Peter Piot, currently Director of the London School of Hygiene & Tropical Medicine has become one of the world's most respected epidemiologists because of his work on the viruses that cause AIDS and Ebola. In the first extract of his memory 2012 No Time to Lose, Piot recalled the identification of a new virus behind a deadly epidemic in Zaire in 1976, the beginnings of Ebola. In this second extract, he and his colleagues are in the hot zone of Zaire and, with the help of the nuns who had survived, making a tragic discovery about how the virus had spread among pregnant women.
Mission Yambuku
I examined his blood, and it was a disaster . The platelet count was terribly low. As green and unimaginative as I was, the real murderer of the virus began to sink in, and my hands trembled a little as I manipulated his blood. Who knew how the virus was transmitted by insects or body fluids or dust.
I cut short weekend in Paris and quickly returned to Antwerp, where my boss Pattyn Stefaan and my colleague Guido Van Der Groen met me in the laboratory, in collaboration with Dr. Kivits, head of the health section of the Department of development aid in Brussels. We spent a few hours tracking down gloves and protective masks and basic laboratory equipment. I tried to familiarize myself with the maximum protection procedures against dangerous viruses, both in the laboratory and in the field. This essentially means protecting your eyes, mouth, nose and hands, and avoiding needle sticks. Guido gave me motorcycle goggles, which proved to be extremely useful.
I also quickly formed in the hematology laboratory procedures and blood tests. Because it was an epidemic of hemorrhagic fever included, which, by definition, symptoms of bleeding I need to watch all kinds of blood parameters: the degree of disseminated intravascular coagulation, which causes uncontrollable bleeding; platelet count and hematocrit; And so on.
But Pattyn was especially interested in learning me to capture bats. For some reason, he was convinced that they appear to be the reservoir of the virus. To be honest, it was the only thing that scared me about the trip. I am poor to catch flying objects in the best of times, even when they have claws and teeth. I nodded as he explained, but I decided on the spot that I would not take a single bat (and failed).
I ran home and packed enough for 10 days. Pattyn insisted that I take a suit and tie, as I would "represent the Belgian government" and to meet representatives of the Zairian government. Then I hunted in my passport, not an easy feat. He had long since expired . (I did not need to go to Paris, since I am a European Community national.) I'd even cut my photo ID to use for certain sports club membership card required for all emergency. and of course, this late excuse and disfigured passport did not have any type of visa for Zaire. I did not know if they would even let me on the plane. that night I could not sleep for nerves and excitement.
During recording, when the police officer to immigration wordlessly me sign on one side with a hostile look, Kivits intervened and had a sort of official supercard that magically gave me passage through immigration and outside my own country. Kivits had several of these tricks up his sleeve. He said, "Find a passenger called Paul Lelièvre-Damit first class. When you arrive in Kinshasa, just follow his instructions. Do exactly what he says and you'll be fine. "
Lelievre-Damit was the head of the Belgian Cooperation in Zaire, and one of the most powerful foreign Kinshasa. When he realized who I was, he interrupted my arrest story about an outbreak and began to swear. "Goddamn! It's always the same with these bloody bureaucrats in Brussels! We face a terrible epidemic, and everything they could find is that you? How old are you? Twenty seven? You are a totally green intern, just a doctor. You've never seen Africa in your life ... "
I winced at its robust graphical splendor of Flemish epithets Undeniably I had no expertise;.. Few skills; I could not save the heart of Africa from a mysterious virus that cartoon boy could have done. But after a few glasses of ouzo it appeared that Lelievre-Damit had played cards with my father when they were both students penniless in Leuven, and that helped a lot. "when we arrived in Kinshasa, just stick with me," he said. "Do not look left or right or turn around. The airport is pandemonium, the police are worse than criminals, and you're as clueless as a puppy you'll be eaten alive."
the next morning, the driver smoothly navigated our DC-10 in Ndjili airport in Kinshasa, where we parked near several wrecks were less fortunate. I was pushing to the front of the plane to find Lelievre-Damit, and I stuck to it down the DC-10 marches as tight as a baby monkey clings to its mother. To be honest, I am not only stunned and hungover I was a little scared. With practiced, fluid movements Lelievre-Damit Pattyn and slid me into the VIP room, where a very respectful servant smiled. There was no mention of anything so vulgar as an identity document.
