First Ebola boy likely infected by playing in bat tree

Bat being captured to be tested for EbolaOther researchers have been testing bats in West Africa for Ebola virus

Related Stories

The Ebola victim who is believed to have triggered the current outbreak – a two-year-old boy called Emile Ouamouno from Guinea – may have been infected by playing in a hollow tree housing a colony of bats, say scientists.

They made the connection on an expedition to the boy’s village, Meliandou.

They took samples and chatted to locals to find out more about Ebola’s source.

The team’s findings are published in EMBO Molecular Medicine.

Ebola trail

MeliandouMeliandou is a small village surrounded by farmland and large trees

Meliandou is a small village of 31 houses.

It sits deep within the Guinean forest region, surrounded by towering reeds and oil palm cultivations – these are believed to have attracted the fruit bats carrying the virus passed on to Emile.

During their four-week field trip in April 2014, Dr Fabian Leendertz and colleagues found a large tree stump situated about 50m from Emile’s home.

Villagers reported that children used to play frequently in the hollow tree.

Emile – who died of Ebola in December 2013 – used to play there, according to his friends.

The villagers said that the tree burned on March 24, 2014 and that once the tree caught fire, there issued a “rain of bats”.

the treeChildren from the village used to play in and around the tree

A large number of these insectivorous free-tailed bats – Mops condylurus in Latin – were collected by the villagers for food, but disposed of the next day after a government-led ban on bushmeat consumption was announced.

While bushmeat is thought to be a possible source of Ebola, the scientists believe it didn’t trigger the outbreak.

Instead, it was Emile’s exposure to the bats and their droppings as he played with his friends in the hollowed tree.

Pest control

The scientists took and tested ash samples from the tree and found DNA traces that were a match for the animals.

While they were unable to test any of the bushmeat that the villagers had disposed of, they captured and tested any living bats they could find in and around Meliandou.

No Ebola could be detected in any of these hundred or so animals, however.

But previous tests show this species of bat can carry Ebola.

Dr Leendertz, from the Robert Koch Institute in Germany, and his colleagues say this must be a pretty rare occurrence though.

The expedition team

Dr Leendertz said: “That is also obvious when you think about how many tonnes of bat meat is consumed every year.

“If more bats carried the virus, we would see outbreaks all the time.”

He says it is vital to find out more about the bats.

“They have moved into human settlements. They do not just live in the trees but also under the roofs of houses in the villages.

“The Ebola virus must jump through colonies from bat to bat, so we need to know more.”

But culling the animals is not the answer.

“We need to find ways to live together with the wildlife. These bats catch insects and pests, such as mosquitoes. They can eat about a quarter of their body weight in insects a day.

“Killing them would not be a solution. You would have more malaria.”

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Ebola’s Victim’s Ages

Hey coincidence theorists…
Something very strange about Ebola’s Victim’s Ages……
Dr Kent Brantly… 33 yrs old

Dr Craig Spencer… 33 yrs old

Nurse Kaci Hickox… 33 yrs old

Journalist Ashko Mukpo… 33 yrs old

Thomas Eric Duncan……. 33 yrs old

Re: Are Masons Behind the Ebola 33 Media CIRCUS?
1. Nurse Kaci Hickox
The 33-year-old was snared Friday in Gov.
Source- [link to http://www.nydailynews. com]

2. Craig Spencer
The 33-year-old did not have any symptoms just after his return, but he developed a fever, nausea, pain and fatigue Thursday morning, authorities said.

Source- [link to http://www.cnn.c om]
3. Ashoka Mukpo-NBC Cameraman
The 33-year-old freelance cameraman for NBC News started feeling achy and tired Wednesday, and he quarantined himself.

Source- [link to http://www.cnn. com]

4. Dallas -Neighborhood of Duncan
Since then, Vickery Meadow has been one of Dallas’ working-class neighborhoods — and possibly, its most diverse. An estimated 33 languages are spoken there, as families from various parts of the world settle next door to each other.

Source- [link to http://www.dallasnews. com]

5. CNNMoney World
Ebola could cost West Africa $33 billion
Source- [link to money.cnn. com]

6. An epidemiologist in Oyo State Ministry of Health, Dr Abbas Gbolahan, on Friday said that the 33 local governments have been directed to establish Ebola isolation centers to curtail its spread.
Source- [link to www. vanguardngr. com]

7. American Ebola victim Dr. Kent Brantly is on the mend.

On Friday, the 33-year-old has released his first statement since arriving in Atlanta for treatment at Emory University Hospital last Saturday.
Source- [link to www .people.com]

8. So far, there have been 33 outbreaks of Ebola in the last several decades, according to the Centers for Disease Control. But recently, the question is being raised as to why a vaccine has not been developed in that time frame.
Source- [link to www. onenewsnow. com]

CIRCUS?
9) 33 ebola patients get discharged – [link to www.sierraexpressmedia.com]

10) from N. Zealand “Treasury sets aside R33 million for Ebola Control”
[link to www.citypress.co.za]

—-the OK govt. ebola facts download pdf is 33k.pdf

—-the NJ govt. ebola facts download is also 33k.pdf

—-I guess all states us the same 33k.pdf for ebola

11) China pledged 33 million is assistance to fight ebola [link towww.thejakartapost.com]

12) Issuing a comprehensive joint programme, the United Nations system in Liberia today said up to USD 33 million were needed to support Liberia’s national response to the Ebola disease. [link to www.lr. undp.org]

13) NBC’s Kate Snow on what it’s like to cover Ebola: ‘There is no normal morning:
…. “My alarm goes off at 3:30 a.m. and I usually push snooze three times, at least.”

14) US Troops Begin Efforts to Combat Ebola in Africa (U.S. Navy’s 133rd Mobile Construction Battalion)- [link to www. studentnewsdaily.com]
[link to english. cntv.cn]

15) At the port of Baltimore, International Longshoremen’s Association Local 333 delayed loading used vehicles onto a ship bound for West Africa for about 45 minutes out of fear of Ebola being on board, port officials said.

