1

Emergency settings and the need to provide accompaniment for Ebola survivors: the psychological care of patients following Ebola virus disease infection and patients affected psychologically by the epidemic in Conakry Keita MM1, Doukouré M1,Chantereau I2, and al

1-Service de psychiatrie de l’hôpital national Donka (Conakry – Guinée) 2-Centre Hospitalier de Saint-Cyr-au-Mont-d’Or (Rhône – France)

Abstract The aim of this study was to report the psycho-social experience of patients having recovered from Ebola virus infection and other persons affected by it psychologically in Conakry (Guinea), and to describe the psychological methods implemented for their care. Materials and methods The study was prospective, cross-sectional and descriptive, and lasted three months in the epidemic crisis period. It concerned patients who had been infected and had recovered, and patients affected psychologically by Ebola, seen in the psychiatric department of Donka national hospital for psychological support on request from the NGO Save the Children. The patients were seen between May and August 2014 and divided into different groups. The interviews were confidential, and under the responsibility of two psychiatrists and psychotherapists. All patients gave their informed consent to take part in the study. For children, parental or legal representative consent was sought. Results Between May 30th and 9th August 2014, sixty-eight (68) patents were seen in the psychiatric department of Donka national hospital for psychological support. Among them, there were 37 Ebola virus-infected subjects reported cured, 17 contact subjects, and 14 non-contact subjects but presenting psychological trauma. The fear of falling ill and dying, anxiety, insomnia, mistrust or avoidance, feelings of rejection, withdrawal, hospitalism for the orphans, and loss of interest in usual activities (anhedonia) were the main psychological problems presented by these patients as a whole. Three of the patients in the overall cohort, or 4.41%, presented a state of post-traumatic stress, and seven (10.9%) presented moderate depression without psychotic symptoms. In the social sphere, 37 patients (54%) experienced rejection and stigmatisation by their community and/or professional entourage. Psychological debriefing, followed by supportive psychotherapy and cognitive-behavioural therapy, with use of antidepressants in some cases, were the therapeutic means deployed. Advice on individual and collective hygiene was provided for all subjects in a prevention drive. Once the patients had regained confidence, they joined a NGO to back up monitoring and awareness-raising teams in the districts of Conakry and across the country. Conclusion Patients who have had Ebola virus infection and have recovered, like those affected in other ways by the epidemic, undergo genuine psychological trauma. The provision of psychological support efficiently alleviated the psychological suffering of these individuals and contributed to their social and professional rehabilitation. A further, wider study on victims of Ebola could enable a clearer understanding of the psychological disruption occasioned, so as to improve psychotherapeutic care. The psychological accompaniment of survivors should be a healthcare priority. Keywords: psychological support, persons infected/cured, persons affected, Ebola, Guinea-Conakry, outbreak, trauma care, mental health, viral diseases

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INTRODUCTION Ebola virus disease (EVD) (previously known as Ebola haemorrhagic fever) causes a serious, acute illness which is often fatal if untreated. Infected subjects remain contagious so long as the virus is present in their blood and other biological fluids, including sperm and maternal milk. Sperm can continue to transmit the virus for as long as seven weeks after clinical recovery. The mean fatality rate is around 50%. In earlier outbreaks of the disease it ranged from 25% to 90% [1,2]. The EVD epidemic in West Africa started in Guinea in December 2013, but was only notified on March 21st 2014, before extending to neighbouring countries (Liberia, Sierra Leone). The epidemic, caused by the Zaire strain of the virus, is thought to have caused the largest number of deaths since the discovery of the first cases in 1976 in the Congo. The Ebola river, located near the Congolese village of Yambuku where the virus was discovered, gave it its name [3]. The most seriously affected countries (Guinea, Sierra Leone and Liberia) have very vulnerable health systems, they lack human resources and infrastructures, and have only just emerged from long periods of conflict and socio-political unrest. On August 8th 2014 the general director of WHO declared that the epidemic was a public health emergency on international scale, and that there was currently no recognised vaccine or treatment against Ebola. Since then, pharmaceutical laboratories in the ISA, such as Mapp Biophamaceutical, have developed ZMAPP, a vaccine that proved successful in the treatment of two American aid workers, Kent Bradley and Nancy Writebol, who contracted the virus in Liberia [4]. This first announcement by WHO, relayed on national radio, television, in the press and by the health authorities, caused panic in the Guinean population, for whom Ebola was synonymous with death, despite the fact that the Guinean government and WHO had already launched a first round of clinical trials on the vaccine VSV-EBOV, developed by the public health Agency in Canada. Around 10 000 volunteers were included in these trials extending over a period of six to eight weeks, with a planned follow-up of three months. Preliminary results were expected for July 2015 [4]. These initial announcements fed nightmare rumours creating almost permanent general anxiety in the population, amounting to mass panic. People who were considered cured were heroes for some, or walking dead for others, already mourned by their families and friends. This generated mistrust, rejection and stigmatisation of convalescent patients by their families and sometimes their professional environments. In 2007, the Republic of Uganda saw an Ebola epidemic of the Bundibugyo type, with 187 cases of infection and 25% fatalities. In the same year, the Congo Democratic Republic saw an outbreak of the Zaire strain infecting 264 people with 71% fatalities. In 2012, an Ebola epidemic of the Bundibugyo type broke out in the Congo Democratic Republic with 57 cases and 27 deaths, amounting to 29% fatalities.