The roads of Kinshasa were amazing, with people and animals wandering at random through them, not to mention cars, rushing in all directions. We drove directly to a meeting at the Fometro, the Tropical Medical Fund, a nongovernmental organization that operated a large part of broad program of Belgium for medical aid in Central Africa. American Karl Johnson header Special Pathogens at the Center for Disease Control (CDC) in the United States struck us attention, it was clearly his meeting and summarized the situation in a nutshell. We were dealing with a virus that was completely new to science. Its potential for transmission particularly medical teams and caregivers-seemed to be extremely dangerous. The reports claimed that more than 80 percent of those infected were dying. We had only one option possible treatment in the form of convalescent serum which had very high levels of antibodies, but we needed to track down these individuals test their blood to be sure it does not contain live virus and then process to be able to inject antibodies in people currently ill
He continued :. the worst we faced was the specter of an epidemic in Kinshasa, an unruly megalopolis with poor infrastructure, unreliable administration, and 3 million citizens used to challenge the arbitrary government controls. Just two weeks earlier, three people of Belgian mission Yambuku-two nuns and a priest had been brought to the capital for treatment. All were now dead, and had infected at least one nurse, Mayinga N'Seka, now hospitalized in critical condition. Efforts have been made to track down all his contacts in the city for quarantine. They included here Johnson paused for a second-staff of the Embassy of the United States, where the nurse had recently finalized arrangements for a student visa to the United States.
Is this the beginning of an epidemic in Kinshasa? Once that this deadly virus is introduced into an environment of this chaos, it is almost impossible to control. It is also an explosive political situation for the government, and it was clear from the bustle of the Minister of Health that the new epidemic was out and panic was already established. At that time, we had no real indication of how the disease was contagious, only that it seemed highly lethal.
priority was therefore Kinshasa, and it was decided that most of the team would there remain temporarily, while a small contingent would travel to Ecuador in the province for three or four recruiting trip to -day logistics bases and outline a plan for a full investigation. Karl asked for volunteers. I was the first to raise his hand. With an air wave of his hand, then Pattyn I also volunteered to visit Kinshasa infected nurse.
We were taken to a hospital Ngaliema clinic for the rich. It was near the Congo River, Gombe, one of the most beautiful parts of the city, which in colonial times was an area reserved for whites. There was a very scary atmosphere in the corridors of the clinic. Dr. Courteille, director of internal medicine, who received us, informed us first the safety instructions. After the death of two nuns, and their Belgian infection of the nurse-Mayinga their mattresses were burned, and their locked rooms and fumigated with formaldehyde vapors on four consecutive days. Elimination of the bodies was done by wrapping in cotton sheets impregnated with a phenolic disinfectant, and the wound body were sealed inside two large heavy plastic bags before being placed in their coffins.
Courteille, who was taking care of nuns and Mayinga, took care not to accompany us to the bedside of a sick nurse, and it seemed that all the staff kept a guarded distance from their former colleague . She was very sick, and completely hopeless, and convinced she was dying.
Mayinga was hospitalized Friday, October 15, with high fever and a severe headache. Now, on 18, she started to bleed; there were black spots, pantyhose around his nose, ears and mouth and spots under the skin where the blood was pooling. She had uncontrollable diarrhea and vomiting. She clung to Peter Elder of the Pasteur Institute, which soothed, talk about the serum that Margaretha Isaacson South Africa administer, which contained antibodies against Marburg virus, from a convalescent patient in Africa South, which could strengthen the immune system to fight the virus. Unfortunately, the serum did not work and Mayinga died a few days later.
We drew blood to perform a number of tests to guide the decision to prescribe a supportive therapy for intravascular coagulation, we found could be the cause of death in hemorrhagic fever. But none of the technicians or staff was ready to handle samples of Mayinga for some good reasons, the laboratory of the hospital did not have a containment facility.
I examined his blood, and it was a disaster. The platelet count was terribly low. As green and unimaginative as I was, the real murderer of the virus began to sink in, and my hands trembled a little as I manipulated his blood. Who knew how the virus was transmitted by insects or body fluids or dust.
**************
In the dark four hours, I watched our military pilots striding angrily before and back on the tarmac. They were clearly full of resentment at the idea of flying to Yambuku in the epidemic area. They refused to help us to charge the device. Finally, they agreed to fly us Bumba as directed, but they said they would not stop there-just drop us off and fly.
A Land Rover was driven on and secure. We loaded into an essence, a few boxes of protective equipment and medicine, and some supplies for the Belgian mission. We sat in the seats of military style along the walls and preparing for a rocky ride.
As the sun rose, pilots loosens a bit. They let us go one by one, in the cockpit, where we could take in the incredible view of the rainforest that flowed beneath us like a vast green sea uprising punctuated now and then with a hamlet of fragile huts. The aircraft was essentially followed the Congo-largest river, nine miles wide in places, the other side often barely visible. Again, I heard the story of pilots watching the birds fall dead on the forest around Yambuku hit the air by the mystery virus, but there was a new twist :. human corpses lining the roads
We landed in Bumba, a riverside town then perhaps 10,000 people and the administrative and commercial capital of the district. For about two weeks, the entire area was quarantined and under martial law, cut off from the rest of the country. And this took place during the rice and coffee crucial harvest, main (if not only) source of liquidity in the region.
