Dr Stéphane Hugonnet. Photo by Taylor-Johnson
Dr Stéphane Hugonnet. Photo by Taylor-Johnson
The World Health Organization (WHO) has been much criticized for responding too late to the Ebola crisis, primarily because of lack of coordination among its regional offices and despite available information about the outbreak.
The following article is by Dr Stéphane Hugonnet, one of WHO’s  first alert and response experts sent to Guinea to investigate cases of Ebola reported in late March 2014. Hugonnet is a medical doctor who has spent the past 20 years working for WHO, Medecins sans Frontieres and others managing outbreaks ranging from cholera, measles and yellow fever to Lassa, Ebola and meningitis. In Guinea, he found a very different sort of outbreak when he arrived.

“We were following this rumour of a small cluster of unexplained deaths in Guinea. Some thought it could be Lassa fever, but the transmission pattern was very compatible with Ebola. When the lab results came back, we learned that there was Ebola Zaire in West Africa. This was a first.

On March 25, I hit the ground running in Guinea as part of team made up of logisticians, a medical anthropologist, laboratory technicians, virologists and infection prevention and control specialists. My job was to rapidly assess the situation in the four affected districts, enhance surveillance and support the setting up of a mobile lab.

The day we left Conakry for Guékédou, Conakry confirmed its first case. It immediately became obvious that this outbreak was not like the others. Conakry is more than 1000 kilometres away from Guékédou. Ebola outbreaks are usually quite localized. Person-to-person transmission had quickly spread from a rural area to a large urban city – also unusual. And, the outbreak was becoming multi-national; cases were confirmed in Liberia and were suspected in Sierra Leone.

Managing any outbreak is harder when it crosses borders

Already, when you have a localized outbreak in the middle of nowhere, everything is a problem at the beginning. There is a lack of resources, lack of people to do the job. When an outbreak crosses borders, it’s even more difficult to manage, even if those infected are from the same tribe and speak the same language. I was very worried.

We quickly worked to set up a mobile lab in Guékédou to deal with the backlog of samples and new cases to be tested. I believe our maximum capacity was testing 50 samples a day at the beginning, which is funny to think of now. Within two days, we were testing samples from the epicentre. The lab deployment was a success.

Very quickly, we also did social anthropology work, particularly around safe burials. Protests, sometimes violent, had already taken place in Guékédou and Macenta. Public opinion about the outbreak was extremely unstable. There were rumours that international health care workers had brought Ebola with them.

Violent protests made our work difficult

For some, they understood only that their loved ones had been taken to treatment centres and never returned. Infected people refused to be hospitalized; some of them even fled hospital. We recognized the great need for more of a “human touch”. Our anthropologist worked with the Ministry of Health and others to persuade them of the importance of showing empathy to families of the infected and of including them in the burial process.

Collaboration with Médecins Sans Frontières was extremely good on surveillance, labs, social mobilization, and anthropological work. At this time, MSF was running treatment centres in Guékédou and Macenta, but centres in Kissidougou and N’Zerekoré were not yet up.

One of my jobs was to convince senior level national staff of the seriousness of this outbreak and get them to stay in Guékédou and take a lead on the response. This was vital.

Through my work I saw that Ebola, in fact, is not so transmissible. A combination of several interventions, even if none is implemented at 100%, (isolation, community engagement, social mobilization, preparing healthcare facilities), can be enough to decrease and interrupt transmission. If you can identify the problem and react early, which was the case in the later outbreaks in Mali, Nigeria and Senegal, you can manage. “