Conversations with the Director: Pierre Rollin

August 22, 2014

A Conversation about Ebola

Pierre Rollin, MD, one of the world’s leading experts on viral hemorrhagic fevers, has been fighting deadly microbes for more than 30 years. He has led dozens of investigations in the United States and in remote villages of Asia, Africa, South America, and the Caribbean—combating everything from Hantavirus and Rift Valley fever outbreaks to Ebola. Along the way Rollin, the deputy branch chief in the Viral Special Pathogens Branch at the National Center for Emerging and Zoonotic Infectious Diseases, has helped author more than 450 publications. Clearly, he is a busy man.

Rollin also serves as the director of the World Health Organization’s Collaborative Center for Viral Hemorrhagic Fevers. So, with history’s worst Ebola outbreak spreading death, fear, and rumor across West Africa, CDC Director Tom Frieden, MD, MPH, seized the moment to host Rollin (who had just returned from three months of fighting Ebola in Guinea) for a Conversation with the Director. Frieden also invited Atlanta’s WABE radio to record their talk in his conference room.

“Small Detail after Small Detail, You Can Start to Limit the Transmission”

Early in their discussion, Frieden asked about Rollin’s first field experience with Ebola in 1995 in the Democratic Republic of the Congo (then Zaire) and zeroed in on one of the keys to Rollin’s success: his nuanced understanding of local cultures, their religious sensitivities, emotional state, and everyday realities while coping with these outbreaks. The knowledge gained from these observations—picked up through years of field experience—is used to prioritize tasks and do whatever it takes to provide his teams with advantages against the virus.

“When we arrived, the hospital was completely devastated,” Rollin said, his accent revealing his French roots. He is well-known for candor, but he is also calm and soft-spoken while recalling scenes most people could only describe as horrors. “There were dead people everywhere, sick people. And the main thing we did at the beginning was cleaning the ward, removing the bodies, and using all the skill we have to train people, also nurses and physicians, because everybody was scared.”

“And have you had the experience of using survivors as part of the care teams in the past?” Frieden asked.

“At that time, no,” Rollin said, “because at that time there were very few survivors. And the ones who survived ran away and didn’t want to come back.” He quietly thinks about his answers before speaking, pausing to find the right words in English. “But we used survivors after 2000, after the Gulu (Uganda) outbreak, where we had some nurses that were sick and survived. I met them again in 2007 after the Bundibugyo outbreak, and they were used there as communication, mostly to explain to the people the risks.”

Ebola risks are many and often misunderstood. The virus spreads through contact with blood or body fluids. As a result, healthcare workers, family, and close friends are at highest risk. And because the body can still spread the virus for a few days after death, preparing and transporting bodies for funerals is particularly risky.

“Burial practice is a big, big problem,” Rollin said. “We try to talk to all the imams (Islamic leaders).” Rollin respects Muslim burial practices—which typically include washing the body and enshrouding it in a cotton or linen cloth—but he also realizes the dangers of handling Ebola victims. “So, we had to discuss with (the imams) to see if it was religiously OK to add bleach to the water.”

Although accommodating religious practices can be challenging, Rollin and his teams understand the importance of doing so, as religious leaders can also help spread important health messages. Frieden and Rollin discussed how the dawn-to-dusk fast during the month of Ramadan can be especially trying for people who wear protective gear and transport and bury bodies or work in healthcare settings. The West African summer heat makes hydration under those conditions essential.

“When you wear all this protective gear, you need to drink,” Rollin said. “And technically, you cannot drink during Ramadan. So we went to the imam to figure out if there was a way around that. During one of the Friday sermons they explained that there is some disposition in the Quran that says that if you can’t follow Ramadan, you can defer to a later time.

Lack of Infrastructure, Social Stigma Add to the Challenge

But accommodating religious and cultural practices and getting local leaders on his side are only the beginning of the effort in these remote and underdeveloped outposts. The lack of infrastructure presents a far bigger challenge.

