Lessons learned from the final Ebola outbreak in Guinea
In mid-March of 2016, I was a new field epidemiologist working in the West African country of Guinea. The Ebola epidemic seemed to be over: We were just 11 days away from being Ebola-free for 90 days, which would mark the official end of the country’s epidemic. Then field coordinator Dr. Angelo Loua walked into our small World Health Organization field office in the southeast region of N’zerekore and announced that an 8-year-old girl had just tested positive for Ebola.
“Please pray for us, it’s Ebola,” I texted my friends and family with confirmation of my worst fears.
In most accounts of the Ebola outbreak, Guinea’s experience is overlooked. Yet it was in Guinea in March 2014 that that the plague began, gripping seven of its eight regions, and from where it spread to Liberia and Sierra Leone. Ebola infected more than 28,000 people and killed more than 11,000 before it was declared over on June 9, 2016.
By early spring of 2016, most of the international organizations that had mobilized to fight the Ebola pandemic had called home their workers. Our field team managed to grow quickly from fewer than 20 staffers to more than 100, including local Guineans and international responders such as my teammates from the US Centers for Disease Control and Prevention. Most of the responders had worked in the region throughout the three-year outbreak. I was fresh out of grad school, completely frightened but ready to help.
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That day in N’zerekore I left behind the academic world of epidemiology theory for real-world disease-control strategies such as contact tracing and monitoring. That meant searching for individuals who could eventually become Ebola victims, all somehow linked to a little girl who would not survive.
Her village, Koropara, had first seen Ebola more than two years before when 15 villagers died from the disease; 10 infected individuals survived. (We later learned that the new flare-up was caused by the still-infected sperm of one of the survivors being transmitted to an uninfected individual.)
What we knew at the time was that the N’zerekore region, where Koropara is located, was infamously known as the place where villagers killed eight members of a health team trying to raise awareness about Ebola in September 2014. This attack was attributed to widespread local distrust of government workers and unfounded fears that the medical teams were spreading the disease rather than trying to stop it.
This legacy of local resistance seemed as persistent as the virus. We learned of the child’s illness through local gossip rather than through the community alert networks that had been established, so it took critical extra days to reach the child. It also took military intervention — soldier-escorts protecting the health teams — and repeated assurances of safety by the local medical staff to the child and her community.
Guinea is, by some measures, less developed than Liberia and Sierra Leone, though all three countries were — and still are — among the world’s poorest nations. In 2014, Guinea’s health system was so fragmented and poorly resourced that Ebola spread undetected for three months. Back then, the government spent a mere $9 per capita on health, with fewer than three health workers for every 20,000 people. This meant that the type of expertise required to detect, assess, report, and respond to potential public health threats was largely nonexistent.
These realities became tremendous obstacles in the scramble to set up and resource Ebola treatment units. Shortly after the disease was detected, President Alpha Condé commissioned hundreds of freshly graduated medical students to become frontline soldiers in the fight against Ebola. This helped turn the tide, as local Guineans supported by international experts became field epidemiologists, infection control specialists, and health communication professionals.
In Koropara, I was impressed by how government health workers and their partners rebuilt community trust through communication and transparency. Instead of establishing their headquarters in a big city some distance away from the outbreak’s epicenter, as had been done before, this time the Ebola responders set up a tent village to house staff and serve as ground zero for all response activities just a few meters away from Koropara, close to where most of the suspected cases lived. That resulted in exceptional community collaboration. Many of those who had been in contact with the girl voluntarily quarantined themselves, received vaccinations, and let us monitor their health for the duration of the flare-up.
Our team, led by Dr. Iya Condé, a gregarious young Guinean doctor, regularly visited the family of a woman who died from Ebola. When her mother — who had washed her dead child’s body in preparation for her funeral — began to show signs of infection, the family reported it to us. They were grateful, not defiant, when she was transported to the treatment unit. And we mourned together when she died.
This innovative approach to integrating the community into the response rapidly shifted the situation from crisis to recovery. This final Ebola episode was suppressed in 21 days, with just 10 fatalities. By the end of the flare-up, 98 percent of all contacts and 100 percent of high-risk contacts — nearly 200 households throughout four villages — had been successfully monitored.
The newly elected new WHO director-general, Tedros Adhanom Ghebreyesus, is the first African to hold that post. As the former minister of health in Ethiopia, he should understand the impact of integrating community members into health programs. This is increasingly important as experts continue to warn that the world is not ready for the next Ebola-like outbreak. The global health community is currently in the middle of several battles, including dispatching more vaccine to combat a yellow fever outbreak in South America, monitoring avian flu outbreaks around the world, and supporting mothers valiantly raising babies affected by Zika while working to prevent new infections.
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Lessons learned from the Ebola outbreak in Guinea emphasize the value of a strong local and tailored response to outbreaks, when possible. Guinea’s fight against Ebola is a story of innovation, humility, and dedication. The country gave the world the wake-up call about the disease, and then offered solutions to take into the future. These include trained local responders, adequately staffed personnel at village health facilities, and a well-informed and engaged community.
Koropara taught us that in the fight against infectious disease outbreaks, community support and input are some of the best weapons for winning the war.
Ngozi Erondu, PhD, is an infectious disease epidemiologist and assistant professor at the London School of Hygiene and Tropical Medicine. She is an expert in health systems research in low- and middle-income countries and a 2017 Aspen New Voices Fellow.