When the C-130 came to a stop, I moved to the door at the back, eager to get to work. What I saw through the open loading dock is printed permanently in my memory: hundreds of people-the whole town seemed he was standing on the red dirt airstrip in the hot sun, we first look and shouting "Oye! Hear Ye! "
The crowd cried because they were expecting deliveries of food and basic goods was the first aircraft to land in several weeks. When they realized we were not delivering food, the more desperate pushed forward, hoping to board the plane, but military police beat them back.
A Flemish determined man appeared, maybe 10 years older . that I, wearing black glasses and a shirt made of local African wax material It occurred to us: Father Carlos, in the order of Scheut, so a colleague Catholic missionary priests who had died of the virus in Yambuku . Father Carlos informed us about the epidemic. He started Yambuku in the first week of September, when the director of the school of the mission, who had traveled through the north on vacation, returned and ill.
After his death, crowds attended his funeral, and within days the hospital's mission began to fill with other patients, including the director's wife. They suffered high fever, headache, hallucinations, and usually bled to death. One after another, her caregivers at the hospital of Yambuku mission is sick, and members of his family, other patients, and dozens of other, seemingly unrelated people.
Nobody knew how many people had died, but those who became ill died within eight days. The few nuns still alive at the Yambuku mission were convinced they would die too soon. One person was known to have recovered from the virus. As regards ongoing cases, there were in Bumba, and several people who had traveled to Bumba Yambuku and were kept in quarantine.
By the time we left for Yambuku we heard of more than one hundred deaths. My natural skepticism began to fall, replaced by misfortune. The stories of Father Carlos and Dr. N'goy, district medical officer who first identified the outbreak, reports the hospital Bumba, the obvious fear of drivers and residents of Bumba and their desperate attempts to flee the city ... the apparent virulence of this disease, high mortality rates, put up with poverty and poor organization characterizes Zaire and the risk of contagion in Kinshasa added to an image that Joel Breman, a CDC senior epidemiologist, summarized as "potentially the most deadly epidemic of the century. "
we left two Rovers, one of them land lent to us by Fr. Carlos and silently led by the overwhelming exuberant strength, unstoppable Equatorial jungle uncut, well over 30 feet up. All kinds of green pressed on us, high walls of leaves and creepers muscle as something of a Tarzan movie. I had never seen how powerful and all-pervasive nature can be, and somehow it aggravated my feeling that we were making our way towards something horrible and uncontrolled.
We stopped at the Unilever plant in Ebonda. the staff were frantic. They had incredibly high expectations for our visit and our brief stay clearly disappointed and upset more women sang and shouted in grief around the small clinic. a number of death occurred recently
I had a photocopy of. image of the virus we had seen in our electron microscope Antwerp, and for some reason, it occurred to me to take it out and show it. This has had a fascinating placebo effect on the crowd. I guess that makes the virus less supernatural seems more real, and maybe less powerful.
Beyond Ebonda the road became almost impassable, just over a pit of mud and water, with entire sections washed away by the torrential equatorial rains. We drove through small villages of no more than 10 to 25 huts, huddling like nests at the foot of towering tropical trees. About half of the villages had erected barriers to control the popular movements in this quarantine period. The elders explained that they had done this without official instructions, as their elders did in the time of smallpox epidemics. We asked if anyone in these villages was being sick; all shook their heads no.
The thick green curtain around the closed road again, and we advanced with great difficulty until the coffee plantations first, then the Church and the red roofs of the mission is Yambuku appeared like mirages in the light of the blinding sun. Surrounded by a carefully swept courtyard lined with royal palms and manicured lawns, they seemed surreal. It was hard to believe that this same clean, orderly, idyllic Yambuku was really the heart of the mysterious killer virus.
The sisters were accommodated in the guest house between fathers convent on the right, and nuns convent and school, on the left. As our group walked, Sister Marcella, the Mother Superior, shouted: "Do not approach! Stay out of the gate or you'll die like us! "
Although she spoke French, I could hear her accent, she was not only Flemish, but also the region it came near Antwerp. I jumped on the gauze line who was hanged to warn visitors away and shook his hand in Flemish, I say.. "Hello, I'm Dr. Peter Piot, the Tropical Institute in Antwerp We are here to help and stop the epidemic. You'll be all right. "
There was a very emotional scene that the three nuns, sisters Marcella, Genoveva and Mariette broke down, clinging to my arm, holding each other and crying helplessly, they all started talking at once. Watching colleagues die one by one was a terrible experience.