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In Guinea, the absence of earlier studies on the psychological care of survivors of Ebola haemorrhagic fever motivated the choice of the present study theme: the psychological care of patients following Ebola virus disease infection and patients affected psychologically by the epidemic in Conakry. The aims of this work were as follows :

1- to report on the psychological experiences of individuals infected and subsequently cured, and of other individuals affected psychologically by the epidemic in Conakry

2- to anticipate the appearance (several weeks or months later) of post-traumatic stress syndrome

3- to facilitate social and professional rehabilitation 4- to describe the psychological techniques implemented, enabling patients to put their distress

into words. I. BACKGROUND

Setting : Guinea is on the western coastline of Africa. The population in 2012 numbered 11 663 627 inhabitants, amounting to a density of 47 individuals per square kilometre. The EVD outbreak in Guinea occurred in the setting of a weak health system, characterised by the inadequacy of infrastructures and health facilities. This latest outbreak in West Africa, where the first cases were notified in March 2014 in Guinea, is the largest and most complex since the virus was discovered in 1976. It has caused more deaths that all the other outbreaks combined. The EVD epidemic overturned the cultural and social codes of these West African countries, where families could no longer bury their dead according to traditional rites, since the bodies were highly contagious. This generated considerable hostility in the population towards expatriate or local aid workers in the treatment centres. Generally speaking, relations with the local communities were more complicated in the setting of Ebola than in other intervention fields. The psycho-traumatic impact of EVD : A traumatic event can involve a single situation, or several prolonged, repeated events, and it can completely overwhelm an individual's ability to integrate the ideas and emotions generated by that experience. Mental trauma can have serious negative consequences in the long term [7]. The EVD epidemic had considerable impact on the well-being of the individuals concerned, on that of their families, and that of the healthcare staff in charge of treating Ebola patients. The disease generates specific problems for people involved (for instance stigmatisation, isolation, fear and possible abandonment by family) and for healthcare staff and other professionals (for instance personal safety and access to updated information) [8].