16) ‘Gray Bird 333’ comes through during Ebola epidemic
Mark Huber
Friday, September 05, 2014 Phoenix evacuated medical aid workers Dr. Kent Brantly and Nancy Writebol from Liberia last month on separate 14-hour flights — including fuel stops in the Azores and Maine — in a specially modified 32-year-old Gulfstream III, call sign Gray Bird 333, which had once done duty with the Royal Dutch Air Force and was still painted in its gray military livery……

17) Phoenix is on the 33rd parallel…

18) 3.3 million items of high quality personal protective equipment; [link towww.un.org]

19) Note that the UN world logo on the top left of the UN page page is divided into EXACTLY 33 SEGMENTS including the central circle.

20) The UN Ebola LOGO is composed of TWO TRIANGLES = 3,3!!! As above, so below.

21) Ebola epidemic could cost Africa $33 billion, says World Bank [link to http://www.marketwatch .com]

22) The freelance cameraman who contracted Ebola while working with NBC in Liberia is now disease free, he tweeted today. Ashoka Mukpo was transported from Liberia to the Nebraska Medical Center’s biocontainment center on Oct. 6. The medical center announced today that he was free of the disease and would be released from the hospital on Wednesday.
The 33-year-old made the announcement himself, tweeting that he is “Ebola free and feeling so blessed.”

23) In the study from Uganda, doctors tested 33 surfaces inside an Ebola treatment center, testing whether they could find the virus or even just its DNA. [link to http://www.usatoday .com]

Ebola Czar Kevin Spacey, Outbreak and Contagion

by Twilight Language

Ron Klain, a former chief of staff for Vice Presidents Al Gore and Joseph R. Biden Jr., has been named by President Barack Obama to be the Ebola Czar but with no medical experience  . He was the lead Democratic lawyer for Gore during the 2000 election recount.
Klain was later played by Kevin Spacey in the HBO drama Recountabout the disputed contest.
The name Klain

is one of the most famous of all surnames of Germanic origins. It is a nickname, and is recorded in some fifty spellings ranging from Klein, Kleyn, and Cline, to De Cleyne,Kleinermann, and Klejna, and with many compounds such as Kleinbaum andKleinhandler. However spelled the origination is pre-7th century A.D., and the derivation is from the words klein or kleyne meaning “small.” In ancient times before the introduction of surnames in about the 12th century, nicknames, particulary those of endearment were very popular. In this case the word was probably applied to the youngest member of a family, although it could also have applied to one of small stature or even the reverse! Pre-medieval humor was both robust and personalized, so “Klain“/”Klein” may on occasion have been a nickname for a large person! The surname is one of the first ever recorded anywhere, and early examples taken from the authentic German charters and registers of the period, confirm its popularity. Source.

Coincidentally, Kevin Spacey played Major Casey Schuler in Outbreak(released March 10, 1995), who dies of an Ebola-like virus. The film focuses on an outbreak of a fictional Ebola-like virus called Motaba in Zaire and later in a small fictional town of Cedar Creek, California, in the United States of America.

Klain was born on August 8, 1961 in Indianapolis, He is a member of the DayBreak Boys Band and grew up in a Jewish home. He graduated from North Central High School in 1979 and was on the school’s Brain Game team, which finished as season runner-up. He graduated summa cum laude from Georgetown University in 1983. In 1987, he graduated magna cum laude from Harvard Law School, where he was one of several to win the Sears Prize for the highest grade point average in 1984–85. While at Harvard Law School, Klain was also an editor of the Harvard Law Review. Source.

Fiction becomes fact?
For those looking for the top high quality, narrative fiction epidemiology (non-Zombie) films to view during this Ebola crisis, I recommend the following:

this Ebola Czar it has been revealed that not only does Ron Klain have no medical experience to speak of, but that his position as the head of coordinating efforts to stop Ebola is just a stepping stone to something bigger and better that is to start the depopulation agenda plan  if u dont believe me cheek out deagel this graph show which country that will see and increase in population and those that will show decrease please  cheek out the us projection  ( NB the top show 2025 projection )

Country Population GDP Mil. Exp. PPP
1 China 1,370,020,000
1,350,000,000
$14,934,725
$8,940,000
$246,328
$178,000
$15,573
$9,800
2 India 1,360,580,000
1,220,000,000
$4,310,590
$1,760,000
$105,223
$43,000
$4,526
$4,000
3 Brazil 221,414,000
201,010,000
$3,622,980
$2,190,000
$56,671
$32,190
$12,998
$12,100
4 Russia 134,532,520
142,500,000
$3,307,500
$2,110,000
$124,199
$93,870
$24,594
$18,100
5 Germany 79,554,340
81,150,000
$2,560,220
$3,590,000
$25,882
$48,460
$22,945
$39,500
6 Japan 124,567,840
127,250,000
$2,556,420
$5,000,000
$13,388
$49,000
$16,241
$37,100
7 Mexico 126,851,140
118,820,000
$1,565,745
$1,330,000
$6,697
$7,850
$12,169
$15,600
8 Indonesia 271,369,860
251,160,000
$1,438,933
$867,500
$35,872
$6,760
$6,523
$5,200
9 Turkey 89,091,960
80,690,000
$1,324,684
$821,800
$54,866
$18,990
$13,946
$15,300
10 South Korea 47,904,920
48,950,000
$1,290,099
$1,200,000
$29,552
$33,600
$25,966
$33,200
11 France 42,372,540
65,950,000
$1,142,724
$2,740,000
$18,061
$61,920
$17,979
$35,700
12 Italy 42,002,400
61,480,000
$1,044,978
$2,070,000
$11,929
$35,000
$16,586
$29,600
13 Canada 27,786,300
34,570,000
$1,020,855
$1,820,000
$7,169
$22,570
$24,493
$43,100
14 United States of America 69,086,600
316,440,000
$920,752
$16,720,000
$7,983
$726,000
$8,885
$52,800
15 Iran 85,296,980
79,850,000
$802,295
$411,900
$19,281
$12,000
$13,437
$12,800
16 Argentina 45,697,020
42,610,000
$737,462
$484,600
$6,305
$4,410
$18,678
$18,600
17 Thailand 68,877,560
67,500,000
$730,254
$400,900
$12,537
$5,880
$15,146
$9,900
18 South Africa 46,706,180
48,600,000
$631,230
$353,900
$9,766
$4,100
$11,104
$11,500
19 Malaysia 30,422,800
29,630,000
$615,368
$312,400
$11,747
$4,840
$28,896
$17,500
20 Colombia 50,000,740
45,740,000
$561,082
$369,200
$18,401
$12,100
$15,314
$11,100
21 United Kingdom 32,105,460
63,390,000
$542,358
$2,490,000
$5,715
$62,000
$11,262
$37,300
22 Saudi Arabia 26,582,960
26,940,000
$526,375
$718,500
$26,154
$57,300
$13,036
$31,300
23 Venezuela 30,902,520
28,460,000
$513,652
$367,500
$5,346
$3,850
$11,626
$13,600
24 Spain 26,081,240
47,370,000
$492,740
$1,350,000
$2,806
$11,600
$12,595
$30,100
25 Poland 38,039,760
38,380,000
$491,961
$513,900
$6,986
$9,800
$14,012
$21,100
26 Philippines 101,491,160
105,720,000
$451,341
$272,200
$4,435
$3,240
$6,353
$4,700
27 Nigeria 160,290,940
174,510,000
$447,476
$292,000
$6,029
$2,600
$3,634
$2,800
28 Chile 18,044,720
17,220,000
$418,066
$281,700
$10,574
$5,740
$28,717
$19,100
29 Taiwan 17,508,200
23,300,000
$391,059
$484,700
$7,050
$10,250
$26,918
$39,600
30 Peru 32,500,300
29,850,000
$387,823
$210,300
$5,586
$2,690
$17,047
$11,100