Later, the sisters said they had read that in the case of an outbreak, a cordon has been put in place to contain the spread of the disease. They interpreted this letter, with an actual cord they strung around the guest house where they had found refuge. They also nailed to a palm tree near a sign in Lingala, warning "Whoever passes this fence will die." It instructed the visitors to ring a bell and leave messages at the foot of the tree. It was scary and sad and says a lot about the fear they had endured.
As Sister Mariette prepared dinner for us, Sister Marcella showed us the books she had recorded all deaths of patients with hemorrhagic fever, and all the information it considered relevant to their disease as recent travel. Nine of the 17 hospital staff members had died, like 39 others among the 60 families living in the mission, and four sisters and two fathers. She broke down several times as she described their symptoms and the agony of death, especially those of her sisters.
Sister Marcella continued to read his well-kept records I scribbled most valuable pieces information. She listed the names of the villages where the deaths occurred. She wondered if the disease could be related to the costs ape meat consumption: villagers often their food for food in the forest and the manager who was, temporarily, our "patient zero" was returned from his travels with several monkeys and antelope carcasses. She noted a high number of deaths among infants born at the clinic of the mission, and also observed a sudden rise in stillbirths among their herd of pigs. There are three months, she said, there was an epidemic among the goats in the Yandongi region.
These are all good lines of inquiry. (Later, I took the blood of pigs in their tail veins, a new experience for me.) None of them panned exactly, but another hypothesis Sister Marcella proved to be quite accurate. "Something strange is happening to the funeral," she says. "Again and again we have seen that the funeral was followed a week later by a lot of new cases among the mourners."
She was clearly pleaded with us for answers, but there was nothing we could say. Our first task was to ask questions. To break the ice, I showed photos of electron microscopy of the new virus, as I did later in all the villages we visited. The sisters also were fascinated by the wormlike structures that had caused so much pain and devastation in their community.
As we had no idea how the virus was transmitted, and whether the virus could somehow survive on materials such as mattresses and linens, we decided to sleep on the floor of a classroom in the girls' boarding school, which we first fumigated with formaldehyde and cleaned with bleach. I'm exhausted, but again could not sleep. There were too many impressions and race issues in my head. We did not know if the epidemic continues to spread or how fast, but we clearly approaching the heart of it soon would be staring us in the face. I also wondered what happens on earth in a funeral Zaire, and what might motivate a Flemish woman to spend his life in the midst of a distant jungle, totally disconnected from the world, without the most basic infrastructure and communication. How could you run a 100-bed hospital, not even a doctor? How do people survive in these villages? How could I be more useful here?
The night was filled with the croaking and animal sounds. I went outside into the blackest of nights where the stars shone uninhibited by the light of the city seemed so close over my head that I could almost reach, and I heard the distinct and sinister sound of drums. Perhaps, the old way, our arrival was announced.
**************
For the next two days we visited the village every morning, the blood test where we could, scribbling every detail and potentially say a piece of data that we can collect. We have seen patients with blood crusting around their mouths or oozing their swollen gums. They bled from their ears and noses and their rectum and vagina; they were intensely lethargic, drained of strength.
In each village, we held a meeting with the chief and elders. After the passage ritual of a plastic cup about distilled alcohol arak- banana, Peter had the courage (or perhaps a good way) to refuse-we asked them to describe their experience of the new disease the number of cases and deaths, dates, if they had been aware of people currently ill. We interviewed all the villagers we met about daily practices unusual-animal contact, new areas of cleared forests, food and beverage, travel, contact with traders.
We have heard of entire families had been wiped out by the virus moving fast. In one case, a woman in Yambuku died days after birth, quickly followed by her newborn. Her thirteen year old girl, who had traveled to Yambuku to support the child fell ill once she returned to her native village and died a few days later; followed by the wife of his uncle, who had taken care of it; then his uncle; and another relative who had come to care for him. This highly virulent human transmission was scary
We were all familiar with our terms of mission. We were here just for three or four days, to act as scouts preparing for the arrival of a great team that would try to set up systems to monitor the epidemic and break ground for further research. Our job was to document what was happening, sketch some basic epidemiology, take samples from severely ill patients, and if possible, find convalescent recovery that could provide plasma to help heal the sick to come.
And we do that job samples harvesting, collecting data and cataloging the basic logistical equipment that most team would need to bring. But we knew that from a human point of view it was just not enough. We needed to stop the virus to infect and kill people.
epidemic curve of the mystery fever began to take shape. The classic epidemiological curve is quite simple; he traces the number of new infections against time. In the simplest type of the soaring number of people infected rises gradually, then resumes rhythm, peaking in the middle of the graph. Once the virus has exhausted its stock of easy victims (weak or easily accessible), the rate of new infections begins to decline until the epidemic fades to a whisper.
We were all aware of the many exceptions that in real life the unexpected outliers, the blips and delays, complications epidemics spread with secondary and tertiary infections.
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