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It can also be recalled that Ebola has an effect on ways in which people provide support for one anther (for instance they cannot touch each other), and on the way in which the death of persons close is met (for instance, they can no longer attend traditional burials), all of which can seriously aggravate the psychological distress of some individuals. In our care system, different professionals intervene with a patient to help him or her to overcome the different aspects of the trauma (medical, psychological, legal etc): medical specialists (most often psychiatrists) psychologists, legal advisers, social workers. Patient management can be coordinated with support groups. The EVD epidemic is an event that generates stress, and has specific features and specific care requirements. Event-related stress constitutes a single trauma that is limited in time. It is unlikely to occur again. Yet it is the fear of relapse that dominates, the fear of a recurrence, in particular because the event originally occurred in accidental manner. Specific care for this type of stress is clearly codified, involving in particular well-tested psychological support frameworks. The psychological intervention There are three types of intervention : • Intervention of a preventive type following a potentially traumatic incident. It is sometimes necessary to intervene promptly to avoid the development of traumatic neurosis (Post-Traumatic Stress Disorder, PTSD in the DSM), characterised by symptoms linked to the psychological shock, which may become chronic. Here the technique used is known as "debriefing", which mainly aims to alleviate anxiety and stress, and to enable an individual subjected to a potentially stressful event, liable to exhibit delayed psychopathological reactions, to find his or her identity and place in reality. To be represented, emotion needs to carry meaning, which is deployed in a narrative delivered to or by another person. The use of debriefing sometimes runs alongside subsequent, more in-depth curative treatment. Debriefing is a therapeutic interview technique implemented within a certain time-lapse after the traumatic event – 24 to 72 hours or more for type 1 trauma (single event) and up to several years after type 2 trauma (numerous or repeated events, as is the case in ill-treatment) [17]. Psychological debriefing is used for willing subjects, in groups or individually, following a traumatic event. • Intervention intended to manage stress. There are different therapeutic stress-management techniques that enable the subject to achieve better control. This type of debriefing is sometimes accompanied by controlled breathing aiming to have an effect on the sympathetic and parasympathetic system, relaxation techniques, meditation, etc. • Intervention of the curative type. Here mainly behavioural-cognitive therapies (CBT) are implemented. We can also recall the use of hypnosis, which is unfortunately often not easy to use. Pain control and the treatment of anxiety are particularly important, and all patients should receive careful follow-up and psychological support [8]. II. METHODS This study was prospective, cross-sectional and descriptive, and lasted three months. It involved patients who had been infected and subsequently cured in the Ebola treatment centre, and

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patients psychologically affected by EVD, seen in the Donka national hospital psychiatry department for psychological support on request from the NGO Save the Children. All gave their informed consent to participate, and for children consent was obtained from the parents or legal representatives. Patients were seen in successive periods and divided into groups. The premises provided several interview rooms. Interviews were confidential and under the responsibility of two psychiatrists/psychotherapists. Children of 2 to 11 years were catered for by the department's paediatric psychiatrist, and were able to express themselves by way of drawings and other techniques suited to the age group. Preventive psychological debriefing coupled with supportive psychotherapy and cognitive-behavioural therapy for some, and/or curative therapy, were the methods deployed. Individual and collective hygiene advice (chlorine, soap) was also given to all patients. III. RESULTS Cf. Appendix Tables IV. DISCUSSION In Guinea, from the moment when the EVD epidemic was reported in March 2014 and June 2nd 2014, the national crisis committee registered 199 confirmed cases and 118 deaths amounting to 59% fatalities, leaving 81 Ebola survivors or cured patients. This situation calls for awareness-raising backed up by clear scientific information to efficiently combat rumours on the subject of EVD. And above all, the direct and indirect victims of EVD alike need psychological support. The illness has been a genuine psychological trauma, with its aftermath of psychological distress and stigmatisation. In Conakry, and even more in rural areas, people mistrust everything and everyone. Official announcements are ignored. The wildest rumours spread, even faster than the virus – on the origins of the disease, how it is transmitted, treatments, the way funds are used - everything is suspect. The idea that Ebola is a disease created and propagated by white people is widespread and resilient. Even in the city, there is talk of the "Ebola business" supposedly run by whites. Communities have of course hidden their patients, because of the general mistrust, and because people do not want to be quarantined and thus to lose their meagre livelihoods. And there is also the conviction that, in all events, medicine is powerless [9]. In Africa, heads of families often have 5 to 15 mouths to feed, with a large proportion of cousins and nephews enlisted in schools. In addition, corpses are venerated, and should receive all the rites of the community to avoid punishment by the spirits of the ancestors for animists, or by God for believers. Ebola corpses are not allowed these rites. Orphans and widows are particularly vulnerable, and are generally a focus of attention in traditional African communities in terms of psychological and material support. Previously, a motherless orphan was entrusted to a maternal female figure, either the grandmother, or another woman in the community recognised as being attentive to the child's care. A widow was remarried in her dead husband's family to one of her brothers-in-law, or another man of her choice in the

