Ebola diaries: First signals - March 2014

Pierre Formenty

Dr Pierre Formenty has spent the past 20 years investigating communicable disease outbreaks, including many Ebola outbreaks. In mid-March 2014, while in Kinshasa, training health care workers to safely take and dispatch blood samples that may contain ‘dangerous pathogens’ such as Ebola virus, he began receiving emails that got him worried.

They described a cluster of cases in Guinea thought to be caused by Lassa virus. But features of the cases and how they occurred made him very concerned that this was not, in fact Lassa fever but possibly Ebola virus disease. Here Dr Formenty describes what it was like to realize that Ebola Zaire had arrived for the first time in the heart of West Africa.

WHO/Stéphane Saporito

“We received the first emails on the Guinea event on Friday 14 March. During the week-end, I was travelling in the DRC [Democratic Republic of Congo] for a training course on how to take blood samples in Ebola. It was a 3-day training course.

The first emails received from Guinea were mentioning suspected cases of Lassa fever. The first emails just gave numbers (9 cases including 8 fatalities) but on 18 March we had a more detailed description. I was a little irritated because in the description they were talking about transmission following funerals and among health care workers which is something that you have for Ebola but is rare for Lassa fever.

So I was thinking what is happening there? This is maybe not Lassa fever this is maybe something else. We have to be prudent; we have to follow this one. I returned to Geneva but continued to follow this carefully.

Could it be Ebola?

It was MSF who sent the samples taken by WHO and the MOH (Guinea Ministry of Health) to France for diagnostic investigation. So I called Paris and said look, test for Lassa fever but please also test for Marburg and Ebola because of this story about people being infected after funerals and also doctors and nurses being infected. Lassa in the classical setting does not spread like fire. The transmission is less than you would see with Marburg or Ebola.

On the Friday 21 March, early morning, I got the answer: it’s positive for filovirus. So it’s maybe Marburg or maybe Ebola. Marburg was not my first choice because we have the Ebola Cote d’Ivoire (the Tai forest strain had caused one case in Cote d’Ivoire in 1994) and for Marburg you need a lot of specific circumstances - you need large Roussettus bat colonies that live in caves - and the open-cut style of mining used in Guinea would not support these types of large bat colonies. So I was thinking more about Ebola right from the start.

I think it was on Friday 21 March around 7 pm that it was identified as Ebola but it was not until Saturday late evening I got the text that confirmed it was Ebola Zaire. I was sitting in a restaurant and I remember thinking this was the worst case scenario for the country. No-one wants this to be Ebola - and if it is Ebola they want it to be the Cote d’Ivoire strain, because the only case of that survived. There is a lot of stigma around Ebola Zaire.

Although it was the worst case scenario for the country, the good news was that we have in principal good control measures that have been effective in many countries.

WHO /Marie-Agnès Heine

First response

During Sunday we swung into action. Because of this meeting in the DRC we had developed many documents, training packages and lists of equipment related to Ebola outbreak investigations; we shared them with the country together with updated SOPs (standard operating procedures) for Ebola outbreak control.

On Friday 21 March, when we knew it was filovirus we had made arrangements to send the PPE (personal protective equipment). On the Monday we organized who was travelling to help investigate and control the outbreak and two international laboratory teams arrived in the country that week: one from Institut Pasteur Dakar was based in Conakry and one from the EU Mobile Lab consortium was deployed in Guéckédou. On 27 March, the first cases were detected in Conakry.

We knew since day one that we needed to protect Sierra Leone and Liberia. Both countries were informed in real time about the event and the laboratory findings, participating in all teleconferences with Guinea.

There was something different there

This outbreak always looked a little strange to me. I didn’t see the same thing when I looked at the numbers. The way the outbreak was sustained and not decreasing quickly. There was something wrong there. And the number of cases: in a few weeks it was increasing in Conakry - more than 50 cases - this was too much for a capital city. And 30% of the cases were health care workers. There was something that was different there."