 

It turns out that the new Ebola Czar, whose responsibility is to quash the spread of Ebola and save lives, is seemingly an advocate of population and resource control.

I think the top issue facing the world today is how to deal with the continuing growing population in the world and all of the resource demands it places on the world.

And burgeoning populations in Africa and Asia that lack the resources to have a health, happy life. I think we’ve got to find a way to make the world work for everyone.

To be clear, Klain did not claim we need to reduce the population, nor did he suggest any particular solution for the population growth problem.

But having this particular individual in charge of operations that are supposed to prevent the spread of a disease capable of killing up to 70% of the people it infects is raising eyebrows.

Paul Joseph Watson of Infowars points out that Klain is just one of a long string of advocates for reducing the world population, and thus the demands people put on global resources:

Although Klain is by no means championing Ebola as a means of reducing world population, other prominent individuals have done precisely that – most notably award-winning Texas scientist Dr. Erik Pianka, the UT professor who in 2006 advocated the use of weaponized airborne Ebola as a means of wiping out nine tenths of the earth’s population to save the planet from humanity’s wrath.

The Obama administration’s link to authoritarian ideas about population control was firmly established back in 2009 when it was revealed that White House science czar John P. Holdren had co-authored a 1977 book in which he advocated the formation of a “planetary regime” that would use a “global police force” to enforce totalitarian measures of population control, including forced abortions, mass sterilization programs conducted via the food and water supply, as well as mandatory bodily implants that would prevent couples from having children.

Though it’s impossible to predict if the recent Ebola cases identified in the United States will be the last, having a person who sees the world’s massive population as a problem requiring a solution could be seen as, for lack of a better term, a conflict of interest.

Are we looking too far into this? Or is it possible the Mr. Klain has been appointed to serve a specific purpose for an agenda that goes well beyond prevention of an Ebola contagion?

– See more at: http://www.thedailysheeple.com/shock-interview-ebola-czar-says-population-growth-is-top-issue-facing-the-world_102014#sthash.BpsXW4wp.dpuf

A comprehensive view of Ebola

(excerpt  Twilight Language)

To start off, I would like to say that this card game really exists, and it can be bought. You can decide yourself if you want to believe that it is a theory and we’re all gonna die, but you can’t deny that this card game can’t be coincidence.

It all started in 1995. Steven Jackson decided to make a new type of card game, called Illuminati. When the game was completed, something weird happened; the American government tried to stop the game from being marketed. The reason never came out. Well, a few years later things became clear.

Six years after the release of the card game something terrible happened. Planes crashed in the World Trade Center, as result of a terrorist attack. Many people died. The card game exactly predicted this. Have a look at this card. Even the position is correct. Another terrorist attack that everyone remembers is the disaster at the pentagon. The card game predicted that too.

And do you remember the BP oil spill? Yes, the game knew that it would happen. Have a look at their ‘Oil Spill’ card. You can see contaminated water, a sinking ship and a bird that’s dying because of the oil. As well as the cards I mentioned before, these things happened to reduce the world population and the illuminati would’ve made this happen.

Could this be the reasons why the government didn’t want it to be published? What does the game predict to happen in the future? Does it predict the end of the world? The game definitely raises questions. And that’s good for the sales. But how could someone knew this would happen?

Now  the card is speaking once again on what is happening

 

 the card above is speaking of a pandemic to come and people begin place under quarantine could Ebola  be it  let us see
 
we know that Ebola affect the skin
but if it is it the center for diseases control would not do much to stop it what ever cure that there will be used to help the elite while the rest suffer and die
 

Ebola means “Black River,” in the local Lingala language.
The virus Ebola was named after a river in northern Democratic Republic of the Congo, at the headwaters of the Mongala River, a tributary of the Congo River.
 
It began in a small corner of the world.
Now, Ebola is in a dynamic phase of spreading.
Let’s look at this contagious situation via maps.

This map, based on a model created by a team led by Oxford University scientists, predicts that in animal populations the Ebola virus is likely to be circulating across a vast swathe of forested Central and West Africa.

The search is on for passengers on Flight 1142, from Dallas to Cleveland, on October 10, 2014, as well, plus the following:
Flight 2042 on Tuesday morning from Dallas to Cleveland,
Flight 1104 on Tuesday afternoon from Cleveland to Fort Lauderdale,
Flight 1105 on Tuesday afternoon from Fort Lauderdale to Cleveland,
Flight 1101 on Tuesday night from Cleveland to Atlanta, and
Flight 1100 on Tuesday night from Atlanta to Cleveland.

