Only specially trained US Army medical lab technicians are allowed to enter the Warm Room, shown here through the window slot on the door, at the Jackson F. Doe Memorial Regional Referral Hospital in Tappita, Liberia. Photo: Cheryl Hatch
The facility looks like a landed manor estate. But inside this remote jungle outpost 200 miles east of Monrovia, the capital of Liberia, is a functioning CDC Biosafety Level 3 laboratory, the standard to do infectious disease research in the United States.
On one level, the fight against Ebola is nothing more than a giant decision matrix, a matter of process after an engineer’s own heart. Take the Tappita Ebola Treatment Unit. Situated near the Ivory Coast border, it is defined by gravity and logic. Potential cases enter uphill at the start of the flow chart and settle into a large Suspected tent. There are three ways to exit: the main path to the Confirmed ward, an escape valve to freedom, and a direct line to the morgue. The plumbing here is both metaphorical and literal; chlorine is constantly sprayed everywhere, and French drains draw the contaminated water down from the potentially sick to the confirmed Ebola-ridden to the lowest level, the ambulance decontamination pit and incinerators.
Using the gallows humor of the place, Tappita's Ebola medical workers joke that everyone in the Suspected tent hope they are sick with malaria. But how to prove they don’t have Ebola? The gold-standard blood test is done by six teams from the US Department of Defense, using lab equipment that was originally designed to help fight a biological war with the Soviet Union.
The current Ebola outbreak is by far the largest in history. As of January 12, 2015, it has claimed 8,386 lives in West Africa and 3,515 in Liberia alone, according to the Centers for Disease Control and Prevention and World Health Organization. When the disease was raging last summer, the Liberian government and USAID asked the US military to supply several "unique capabilities," skills and equipment other organizations could not provide in a timely manner. Captain Jerod Brammer and his team, sitting at Aberdeen Proving Ground, Maryland, just waiting to deploy, were certainly qualified to help out.
The Chinese government built the Jackson F. Doe Memorial Regional Referral Hospital in Tappita, Liberia, which opened in February 2011. The US Army now uses three rooms in the large hospital for its mobile blood lab for processing blood samples for the Ebola virus. Photo: Cheryl Hatch
Brammer runs Tappita's Ebola lab. He joined the Army as an enlisted infantry grunt, and jumped with the 173rd Airborne Bridge into the Bashur Airfield in northern Iraq in 2003. After another combat tour in Afghanistan, he went back to school and became a microbiologist. He has two enlisted technicians working for him at the lab in Tappita, Staff Sergeant Joshua Boggess from Hometown, West Virginia (can’t make that up), and Specialist Kayoed Ilesanmi, from Lagos, Nigeria. Ilesanmi is 28 years old, and has a master’s degree in health and wellness.
We brought enough stuff to run hundreds of blood samples, but it turns out location is more important than volume.
The Tappita blood testing lab consists of three small rooms in an enormous hospital that dwarfs every other structure in the village. According to the tablet plaque on a monument at the entrance, the Chinese government built the hospital less than four years ago, a gift to Liberian people. Next door to the palatial hospital is Tappita’s Ebola Treatment Unit; it is operated by the American non-profit Heart to Heart International, and constructed out of white tarp, plywood, and gravel.
“When we got here, we brought enough stuff to run hundreds of blood samples,” Brammer told me, “but it turns out location is more important than volume.”
We didn't see any patients, in the hospital or at the ETU. We weren't even allowed inside the ETU. We saw workers, but no patients. If a blood sample were to come in while we were there, Brammer said the first thing he'd do is kick us out.
The protocols and processes inside of the testing area are even more stringent than in the ETU itself. Originally, Army labs like this one were kitted out so they could confirm whether a soldier had been exposed to a chemical agent, or to test for the presence of Soviet weaponized biological agents, such an anthrax, small pox, and botulinum toxin. Here in Liberia, though, the goal is to get a confirmation that a patient has Ebola in two hours, rather than two days. The longer a person without Ebola waits in an ETU, the better chance they will actually catch it while there.
Spc. Kayode Ilesanmi, 28, from Lagos, Nigeria, dons his Tyvek personal protective equipment suit during a demonstration at the 1st Area Medical Lab at the Jackson F. Doe Memorial Regional Referral Hospital in Tappita, Liberia. Ilesanmi is one of the Army's medical laboratory technicians that process blood samples for presence of the Ebola virus. Photo: Cheryl Hatch
Adjacent to the front door of their lab is a plywood bin. Here blood samples are dropped off, double bagged, and sealed in plastic coolers. Motorcycle couriers bring in samples from all over the county. Others come from the ETU next door. Sometimes the emergency room doctor at the Chinese hospital asks for an Ebola test for every broken leg and cough. When Brammer gets word that a sample has arrived, his team dresses out and starts their day by spraying down the entire entranceway with bleach.
The process goes like this: The lab is divided into cold, warm, and hot zones. (For our safety, we were restricted from entering Tappita’s warm and hot zones.) To work in the hot zone, they wear layers of Tyvek, three pairs of gloves, a face shield, a fan-powered respirator drawing air through three charcoal filters, and chemical warfare overboots that have barely changed since the 1980s. The sample is placed into a glove box, a sort of fish tank with inside-out gauntlets penetrating the front pane of glass. When Brammer or his team members reach into the glove box, there are five layers of rubber and latex between them and the Ebola blood. This is as close as any US soldier gets to the virus during their tour in Liberia.
First, Brammer will use ethanol to inactivate the Ebola virus, then he precipitates out the RNA. Do you remember precipitate from high school chemistry, the crusty solid you unsuccessfully tried to extract from a liquid solution? That bit of possible-Ebola RNA can be mixed with saline and dipped with an assay, to run an Ebola pregnancy test, or sent to the RAPID for the gold standard confirmation, a polymerase chain reaction test.
Spc. Kayode Ilesanmi, 28, from Lagos, Nigeria, from left, Staff Sgt. Joshua Boggess, 30, from Hometown, West Virginia, and Capt. Jerod Brammer, man the 1st Area Medical Lab at the Jackson F. Doe Memorial Regional Referral Hospital in Tappita, Liberia. As Army medical laboratory technicians, the soldiers operate the lab that processes blood samples for presence of the Ebola virus. Photo: Cheryl Hatch
In Army-speak, RAPID stands for Ruggedized Advanced Pathogen Identification Device. It doesn't look fancy, kinda like a shower head stuck inside of a suitcase. But by growing inert samples of specific viruses, it can provide definitive proof of the presence of a pathogen. Sales of RAPIDs peaked after the anthrax scare of 2001, but now you can buy a used one on eBay for $2500.
The precipitate goes into the RAPID, and the operator watches the Ct value, the cycle threshold, the positive sign that the virus is duplicating. One bit of Ebola RNA becomes two, two becomes four, four becomes eight. If the growth flames out, then there is no Ebola present. But if it grows large enough fast enough, if it takes off exponentially past the Ct, then a positive result is confirmed.
That’s when you know you’ve really got Ebola
“That’s when you know you’ve really got Ebola,” said Brammer. He said this with professional distance and a scientist’s satisfaction, no tummy rumble to be working so intimately with a virus that has caused so much fear.
In some ways, Ebola acts more like a chemical weapon than a disease. Consider the similarities to the nerve agent VX: incredibly deadly, dangerous as a liquid, very little hazard through the air, killed by chlorine and sunlight and only a little bit of weather and time. “People wondered if we were trained enough to do this job,” Boggess said. “We’ve been training to do this job our whole career in the Army.”
Travel support for this story was provided by the Pulitzer Center on Crisis Reporting.