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community, who then took charge of her with her children after a traditional period of widowhood of four months and ten days among Moslems (to allow for a pregnancy, in which case she would wait for the child to be born to remarry). Widowers were rapidly provided with a wife of their choice "to dry his tears and care for the orphans". But Ebola, known for its virulence and high fatality rate, disrupted all these social traditions, complicating the maternal care of orphans and remarriage among widows and widowers. The NGO Save the Children was only able to access 68 of the 81 survivors for psychological assistance, i.e. 45.67%. Our work concerned the 54% who agreed to meet a psychologist. Their first common reaction was to thank God/Allah for having escaped death, after having been close to dying and then being cured, and also to thank all the staff. The fact that other survivors did not respond to the offer can be explained by the fact that certain cured patients, labouring under the psychological distress caused by the illness and rumours, continued to seek care from traditional medicine and/or marabouts, since the first messages circulated by the health authorities stated that there was no cure for Ebola ("no treatment or vaccine available to date"). This information did not encourage patients to resort to modern medicine. If there is no cure, why should the illness be reported? Better to trust traditional medicine and practitioners – salt water, coconut oil or lemons were thought to provide a cure. Thus certain patients escaped from the confinement centres to consult traditional practitioners. It is particularly important in this country to die near one's family, and also to abide by funeral rites [8]. Contact patients (25%) and non-contact patients, i.e. including widow(er)s and orphans (21%) were affected in different manners. However one point in common was the stigmatisation by their entourage for fear of contamination, as well as insomnia, grief for the death of someone close, and fear of divine punishment for failure to follow traditional mourning rituals. Male gender. Males were more frequently affected in our cohort as a whole – 60.29% vs 39.7% females, a gender-ration of 1.51. In African tradition, men are on the front line in difficult situations, such as the care of an Ebola patient because they are thought to stand up to adverse events better than women. This could explain the difference. The age group most frequently affected in the cohort was the 22-32 age group (young working adults) with 38.23%. This figure is in line with WHO data. The 17 Ebola contacts affected by the death of family members (25% of the overall sample) had not contracted the disease but were afflicted by the sudden loss of loved ones, most often the mother or the father or another resource person in the family. These families experienced between 2 and 7 deaths among their members. It is easy to see that premature death amounts to a family tragedy.

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The 14 patients who were not contacts also sustained psychological trauma. They were not with their families at the time of their illness, and only returned after their deaths and the 21 days quarantine imposed by the Red Cross. Among these contact and non-contact patients there were 14 orphans (45.16%), 8 widows (25.8%) and 9 widowers (29.03%). When age groups are crossed with the psychological symptoms observed, orphans between 2 and 12 years of age were the most affected, at 28.57% of the 14 cases for whom the symptoms were the most pronounced (wanting to see their mother, despair, crying, isolation and rejection, irritability, disobedience, fear of contracting the disease, anxiety, insomnia, nightmares, difficulty concentrating, feelings of abandonment, loss of interest in play, anorexia, lack of implication in school). Only one orphan aged five with good family support (grandmother providing maternal care) presented no particular symptom. The distribution of patients according to the psychopathological problems encountered showed a clear predominance of acute stress (54%). This clinical characteristic features the fear of falling ill, virtually permanent anxiety, insomnia alternating with nightmares, stigmatisation by the entourage, feelings of rejection and shame. In popular culture, Ebola is synonymous with death because of its virulence, the fatality rate and its "spectacular" symptoms. The Ebola virus has become one of the most dreaded incarnations of biological threat [4]. In our study, the Ebola victims were seen 3 to 5 months after being cured, but they were also psychologically traumatised by deaths in their families. The psychological debriefing was essential to enable them to put words on their suffering. The patients were first subjected to debriefing and then received support psychotherapy. These techniques enabled them to overcome the huge emotion and the rumours, and to reposition themselves with respect to the future. However 30.88% of our patients had good family support, and normal sleep and appetite, despite mild anxiety. After debriefing and group therapy, the pursuit of personal and collective hygiene was recommended. Moderate depressive syndromes without psychotic symptoms were diagnosed for 10.29% of our patients. This group also received debriefing followed by support psychotherapy, along with clear, updated scientific information on the disease, restoring their confidence in themselves and their environment. Appointments were made for subsequent encounters. Post-Traumatic Stress (PTSD in DSM-IV-TR) was diagnosed for 4.46% of our patients. These patients, seen 5 months after the event, presented a characteristic clinical profile with specific symptoms such as reliving (flash-back) – the repetition of hallucinatory images of dying parents, groaning in their blood and uttering their last words (my son, my dear wife... it's over, I cannot go on, take care of your brothers, our family..." etc. Here the visions occurred several times a day.