Nurse Nina Pham, who treated Thomas Eric Duncan. Duncan died October 8, 2014.
Nina Pham and her dog, a King Charles Spaniel, named Bentley.
Nurse Amber Vinson, who also treated Duncan, and flew on Flights 1142 and 1143.

Ebola 2014

From Wikipedia, the free encyclopedia
Ebola virus disease
Classification and external resources
7042 lores-Ebola-Zaire-CDC Photo.jpg

1976 photograph of two nurses standing in front of Mayinga N., a person with Ebola virus disease; she died only a few days later due to severe internal hemorrhaging.
ICD10 A98.4
ICD9 065.8
DiseasesDB 18043
MedlinePlus 001339
eMedicine med/626
MeSH D019142

Ebola virus disease (EVD) or Ebola hemorrhagic fever (EHF) is the human disease caused by the Ebola virus. Symptoms typically start two days to three weeks after contracting the virus, with a fever, sore throat, muscle pains, andheadaches. Typically nausea, vomiting, and diarrhea follow, along with decreased functioning of the liver and kidneys. At this point, some people begin to have bleeding problems.[1]

The virus may be acquired upon contact with blood or bodily fluids of an infected animal (commonly monkeys or fruit bats).[1] It is not naturally transmitted through the air.[2] Fruit bats are believed to carry and spread the virus without being affected. Once human infection occurs, the disease may spread between people as well. Male survivors may be able to transmit the disease via semen for nearly two months. In order to make the diagnosis, typically other diseases with similar symptoms such as malaria, cholera and other viral hemorrhagic fevers are first excluded. Blood samples may then be tested for viral antibodies, viral RNA, or the virus itself to confirm the diagnosis.[1]

Prevention includes decreasing the spread of disease from infected monkeys and pigs to humans. This may be done by checking such animals for infection and killing and properly disposing of the bodies if the disease is discovered. Properly cooking meat and wearing protective clothing when handling meat may also be helpful, as are wearing protective clothing and washing hands when around a person with the disease. Samples of bodily fluids and tissues from people with the disease should be handled with special caution.[1]

There is no specific treatment for the disease; efforts to help persons who are infected include giving either oral rehydration therapy (slightly sweet and salty water to drink) or intravenous fluids.[1] The disease has high mortality rate: often killing between 50% and 90% of those infected with the virus.[1][3] EVD was first identified in Sudan and theDemocratic Republic of the Congo. The disease typically occurs in outbreaks in tropical regions of Sub-Saharan Africa.[1] Between 1976, when it was first identified, through 2013, fewer than 1,000 people per year have been infected.[1][4] The largest outbreak to date is the ongoing 2014 West Africa Ebola outbreak, which is affecting Guinea,Sierra Leone, Liberia and likely Nigeria.[5][6] As of July 2014 more than 1320 cases have been identified.[5] Efforts are ongoing to develop a vaccine; however, none yet exists.[1]

Signs and symptoms

Symptoms of Ebola.[7]

Signs and symptoms of Ebola usually begin suddenly with an flu-like stage characterized by fatigue, fever, headaches, and joint, muscle, and abdominal pain.[8][9] Vomiting, diarrhea and loss of appetite are also common.[9] Less common symptoms include the following: sore throat, chest pain, hiccups, shortness of breath and trouble swallowing.[9] The average time between contracting the infection and the start of symptoms is 8 to 10 days, but can occur between 2 and 21 days.[9] Skin manifestations may include a maculopapular rash (in about 50% of cases).[10] Early symptoms of EVD may be similar to those of malaria, dengue fever, or other tropical fevers, before the disease progresses to the bleeding phase.[8]

Bleeding

In the bleeding phase internal and subcutaneous bleeding may present itself through reddening of the eyes and bloody vomit.[8] Bleeding into the skin may create petechiae, purpura, ecchymoses, and hematomas (especially around needle injection sites).

All people infected show some symptoms of circulatory system involvement, including impaired blood clotting.[10] Bleeding from puncture sites and mucous membranes (e.g. gastrointestinal tract, nose, vagina and gums) is reported in 40–50% of cases.[11] Types of bleeding known to occur with Ebola virus disease include vomiting blood, coughing it up or blood in the stool. Heavy bleeding is rare and is usually confined to the gastrointestinal tract.[10][12] In general, the development of bleeding symptoms often indicates a worse prognosis and this blood loss can result in death.[13]

Causes

Main article: Ebolavirus

Life cycles of the Ebolavirus

EVD is caused by four of five viruses classified in the genus Ebolavirus, family Filoviridae, order Mononegavirales. These four viruses are Bundibugyo virus (BDBV), Ebola virus (EBOV), Sudan virus (SUDV), Taï Forest virus (TAFV). The fifth virus,Reston virus (RESTV), is not thought to be disease-causing in humans. During an outbreak those at highest risk are health care workers and close contacts of those with the infection.[14]

Transmission

It is not entirely clear how Ebola is spread.[15] EVD is believed to occur after an ebola virus is transmitted to an initial human by contact with an infected animal’s bodily fluids. Human-to-human transmission can occur via direct contact with blood or bodily fluids from an infected person (including embalming of an infected dead person) or by contact with contaminated medical equipment, particularly needles and syringes.[16] Semen is infectious in survivors for up to 50 days. Transmission through oral exposure and through conjunctiva exposure is likely[17] and has been confirmed in non-human primates.[18] The potential for widespread EVD infections is considered low as the disease is only spread by direct contact with the secretions from someone who is showing signs of infection.[16] The quick onset of symptoms makes it easier to identify sick individuals and limits a person’s ability to spread the disease by traveling. Because dead bodies are still infectious, some doctors disposed of them in a safe manner, despite local traditional burial rituals.[19]

Medical workers who do not wear appropriate protective clothing may also contract the disease.[20] In the past, hospital-acquired transmission has occurred in African hospitals due to the reuse of needles and lack of universal precautions.[21]