“You need 100 liters of water a day per patient for all the disinfectants that you’re going to use—all the spraying around—it’s huge. And when you have hospitals where you have no running water, then you have to have the logistics to bring the truck to make that work.”

Frieden asked about another challenge: tracing disease contacts. Rollin pointed out that fear of social stigma makes contact tracing especially difficult.

“In some areas, people don’t want to be on the contact list because they think they’re being put on the death roll,” Rollin explained. “The problem with that also is the communication with the people. When people do contact listing, some think, ‘Oh, you just go and see if the people are OK, yes or no. Oh, he has fever, yes or no,’ but it has to be used to pass messages to the people.”

Rollin expressed dismay with some workers who trace contacts, suggesting they are not always sufficiently sensitive, often due to their own fears. He said that when contact tracers dress in protective gear just to knock on doors, they can spread fear rather than information.

This reminded Frieden of work he did with tuberculosis patients. “You have to make the patients the focus of the program, the VIPs of the program, and make sure they get the services they need, and then you get cooperation.”

Rollin agreed. “When you do the contact tracing, if you stay at one or two meters away, there is no risk. If we pass the message saying that Ebola is passed by direct contact, we have to behave the same way. We can’t say that to the people and then show up (wearing full protective gear) when you go in the village, because then you’re going to scare everybody.”

Although Ebola risks are often exaggerated, just as many risks are not understood. Frieden asked about the risk of transmission from fomites, that is, objects such as needles, bedding, and clothing that might spread the disease. Rollin said the research indicates the risk is mostly minimal and that the main driver of infection remains the cleaning of patients directly—their blood, urine, feces, sweat, and saliva, for example, without wearing protective gear.

Frieden asked about the consumption of wild animals or “bush meat” such as apes, which have been known to carry Ebola. Rollin said the risk mostly comes from hunting, handling, and preparing bush meat, rather than from eating it.

“I think stopping bush meat consumption is a dream,” Rollin said. “I like animals, but (West Africans) have no other meat. So, if you want them to have access to animal protein, you have to have bush meat. We never saw that there is a risk with bush meat that is already processed, either smoked or cooked. The risk is for people hunting the animals.”

Rollin also pointed out that while there may be a rare jump from bat or ape to human to begin an Ebola outbreak, in all of the Ebola outbreaks to date, most transmission is from human to human. And in some places where bats infected with Ebola live and are consumed, there have been no Ebola outbreaks in years.

Rollin suggested that much of the media frenzy surrounding the current Ebola outbreak is counterproductive because it eventually delays travel, which has unintended consequences.

“The airlines are afraid to fly, and the embassies are getting all the nonessential people out, and the airlines are even more afraid to go, and very soon we will have no airline to go into the country to help or bring in supplies, and the country will be hurt economically, and that’s a big problem.”

Meanwhile, Rollin said, if Ebola arrives in the United States or Western Europe, he doesn’t think it will be a significant public health challenge.

“I don’t think there will be an outbreak,” Rollin said. “There could be maybe one or two secondary cases, but with the systems in place in the hospitals—people washing their hands, people using disposable equipment, not reusing equipment, wearing gloves, wearing goggles, wearing gowns—the risk of transmission is completely different than what we see in the endemic areas. Because of the hospital infection control, because of the training of the people, a large outbreak will never happen.”

Frieden and Rollin agreed that optimism is realistic in the United States, just as immediate action is critical in Africa.

“The fact is, this is a deadly, devastating disease in Africa,” Frieden told WABE after the discussion. “If you’re scared and you’re taking care of an Ebola patient, use that fear to make sure you’re taking all the infection control precautions. If you’re scared and you’re a healthcare worker in this country, be sure you take a travel history and find out if your patient has been to West Africa in the last 21 days. Then, if they have a fever, isolate them, and get a diagnosis. If you’re scared and you’re part of CDC, plow that fear into additional focus and energy into helping to stop the outbreak at the source. And for everyone else, I hope their fear doesn’t outweigh their compassion.”

This Inside Story by Luis M. Luque

CDC Connects Story Manager: Kathy Chastney