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Avoidance of hospital and fear of white coats (recalling the protective clothing of healthcare staff) were reported by our patients. This was accompanied by other major symptoms such as nightmares, insomnia, fear of (re)contracting Ebola, anxiety, starts at the slightest sound of ambulance sirens and mistrust of the entourage for fear of rejection. Subjects declared cured were heroes for some, but living dead for others already mourning for them. This also engenders mistrust, rejection and stigmatisation of convalescent subjects by their entourage or community. This last group of patients (PTSD) particularly drew our attention on account of the severity of their symptoms. They underwent collective debriefing to de-dramatise the situation. Each person, hearing other people's narrative, understands that he or she is not the only one undergoing the consequences of the trauma. Support psychotherapy and cognitive behavioural therapy sessions were organised. Two patients in this group were prescribed antidepressants of the SSRI type (Paroxetine) which proved efficacious after three weeks, and follow-up was to be pursued for six months. Child orphans were followed by the department paediatric psychiatrist. Results of psychological follow-up among recovered Ebola-infected subjects and subjects otherwise affected by the epidemic Psychological debriefing coupled with supportive psychotherapy and cognitive behavioural therapy formed the therapeutic approach implemented. Individual and collective hygiene advice was provided for all subjects for the prevention of spread, especially for convalescent patients. Patients previously infected and cured regained confidence, because they knew they were immunised against the Ebola virus, and they formed a NGO to back up the awareness-raising and surveillance teams in combating rumour, and in reaching the families of concealed cases in Conakry and outside. By organising focus groups in urban districts and public venues, these recovered patients have taken an active part in combating stigmatisation and mistrust (workshops on the subject of Ebola, such as those organised by Axiome-Génie Conseil with the World Bank, and also public and private press media). This NGO of formerly infected Ebola patients has taken active part in combating stigmatisation and mistrust. Conclusion

People who were infected by Ebola and then recovered, and likewise those affected psychologically by the epidemic in Conakry, underwent genuine psychological trauma. Psychological debriefing, supportive psychotherapy and cognitive-behavioural therapy, along with medication in some cases, were the successful means implemented by our team to relieve the mental suffering of the victims and facilitate their social and professional rehabilitation. For the children, a fairly large proportion of our sample, expression techniques suited to age were implemented. This all shows the importance of psychiatrists, social workers and psychologists integrated into a multidisciplinary team in charge of managing recovered Ebola patients. The psychological accompaniment of survivors, despite the fact that it could be thought that a cure solves the problem, should be a health priority.

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This work was conducted over a limited period in a time of crisis. A study based on an evaluation methodology extended to other recovered Ebola patients and other people affected psychologically by Ebola-related events could enable the scale of the psychological damage to be assessed, and prevention of psychological complications in the aftermath of Ebola, providing appropriate psychotherapeutic care at the right time.

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APPENDIX TABLES

Table I : Distribution of patients according to their situation

Situation Numbers Percentage (%)

Patients infected and cured

37

54

Patients affected

psychologically - contacts

17

25

Patients affected

psychologically - non contacts

14

21

Total

68

100

Table II : Distribution of patients according to gender

Gender Total Percentage (%)

Male

41

60,29

Female

27

39,70

Total

68

100

Sex-ratio : M/F= 1,51 Table III: Distribution of patients according to age

Age group Number of cases Percentage (%)

2- 11

21

30,88

12-21

21

30,88

22-32

26

38,23

Total

68

100

Mean age: 21.5 yrs

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Table IV: Distribution of patients according to symptoms encountered

Problems encountered Syndrome diagnosis Numbers Percentage %

- Fear of falling ill again, anxiety, insomnia and nightmares, stigmatisation, feelings of rejection and shame

State of acute stress

37

54%

- Difficulty concentrating, despair, self-devaluation - Relational difficulties - Depressive mood, anhedonia, insomnia, anorexia