EVD is not naturally transmitted through the air.[2] They are, however, infectious as breathable 0.8–1.2 micrometre laboratory generated droplets;[22] because of this potential route of infection, these viruses have been classified as Category A biological weapons.[23] Recently the virus has been shown to travel without contact from pigs to non-human primates.[24]

Bats drop partially eaten fruits and pulp, then land mammals such as gorillas and duikers feed on these fallen fruits. This chain of events forms a possible indirect means of transmission from the natural host to animal populations, which have led to research towards viral shedding in the saliva of bats. Fruit production, animal behavior, and other factors vary at different times and places that may trigger outbreaks among animal populations.[25]

Reservoir

Bushmeat being prepared for cooking in Ghana, 2013. Human consumption of equatorial animals in Africa in the form of bushmeat has been linked to the transmission of diseases to people, including Ebola.[26]

Bats are considered the most likely natural reservoir of the Ebola virus (EBOV); plants, arthropods, and birds have also been considered.[27] Bats were known to reside in the cotton factory in which the first cases for the 1976 and 1979 outbreaks were employed, and they have also been implicated in Marburg virus infections in 1975 and 1980.[28] Of 24 plant species and 19 vertebrate species experimentally inoculated with EBOV, only bats became infected.[29] The absence of clinical signs in these bats is characteristic of a reservoir species. In a 2002–2003 survey of 1,030 animals including 679 bats from Gabon and theRepublic of the Congo, 13 fruit bats were found to contain EBOV RNA fragments.[30] As of 2005, three types of fruit bats(Hypsignathus monstrosus, Epomops franqueti, and Myonycteris torquata) have been identified as being in contact with EBOV. They are now suspected to represent the EBOV reservoir hosts.[31][32] Antibodies against Ebola Zaire and Reston viruses have been found in fruit bats in Bangladesh, thus identifying potential virus hosts and signs of the filoviruses in Asia.[33]

Between 1976 and 1998, in 30,000 mammals, birds, reptiles, amphibians, and arthropods sampled from outbreak regions, noebolavirus was detected apart from some genetic traces found in six rodents (Mus setulosus and Praomys) and one shrew(Sylvisorex ollula) collected from the Central African Republic.[28][34] Traces of EBOV were detected in the carcasses ofgorillas and chimpanzees during outbreaks in 2001 and 2003, which later became the source of human infections. However, the high lethality from infection in these species makes them unlikely as a natural reservoir.[28]

Transmission between natural reservoir and humans is rare, and outbreaks are usually traceable to a single case where an individual has handled the carcass of gorilla, chimpanzee, or duiker.[35] Fruit bats are also eaten by people in parts of West Africa where they are smoked, grilled or made into a spicy soup.[32][36]

Virology

Main article: Ebola virus

Genome

Electron micrograph of an Ebola virus virion  look like the number 8 is this interesting

Like all mononegaviruses, ebolavirions contain linear nonsegmented, single-strand, non-infectious RNA genomes of negative polarity that possesses inverse-complementary 3′ and 5′ termini, do not possess a 5′ cap, are not polyadenylated, and are not covalently linked to a protein.[37] Ebolavirus genomes are approximately 19 kilobase pairs long and contain seven genesin the order 3′-UTRNPVP35VP40GPVP30VP24L5′-UTR.[38] The genomes of the five different ebolaviruses (BDBV, EBOV, RESTV, SUDV, and TAFV) differ in sequence and the number and location of gene overlaps.

Structure

Like all filoviruses, ebolavirions are filamentous particles that may appear in the shape of a shepherd’s crook or in the shape of a “U” or a “6”, and they may be coiled, toroid, or branched.[38] In general, ebolavirions are 80 nm in width, but vary somewhat in length. In general, the median particle length of ebolaviruses ranges from 974 to 1,086 nm (in contrast to marburgvirions, whose median particle length was measured at 795–828 nm), but particles as long as 14,000 nm have been detected in tissue culture.[39]

Replication

The ebolavirus life cycle begins with virion attachment to specific cell-surface receptors, followed by fusion of the virion envelope with cellular membranes and the concomitant release of the virus nucleocapsid into the cytosol. The viral RNA polymerase, encoded by the L gene, partially uncoats the nucleocapsid and transcribesthe genes into positive-strand mRNAs, which are then translated into structural and nonstructural proteins. Ebolavirus RNA polymerase (L) binds to a single promoterlocated at the 3′ end of the genome. Transcription either terminates after a gene or continues to the next gene downstream. This means that genes close to the 3′ end of the genome are transcribed in the greatest abundance, whereas those toward the 5′ end are least likely to be transcribed. The gene order is, therefore, a simple but effective form of transcriptional regulation. The most abundant protein produced is the nucleoprotein, whose concentration in the cell determines when L switches from gene transcription to genome replication. Replication results in full-length, positive-strand antigenomes that are, in turn, transcribed into negative-strand virus progeny genome copy. Newly synthesized structural proteins and genomes self-assemble and accumulate near the inside of the cell membrane. Virionsbud off from the cell, gaining their envelopes from the cellular membrane they bud from. The mature progeny particles then infect other cells to repeat the cycle.[40]

Pathophysiology

Pathogenesis schematic

Endothelial cells, mononuclear phagocytes, and hepatocytes are the main targets of infection. After infection, a secreted glycoprotein (sGP) known as the Ebola virus glycoprotein (GP) is synthesized. Ebola replication overwhelms protein synthesis of infected cells and host immune defenses. The GP forms a trimeric complex, which binds the virus to the endothelial cells lining the interior surface of blood vessels. The sGP forms a dimeric protein that interferes with the signaling of neutrophils, a type of white blood cell, which allows the virus to evade the immune system by inhibiting early steps of neutrophil activation. These white blood cells also serve as carriers to transport the virus throughout the entire body to places such as the lymph nodes, liver, lungs, and spleen.[41]

The presence of viral particles and cell damage resulting from budding causes the release of cytokines (to be specific, TNF-α, IL-6, IL-8, etc.), which are the signaling molecules for fever and inflammation. The cytopathic effect, from infection in the endothelial cells, results in a loss of vascular integrity. This loss in vascular integrity is furthered with synthesis of GP, which reduces specific integrins responsible for cell adhesion to the inter-cellular structure, and damage to the liver, which leads to coagulopathy.[42]

