Tarik Rhandour, is a Field Epidemiology Training Program (FETP) graduate who had completed his residency last year. As part of his program requirements, he spent a few weeks during 2014 in Conakry, the capital city and largest in Guinea, where he gained hand-on experience with handling the Ebola epidemic. Following his return from Africa, he sat with us to tell us his story.
How it Came to Be
“I was still a resident at the National School of Public Health in Rabat Morocco, when we got a letter from the Centers of Disease Control and Prevention (CDC) representative in Conakry”, he said, “The CDC Epidemic Intelligence Service was working on the investigation, surveillance and response to the Ebola crises and the entity needed support from a French speaking FETP, and I volunteered. Administrative procedures delayed me from going on the designated date but nevertheless, I was there in June 2014.”
His visit was arranged in collaboration with the United States Agency for International Development. (USAID), CDC and the Training Program in Epidemiology and Public Health Interventions Network (TEPHINET). “I arrived there on the night of June 14th, 2014 and it was a Saturday. We started work on Sunday. On our first day, we got aqainted with the team working with us from the World Health Organization (WHO) office. I was integrated with a team of three from the EIS and our team was Dr. Pierre Rollin,” he explained, “of French origin, Dr. Rollin had worked with the CDC. Where he brought to the team 20 years of experience with Ebola. Within the group, we all had similar tasks to carry out.”
Dr. Rhandour stated that there were several challenges to be overcome in the field. “The first challenge we faced involved data compilation. We found discrepancies between the data collected by WHO and the data collected on the ground. We were working on the Epi Info 7 application developed by CDC especially for all hemorrhagic fevers. The same application was used by WHO officers, yet there were some problems in the documentation between both sides. So, getting the clean data took time. I also joined the team in the sixth month of the epidemic. This means that we had already passed the first peak period and we were moving into the second, “he said.
The team had to clean six months of compiled data. “We used to make rounds every day at the Ebola Treatment. Center. The center was a space in the Conakry Hospital consisting of tents set to treat Ebola patients.” Said Dr. Rhandour, We used to complete data by consulting medical and laboratory records at “Medecin Sans frontière” MSF EBOLA treatment center”, We used to finish these tasks around 5 or 6 pm and then we used to go to the hotel to continue comparing the variables and content we had taken home with us with the content provided to us by the WHO. We used to compare both data sources and create a unified data base.”
Dr. Rhandour, who was also charged with interpreting patient’s testimonies in French, explained that the resistance of people was another challenge both he and the rest of the team were met with. There was one particular case in which the head of a house did not allow his son’s wife to go to hospital even she had clinical signs and had contact with confirmed case of Ebola. For this case, Dr. Rhandour and his colleague from CDC had to intervene. “We went to the city of Boffa which is about 160 km north of Conakry, we stayed there for five days and during our stay we had three missions to accomplish The first was to complete building the transmission chain for boffa cases and contacts using data collected from local sources, the second was to help with information materials (updating and printing posters, flyers) and the third was to educate the population on the importance of early notifying and allowing the local health authorities to transfer suspect cases to the hospital.
One of the reasons the Ebola epidemic spread so aggressively was the resistance of the people to getting treatment,” he explains.
To solve this issues the team met with community heads, leaders, and decision makers in ministries of interior. Health, religious affairs “Fortunately we were able to convince this family to send the lady to the hospital. However, the woman’s son died of Ebola and I attended the burial service.” He said.
“It was in this experience that I got the better understanding of African burial rituals. Through our investigations, we understood that 12 women touched the deceased. They touched the body as part of their traditions. Such behaviors do not necessarily make the disease contagious but they do make the people carrying them out at risk. When we conducted the contact tracing for this particular case, we found that at least 50 people were at risk. They used to take patients to a private doctor and this private doctor did not suspect Ebola disease, and this made us obliged to check how many people were exposed to EBOLA at the private clinic in the same day. This is only one example of how difficult it was for us to conduct a contact tracing.”
The Lessons Learned
Dr. Rhandour affirmed that the challenges were many. Some were challenges related to the patients themselves “After being diagnosed with Ebola some patients escaped back to their homes or families. This in some cases caused them to stay alive while their entire families died from the disease, in one case one patient told me, ‘I wish I had died, it’s easier than staying the only one alive’. His problem was not only that he stayed alive alone, but it was also that he was regarded as a social stigma in his community. Society tends to reject such people with Ebola. In another case a student was diagnosed with the disease. He got treated and he returned back to his apartment only to find that the landlord had thrown his personal belongings out and that he rented the apartment to another tenant. This story took place in Conakry, “he explained.
To change this perception, the team did a campaign through which they took pictures with the cured Ebola patients. The aim of this campaign was to show that once a patient is cured he/she can resume a normal life. He/she can interact in the community.
Dr. Rhandour explains that despite the challenges this was an amazing opportunity for him.” At the time I was still an FETP resident so, this experience allowed me to interact directly with people who had more experience than me in the field. Most of the doctors working with us had experience with malaria, HIV, and other diseases. They also had experience working in Africa while I was the only one who was taking part in such an investigation for the first time. I also got to learn just how difficult the nature of this particular epidemic could be. I learned that there were many stakeholders that we needed to involve in order to control its spread. We used to work with WHO office, MSF, UNICEF, the Red Cross, the Red Crescent, the ministry of health, the communities, the ministry of religious affairs, and the ministry of interior. Together these entities formed over 10 stakeholders. Another side we had to deal with was the media. The team leader used to participate in the weekly mass conference. Working in the field also made me understand more why this epidemic is especially difficult to keep under control. I saw the evidence first- hand and it is much more accurate than hearing about it. The epi-center located in an area located on the boarders of Sierra Leone and Liberia was responsible for this area which was predominantly populated by refugees and we were working there.” He added.
The first Ebola case was detected in December 26th 2013 and the health authorities didn’t recognize the disease at first, the first case was diagnosed in March 2014 by the laboratory of Lyon in France, and the Guinean Ministry of Health has declared the epidemic of EBOLA 21 March 2014.
Dr. Rhandour ended his talk with us by stating that he improved his skills in areas of surveillance, data analysis, Investigation, contact tracing, communication with the population and his personal knowledge. “6 months after coming back, I am still available to go there again, “he says.