Moderate depressive syndrome without psychotic symptoms

07

10,29%

- Nightmares, insomnia, fear of falling ill again, anxiety, starts, mistrustfulness, reliving (flash-back), avoidance. Fear of white coats (recalling protective clothing of staff)

Post-traumatic stress disorder (PTSD)

03

4,46%

-Good-quality family support, -Mild anxiety -Good appetite and sleep

None

21

30,88%

TOTAL

-

68

100%

Supplementary tables (partial cohort results)

Table V-1 : Distribution numbers of deaths in the family for the 17 contacts

Contacts affected psychologically

Number of Ebola deaths in the family

1 3

2 6

3 4

5 7

6 2

12

Table V-2 : Distribution of patients between contacts and non-contacts psychologically affected by the death of family members.

Situation

N° contacts affected psychologically

N° non-contacts affected

psychologically

Total

%

Orphans 8 6 14 45,16

Widows 5 3 8 25,80

Widowers 4 5 9 29,03

Total

17

14

31

100

Table V-3 Distribution according to symptoms of the 14 non-contacts affected psychologically by the death of family members

Age group Symptoms

2 - 11 yrs

12 – 21 yrs

22 yrs and

over

- Despair, crying, wanting to see mother, isolation with feelings of rejection, irritability, disobedience, fear of getting the disease, anxiety, insomnia, nightmares, difficulty concentrating, stigmatisation and feelings of abandonment, lack of interest in play, anorexia - Lack of involvement in school

3

1

-

- Difficulty concentrating, despair, feeling devalued, guilt, relational difficulties - Depressive mood with anhedonia, insomnia and anorexia

-

-

3

- Nightmares, insomnia, fear of contracting Ebola, anxiety, starts, mistrust, reliving (flash-back), avoidance, fear of white coats (recalling staff protective equipment)

-

1

2

- Good-quality family support - Mild anxiety - Normal sleep and appetite

1

-

3

TOTAL

4

2

8

13

REFERENCES

1. Sylvain B, et al. Emergence of Zaire Ebola virus Disease in Guinea. The new England journal of medicine 2014 ; 9 :

1418-25

2. Feldmann H, Geisbert TW. Ebola haemorrhagic fever. Lancet 2011 ; 377 : 849-62

3. Barry M, Traoré FA, Sako FB, Kpamy DO, Bah E I, Poncin M et al. Ebola outbreak in Guinea : epidemiological,

clinical and outcome features. Med Mal Inf 2014 ; 44 : 491-4

4. Maladie à virus Ebola : mesures de prévention et de contrôle pour les hôpitaux. Institut de Santé Publique de

Quebec. Comité sur les infections nosocomiales du Québec Août 2014.

Disponible sur : https://www.inspq.qc.ca/infectionsnosocomiales/comite-cinq.

5. Baize Sylvain, Ph.D et coll. Emergence of Zaire Ebola Virus Disease in Guinea, N Engl J Med 2014 ; 371 : 1418-25

October 9, 2014 DOI: 10.1056/NEJMoa1404505.

6. Fournier Catherine. Ebola : les psys aussi luttent contre l’épidémie. Francetvinfo. 21 novembre 2014

Disponible en ligne : http://www.francetvinfo.fr/sante/maladie/ebola/ebola-les-psys-aussi-luttent-contre-l-

epidemie_750047.html

7. Haute Autorité de la Santé en France (HAS) prise en charge de l'ESPT - chapitre psychothérapies structurées,

Disponible sur : http : //fr. Wikipédia .org/wiki/ traumatisme_ psychologique - juin 2007 - page 18

8. OMS : Maladie à virus : Aide-mémoire N° 103 Avril 2015. Disponible sur

www.who.int/mediacentre/factsheets/fs103/fr/ (Dernière consultation 07/06/2015 à 00h 30mn

9. Tatu Natacha. A Conakry, les rumeurs les plus folles se propagent plus vite qu'Ebola envoyée spéciale en Guinée.

Le Nouvel Observateur : 13 octobre 2014

Disponible sur : http://tempsreel.nouvelobs.com/virus-ebola/20141012.OBS1871/a-conakry-les-rumeurs-les-

plus-folles-se-propagent-plus-vite-qu-ebola.html

10. Chantereau Isabelle. Evolution des cadres de référence théorico-cliniques des psychotraumatismes. présentation

orale lors des journées médicales franco-guinéennes

(10 au 14 mai 2015).