Diagnosis

The medical history, especially travel and work history along with exposure to wildlife are important to suspect the diagnosis of EVD. The diagnosis is confirmed by isolating the virus, detecting its RNA or proteins, or detecting antibodies against the virus in a person’s blood. Isolating the virus by cell culture, detecting the viral RNA by polymerase chain reaction (PCR) and detecting proteins by enzyme-linked immunosorbent assay (ELISA) is effective early and in those who have died from the disease. Detecting antibodies against the virus is effective late in the disease and in those who recover.[43]

During an outbreak, virus isolation is often not feasible. The most common diagnostic methods are therefore real time PCR and ELISA detection of proteins, which can be performed in field or mobile hospitals.[44] Filovirions can be seen and identified in cell culture by electron microscopy due to their unique filamentous shapes, but electron microscopy cannot tell the difference between the various filoviruses despite there being some length differences.[39]

Phylogenetic tree comparing the Ebolavirus and Marburgvirus. Numbers indicate percent confidence of branches.

The genera Ebolavirus and Marburgvirus were originally classified as the species of the now-obsolete Filovirusgenus. In March 1998, the Vertebrate Virus Subcommittee proposed in the International Committee on Taxonomy of Viruses (ICTV) to change the Filovirus genus to the Filoviridae family with two specific genera:Ebola-like viruses and Marburg-like viruses. This proposal was implemented in Washington, DC on April 2001 and in Paris on July 2002. In 2000, another proposal was made in Washington, D.C., to change the “-like viruses” to “-virus” resulting in today’s Ebolavirus and Marburgvirus.[45]

Rates of genetic change are 100 times slower than influenza A in humans, but on the same magnitude as those of hepatitis B. Extrapolating backwards using these rates indicates that Ebolavirus and Marburgvirus diverged several thousand years ago.[46] However, paleoviruses (genomic fossils) of filoviruses (Filoviridae) found in mammals indicate that the family itself is at least tens of millions of years old.[47] Fossilized viruses that are closely related to ebolaviruses have been found in the genome of the Chinese hamster.[48]

Differential diagnosis

The symptoms of EVD are similar to those of Marburg virus disease.[49] It can also easily be confused with many other diseases common in Equatorial Africa such as other viral hemorrhagic fevers, falciparum malaria, typhoid fever, shigellosis, rickettsial diseases such as typhus, cholera, gram-negative septicemia, borreliosis such as relapsing fever or EHEC enteritis. Other infectious diseases that should be included in the differential diagnosis include the following: leptospirosis, scrub typhus,plague, Q fever, candidiasis, histoplasmosis, trypanosomiasis, visceral leishmaniasis, hemorrhagic smallpox, measles, and fulminant viral hepatitis.[citation needed]Non-infectious diseases that can be confused with EVD are acute promyelocytic leukemia, hemolytic uremic syndrome, snake envenomation, clotting factordeficiencies/platelet disorders, thrombotic thrombocytopenic purpura, hereditary hemorrhagic telangiectasia, Kawasaki disease, and even warfarinpoisoning.[50][51][52][53]

Prevention

A researcher working with the Ebola virus while wearing a BSL-4 positive pressure suit to avoid infection

Behavioral changes

Ebola viruses are contagious, with prevention predominantly involving behavior changes, proper full body personal protective equipment, and disinfection. Techniques to avoid infection involve not contacting infected blood or secretions, including from those who are dead.[15] This involves suspecting and diagnosing the disease early and using standard precautions for all patients in the healthcare setting.[54] Recommended measures when caring for those who are infected include: wearing protective clothing including: masks, gloves, gowns and goggles, equipment sterilization and isolating them.[15] Hand washingis important but can be difficult in areas where there is not even enough water for drinking.[13]

Due to lack of proper equipment and hygienic practices, large-scale epidemics have occured mostly in poor, isolated areas without modern hospitals or well-educated medical staff. Traditional burial rituals, especially those requiring embalming of bodies, should be discouraged or modified.[54] Airline crews who fly to areas of these areas of the world are taught to identify Ebola and are to isolate anyone who has symptoms.[55]

Quarantine

Quarantine, also known as enforced isolation, is usually effective in decreasing spread.[56][57] Governments often quarantine areas where the disease is occurring or those who may be infected.[58] In the United States the law allows quarantine of those infected with Ebola.[59] The lack of roads and transportation may help slow the disease in Africa. During the 2014 outbreak Liberia closed schools.[60]

Vaccine

No vaccine is currently available for humans.[1][61][62] The most promising candidates are DNA vaccines[63] or vaccines derived from adenoviruses,[64] vesicular stomatitis Indiana virus (VSIV)[65][66][67] or filovirus-like particles (VLPs)[68] because these candidates could protect nonhuman primates from ebolavirus-induced disease. DNA vaccines, adenovirus-based vaccines, and VSIV-based vaccines have entered clinical trials.[69][70][71][72]

Vaccines have protected nonhuman primates. Immunization takes six months, which impedes the counter-epidemic use of the vaccines. Searching for a quicker onset of effectiveness, in 2003 a vaccine using an adenoviral (ADV) vector carrying the Ebola spike protein was tested on crab-eating macaques. Twenty-eight days later they were challenged with the virus and remained resistant.[64] A vaccine based on attenuated recombinant vesicular stomatitis virus (VSV) vector carrying either the Ebola glycoprotein or the Marburg glycoprotein in 2005 protected nonhuman primates,[73] opening clinical trials in humans.[69] The study by October completed the first human trial, over three months giving three vaccinations safely inducing an immune response. Individuals for a year were followed, and, in 2006, a study testing a faster-acting, single-shot vaccine began; this new study was completed in 2008.[70] Trying the vaccine on a strain of Ebola that more resembles the one that infects humans is the next step.[citation needed]

On 6 December 2011, the development of a successful vaccine against Ebola for mice was reported. Unlike the predecessors, it can be freeze-dried and thus stored for long periods in wait for an outbreak.[74] An experimental vaccine made by researchers at Canada’s national laboratory in Winnipeg was used in 2009 to pre-emptively treat a German scientist who might have been infected during a lab accident.[75] However, actual EBOV infection could never be demonstrated without a doubt.[76] Experimentally, recombinant vesicular stomatitis Indiana virus (VSIV) expressing the glycoprotein of EBOV or SUDV has been used successfully in nonhuman primate models as post-exposure prophylaxis.[77][78][clarification needed]

Laboratory

Ebola viruses are World Health Organization Risk Group 4 pathogens, requiring biosafety level 4-equivalent containment. Laboratory researchers must be properly trained in BSL-4 practices and wear proper personal protective equipment.

