t completely isolate myself from others.
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| Saying goodbye to my family (from 3 meters away) |
The day after Christmas, things started to move very fast. In discussion with the CDC and others, it was recommended that I, along with the other CME staff that had been exposed, be moved to Beni. Beni was near the epicenter of the outbreak and, in addition, is a city that has been the target on multiple occasions of rebel attacks. That said, the Ebola treatment center there had access to all the experimental therapeutics that were being compared head-to-head as part of a randomized-controlled trial, whereas the Ebola treatment center that was being set up in Komanda was not yet fully operational and did not have the medications. The tentative plan was for us to be flown by UN humanitarian air helicopter the evening of the 26thor on the 27th. I had a meeting with Drs. Davin and Remy, the Medical Director of our hospital and the head of our health zone, respectively. They both expressed strong reservations about the idea, particularly due to the safety situation. They said they would only let their employees go if there was a guarantee of safety—which is impossible in Eastern Congo. And then they informed me of what would prove to be a deal-breaker for the Beni transfer: the government had just announced that the people of Beni and Butembo (both opposition strongholds) could not vote in the presidential election due to the Ebola outbreak. In discussing this development with Davin and Remy, and later with Serge and other partners, it was clear that this announcement significantly increased the risk of violence in Beni. Our plans were put on hold. And sure enough, the next morning, Beni was in the news: an Ebola isolation center had been attacked.
With increased insecurity in Beni, suddenly my access to potentially life-saving Ebola medications was called into question. The combination of this development with the realization that, according American government protocols, my exposure was considered high risk (I was within 3 feet of an Ebola patient without personal protective equipment in the last 24 hours prior to the patient’s death), led to the recommendation that I be evacuated to the US. Late in the evening on the 26th, I was informed that I would need to fly the next day to Goma. I was told to pack light and that transport would be arranged to Bunia and then, from there by plane to Goma.
Leaving Nyankunde for long periods isn’t easy. The next morning, I had to inform our workers, pay them advances, give them instructions (which I apparently didn't do very well since one of our part-time workers worked for over 200 hours over a 5 week period while we were gone!). At 10am I was picked up and driven to Bunia, and then later in the afternoon, I was flown to Goma.
One of the difficult parts of all this was that it was not clear with whom I should share my situation and plans, and from whom I should withhold this information. The resources and logistics required to arrange an international evacuation made it very important that I not be delayed, that I get quickly and safely to Goma. At the same time, I was a high-risk Ebola exposure, and I was going by plane to a city that had not yet been touched by Ebola. I knew that, in the absence of symptoms, I was not contagious. I also knew that most people would not want to sit next to someone who had recently been exposed to Ebola, even if they were asymptomatic. In order to avoid any barriers to me arriving on time to the med-evac, I decided not to share about my exposure.
On arrival in Goma, I was picked up by an ophthalmologist to whom I had been connected by a mutual friend and who had agreed to host me for the night. It was a relief to have a host who understood my situation, who was well connected, and who could help in the event that any problems arose. From the window of my apartment, I had a spectacular view of the volcano Nyiragongo, looming over Goma, smoke rising from its caldera.
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| Goma from the air, sitting between beautiful Lake Kivu and the highly active Nyiragongo Volcano |
On December 28, a gray Phoenix Air jet arrived at the Goma airport – just for me. I wasn’t sure how
the plane crew would treat me given my exposure. Surprisingly, even before taking my temperature, one of the pilots took my bag from me, not even wearing gloves. Perhaps they could tell by the fact that I was walking to the plane that I wasn’t sick. And once on the plane and after an initial normal set of vital signs was measured, I was more or less a free man. The only place that was off limits was the front toilet. In the rear of the plane was an isolation tent. Given I was asymptomatic with normal vitals, I was not isolated there. The only bed in the plane, however, was in the tent, so I self-isolated, so to speak, to get some rest.
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| The isolation tent in the Phoenix Air jet |
We flew from Goma to Kinshasa, Kinshasa to Dakar, Dakar to the Azores, the Azores to Dulles, and Dulles to Omaha. I was told we got struck by lightning twice when flying over Congo, but the trip was otherwise uneventful.
I completed the final 14 days of my 21 day quarantine in Omaha, at the University of Nebraska. There was no media presence at my arrival at the airport, nor during my stay. University of Nebraska had written a preemptive press release, specifying the general details of my exposure and evacuation, leading to several brief articles in various newspapers but amazingly, it seemed that no one dug further to figure out who I was. Media attention was a concern for multiple reasons, not least due to some of the statements that our current president had made about evacuations of Ebola patients to the USA during the West Africa Ebola epidemic.
I was incredibly well taken care of at the University of Nebraska. My hospital room, formerly a patient room, had been converted into more of a hotel room, with a comfortable bed, a desk, and a refrigerator. Pictures that my wife had emailed had been framed for me. When I arrived, my room was stocked with snacks and drinks, even a novel or two and some magazines. On multiple occasions, nurses or doctors brought food and drinks: Omaha barbeque, craft beer, muffins, cookies…the list goes on. Not least, a room with large windows and a view had been converted into an exercise room with a treadmill and a stationary bike. Unbelievably, I actually got in shape in quarantine! In addition to FaceTiming usually twice daily with my wife and kids, I had regular conversations with a psychologist affiliated with the biocontainment unit. Multiple doctors stopped by to learn more about our work in the Congo and my experience being evacuated. My quarantine ended on January 11, and on the 12th, I left Nebraska and met Anna and the kids in Pensacola for some much needed time together.
It’s now May 29, and at this point there is no end in sight for this Ebola outbreak. As of today, there have been 1,945 cases and 1302 deaths. Despite 126,565 people being vaccinated, daily case numbers are not slowing down. There continues to be widespread fear of Ebola control efforts, exacerbated by lack of education, the clash of control efforts with longstanding cultural practices such as burials, and manipulation of public opinion by opportunist politicians to believe that Ebola is somehow a ploy by the government to stay in power. Militia violence continues to interfere with (and often directly target) Ebola control efforts. The WHO, the Congolese Ministry of Health, MSF and others are rethinking their strategies and trying to find ways to create partnerships with local communities to fight suspicion and misinformation. Amazingly, Ebola has not yet reached Uganda and Rwanda…but I think there is a very real risk of an epidemic rivaling what was seen several years ago in West Africa.
The good news is that organizations such as MSF, Samaritans Purse, French NGO ALIMA, the International Medical Corps, and others are working hard in collaboration with the WHO, the Congolese Ministry of Health, and local hospitals and health centers to fight this disease, in many cases risking their lives to do so. The CDC is also involved though due to security concerns its on-the-ground presence has been very limited. And with a vaccine that data suggests is very efficacious and multiple therapies available as part of a head-to-head trial, there are increasing numbers of tools with which to fight this disease.
At the moment, however, it’s far from clear how many more lives will be lost before this outbreak is brought under control.
After returning to DRC in early February and working until mid May, we are now in the States for a planned 3 month leave to visit family and friends, work a bit…and hopefully to rest. Our plan is to return to DRC in mid-August.
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