11. Cremniter D, Laurent A. Syndrome de stress post-traumatique : clinique et thérapie. EMC Toxicologie Pathologie

2005 ; 2 : 178-184

12. Diallo Goudoussi Abdou. Et vint le virus Ebola. L’Harmattan 2015 : 74p.

13. Mouchenik Y, Baubet T, Moro MR. Manuel des psychotraumatismes. La pensée sauvage 2012 ; 278p.

14. Massé R. Culture et santé publique : les contributions de l'anthropologie à la prévention et à la promotion de la

santé. Gaëtan Morin 1995 ; 499p.

15. Josse E. Etat de stress aigu et état de stress post-traumatique, quoi de neuf dans le DSM-5 ? 26 novembre 2013 -

Disponible sur http://www.resilience-psy.com/spip.php?article46

16. DSM V – Criteria for PTSD - National center for PTSD

In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

14

Hospital National Donka – Conakry-Guinea

Psychologists intervene with medical teams in West Africa,

but also when they return to Europe.

Needed support because of accumulated stress faced by caregivers in the disease.

15

APPENDIX

Table I : Distribution of patients according to their situation

Situation Numbers Percentage (%)

Patients infected and cured

37

54

Patients affected

psychologically - contacts

17

25

Patients affected

psychologically - non contacts

14

21

Total

68

100

Table II : Distribution of patients according to gender

Gender Total Percentage (%)

Male

41

60,29

Female

27

39,70

Total

68

100

Sex-ratio : M/F= 1,51 Table III: Distribution of patients according to age

Age group Number of cases Percentage (%)

2- 11

21

30,88

12-21

21

30,88

22-32

26

38,23

Total

68

100

Mean age: 21.5 yrs

16

Table IV: Distribution of patients according to symptoms encountered

Problems encountered Syndrome diagnosis Numbers Percentage %

- Fear of falling ill again, anxiety, insomnia and nightmares, stigmatisation, feelings of rejection and shame

State of acute stress

37

54%

- Difficulty concentrating, despair, self-devaluation - Relational difficulties - Depressive mood, anhedonia, insomnia, anorexia

Moderate depressive syndrome without psychotic symptoms

07

10,29%

- Nightmares, insomnia, fear of falling ill again, anxiety, starts, mistrustfulness, reliving (flash-back), avoidance. Fear of white coats (recalling protective clothing of staff)

Post-traumatic stress disorder (PTSD)

03

4,46%

-Good-quality family support, -Mild anxiety -Good appetite and sleep

None

21

30,88%

TOTAL

-

68

100%

Supplementary tables (partial cohort results)

Table V-1: Distribution numbers of deaths in the family for the 17 contacts

Contacts affected psychologically

Number of Ebola deaths in the family

1 3

2 6

3 4

5 7

6 2

17

Table V-2: Distribution of patients between contacts and non-contacts psychologically affected by the death of family members.

Situation

N° contacts affected psychologically

N° non-contacts affected

psychologically

Total

%

Orphans 8 6 14 45,16

Widows 5 3 8 25,80

Widowers 4 5 9 29,03

Total

17

14

31

100

Table V-3 Distribution according to symptoms of the 14 non-contacts affected psychologically by the death of family members

Age group Symptoms

2 - 11 yrs

12 – 21 yrs

22 yrs and

over

- Despair, crying, wanting to see mother, isolation with feelings of rejection, irritability, disobedience, fear of getting the disease, anxiety, insomnia, nightmares, difficulty concentrating, stigmatisation and feelings of abandonment, lack of interest in play, anorexia - Lack of involvement in school

3

1

-

- Difficulty concentrating, despair, feeling devalued, guilt, relational difficulties - Depressive mood with anhedonia, insomnia and anorexia

-

-

3

- Nightmares, insomnia, fear of contracting Ebola, anxiety, starts, mistrust, reliving (flash-back), avoidance, fear of white coats (recalling staff protective equipment)

-

1

2

- Good-quality family support - Mild anxiety - Normal sleep and appetite

1

-

3

TOTAL

4

2

8