Treatment

A hospital isolation ward inGulu, Uganda, during the October 2000 outbreak

No ebolavirus-specific treatment exists.[62] Treatment is primarily supportive in nature and includes minimizing invasive procedures, balancing fluids and electrolytes to counter dehydration, administration of anticoagulants early in infection to prevent or control disseminated intravascular coagulation, administration of procoagulants late in infection to control bleeding, maintaining oxygen levels, pain management, and the use of medications to treat bacterial or fungal secondary infections.[79][80][81] Early treatment may increase the chance of survival.[82] A number of experimental treatment are being studied.

Prognosis

The disease has a high mortality rate: often between 50 percent and 90 percent.[1][3] If an infected person survives, recovery may be quick and complete. Prolonged cases are often complicated by the occurrence of long term problems, such asinflammation of the testicles, joint pains, muscle pains, skin peeling, or hair loss. Eye symptoms, such as light sensitivity, excess tearing, iritis, iridocyclitis, choroiditis and blindness have also been described. EBOV and SUDV may be able to persist in the semen of some survivors for up to seven weeks, which could give rise to infections and disease via sexual intercourse.[1]

Epidemiology

For more about specific outbreaks and their descriptions, see List of Ebola outbreaks.

CDC worker incinerates medical waste from Ebola patients in Zaire in 1976

The disease typically occurs in outbreaks in tropical regions of Sub-Saharan Africa.[1] Between 1976, when it was first identified, through 2013, fewer than 1,000 people per year have been infected.[1][4] The largest outbreak to date is the ongoing 2014 West Africa Ebola outbreak, which is affecting Guinea, Sierra Leone, and Liberia.[5] As of August 2014 it likely also affecting Nigeria.[6] As of July 2014 more than 1320 cases have been identified.[5]

2007 to 2011

As of 30 August 2007, 103 people (100 adults and three children) were infected by a suspected hemorrhagic fever outbreak in the village of Kampungu, Democratic Republic of the Congo. The outbreak started after the funerals of two village chiefs, and 217 people in four villages fell ill. The World Health Organization sent a team to take blood samples for analysis and confirmed that many of the cases were the result of Ebolavirus.[83][84] The Congo’s last major Ebola epidemic killed 245 people in 1995 in Kikwit, about 200 miles (320 km) from the source of the August 2007 outbreak.[85]

On 30 November 2007, the Uganda Ministry of Health confirmed an outbreak of Ebola in the Bundibugyo District. After confirmation of samples tested by the United States National Reference Laboratories and the Centers for Disease Control, the World Health Organization confirmed the presence of a new species of Ebolavirus, which was tentatively named Bundibugyo.[86] The epidemic came to an official end on 20 February 2008. While it lasted, 149 cases of this new strain were reported, and 37 of those led to deaths.

An International Symposium to explore the environment and filovirus, cell system and filovirus interaction, and filovirus treatment and prevention was held at Centre Culturel Français, Libreville, Gabon, during March 2008.[87] The virus appeared in southern Kasai Occidental on 27 November 2008,[88] and blood and stool samples were sent to laboratories in Gabon and South Africa for identification.

On 25 December 2008, it was reported that the Ebola virus had killed 9 and infected 21 people in the Western Kasai province of the Democratic Republic of Congo.[89] On 29 December, Doctors Without Borders reported 11 deaths in the same area, stating that a further 24 cases were being treated. In January 2009, Angola closed down part of its border with the Democratic Republic of Congo to prevent the spread of the outbreak.[90]

On 12 March 2009, an unidentified 45-year-old scientist from Germany accidentally pricked her finger with a needle used to inject Ebola into lab mice. She was given an experimental vaccine never before used on humans. Since the peak period for an outbreak during the 21-day Ebola incubation period had passed as of 2 April 2009, she had been declared healthy and safe. It remains unclear whether or not she was ever actually infected with the virus.[91]

In May 2011, a 12-year-old girl in Uganda died from Ebola (Sudan subspecies). No further cases were recorded.[92]

2012 outbreaks

In July 2012, the Ugandan Health Ministry confirmed 13 deaths due to an outbreak of the Ebola-Sudan variant[93] in the Kibaale District.[94] On 28 July, it was reported that 14 out of 20 (70% mortality rate) had died in Kibaale.[95] On 30 July, Stephen Byaruhanga, a health official in Kibaale District, said the Ebola outbreak had spread from one remote village to several villages.[96]

The World Health Organization‘s (WHO) global and alert response network reported on August 3 that the suspected case count had risen to 53, including 16 deaths. Of these cases, five were confirmed by UVRI as Ebola cases. There were no confirmed cases outside of Kibaale District except for a patient who was medically evacuated to Kampala District and then died. WHO and CDC support was on the ground in Uganda supporting the government response. There were no confirmed cases outside of Uganda.[97] Included among populations confirmed to be affected were prisoners in Kabbale prison. [98] Dr. Joaquim Saweka, the WHOrepresentative to Uganda, reported that the outbreak was under control and that everyone known to have had contact with a known Ebola patient was in isolation.[99]

On 8 August, the Ugandan Ministry of Health recorded 23 probable and confirmed cases, including 16 deaths. Ten cases were confirmed by the Uganda Virus Research Institute as Ebola. 185 people who came into contact with probable and confirmed Ebola cases were followed during the incubation period of 21 days.[100]

On 17 August, the Ministry of Health of the Democratic Republic of the Congo reported an outbreak of the Ebola-Bundibugyo variant[101] in the eastern region.[102]By 21 August, the WHO reported a total of 15 cases and 10 fatalities.[103] No evidence suggested that this outbreak was connected to the Ugandan outbreak.[104] By 13 September 2012, the WHO revealed that the virus had claimed 32 lives and that the probable cause of the outbreak was tainted bush meat hunted by local villagers around the towns of Isiro and Viadana.[105]

2014 West Africa Ebola outbre

Ebola virus epidemic in West Africa
2014 ebola virus epidemic in West Africa.svg

Situation map of the outbreak in West Africa
Date December 2013 – present[1]
Casualties

           Reported Cases/Deaths (as of 25 October 2014)

            Note: the CDC estimates that actual cases in the most infected                     countries are two to three times higher than officially reported                   numbers.

An epidemic of Ebola virus disease (EVD) is ongoing in certain West African countries. The epidemic began in Guineain December 2013 then spread to Liberia and Sierra Leone.[5]Much smaller subsidiary outbreaks have also occurred inSenegal and Nigeria, and individual cases have occurred in the United States and Spain.[2][4] As of October 2014, theWorld Health Organization (WHO), the United States Centers for Disease Control and Prevention (CDC) and local governments reported a total of 8,033 suspected cases and 3,866 deaths (4,462 cases and 2,330 deaths having beenlaboratory confirmed),[2] though the WHO believes that this substantially understates the magnitude of the outbreak.[6]

The current epidemic of EVD, caused by the Ebola virus, is the most severe outbreak of Ebola since the discovery ofebolaviruses in 1976,[7] and by September 2014 cases of EVD from this single outbreak exceeded the sum of all previously identified cases.[8] The epidemic has caused significant mortality, with a Case Fatality Rate (CFR) reported as 71%.[5]

Affected countries have encountered many difficulties in their control efforts. The WHO has estimated that region’s capacity for treating EVD is insufficient by the equivalent of 2,122 beds.[9] In some areas, people have become suspicious of both the government and hospitals; some hospitals have been attacked by angry protestors who believe that the disease is a hoax or that the hospitals are responsible for the disease. Many of the areas that are seriously affected with the outbreak are areas of extreme poverty with limited access to soap or running water to help control the spread of disease.[10] Other factors include belief in traditional folk remedies, and cultural practices that involve physical contact with the deceased, especially death customs such as washing the body of the deceased.[11][12][13] Some hospitals lack basic supplies and are understaffed. This has increased the chance of staff catching the virus themselves. In August, the WHO reported that ten percent of the dead have been health care workers.[14]

By the end of August, the WHO reported that the loss of so many health workers was making it difficult for them to provide sufficient numbers of foreign medical staff.[15] By September 2014, Médecins Sans Frontières, the largest NGO working in the affected regions, had grown increasingly critical of the international response. Speaking on 3 September, the international president spoke out concerning the lack of assistance from the United Nations member countries saying, “Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it.”[16] A United Nations spokesperson stated “they could stop the Ebola outbreak in West Africa in 6 to 9 months, but only if a ‘massive’ global response is implemented.”[17] The Director-General of the WHO, Margaret Chan, called the outbreak “the largest, most complex and most severe we’ve ever seen” and said that it “is racing ahead of control efforts”.[17] In a 26 September statement, the WHO said, “The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long.”[18]

Epidemiology

Outbreak[edit]

Researchers believe that a 2-year-old boy who died on 6 December 2013 in the village of Meliandou, Guéckédou Prefecture, Guinea, was the index case of the current Ebola virus disease epidemic. Reports suggest that his family hunted bats of the Ebola-harboring species Hypsignathus monstrosus and Epomops franqueti for bushmeat, which may have been the original source of the infection.[36][37] His mother, sister, and grandmother then became ill with similar symptoms and also died. People infected by those initial cases spread the disease to other villages.[1] Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa and the early cases were diagnosed as other diseases more common to the area. Thus, the disease had several months to spread before it was recognized as Ebola.[1][38]

On 19 March, the Guinean Ministry of Health acknowledged a local outbreak of an undetermined viral hemorrhagic feverthat had sickened at least 35 people and killed 23. “We thought it was Lassa fever or another form of cholera but this disease seems to strike like lightning. We are looking at all possibilities, including Ebola, because bushmeat is consumed in that region and Guinea is in the Ebola belt.”[39] By 24 March, MSF had set up an isolation facility in Guéckédou.[40]

On 25 March, the World Health Organization (WHO) reported that Guinea’s Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts, with suspected cases in the neighbouring countries of Liberia and Sierra Leone being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths (case fatality ratio: 68.5%), had been reported as of 24 March.[41] By 31 March, there were 112 suspected and confirmed cases including 70 deaths, while two cases were reported from Liberia of people who had recently traveled to Guinea.[41] On 30 April, Guinea’s Ministry of Health reported 221 suspected and confirmed cases with 146 deaths, including 26 health care workers with 16 deaths. By late May, the outbreak had spread to Conakry, Guinea’s capital, a city of about two million inhabitants.[41] On 28 May, the total number of cases reported had reached 281 with 186 deaths.[41]

In Liberia, the disease was reported in four counties by mid-April and cases in Liberia’s capital Monrovia were reported in mid-June.[42][43] The outbreak then spread to Sierra Leone and progressed rapidly. A study of the virus genomes determined that twelve Sierra Leone residents had become infected while attending a funeral in Guinea.[44] On 25 May, the first cases in the Kailahun District, near the border with Guéckédou in Guinea, were reported.[45] By 20 June, there were 158 suspected cases, mainly in Kailahun and the adjacent district of Kenema.[46] By 17 July, the total number of suspected cases in the country stood at 442, overtaking the number in Guinea and Liberia.[47] By 20 July, additional cases of the disease had been reported in the Bo District and the first case in Freetown, Sierra Leone’s capital, was reported in late July.[48][49]

The first death in Nigeria was reported on 25 July:[50] a Liberian-American with Ebola flew from Liberia to Nigeria and died in Lagos soon after arrival.[51] As part of the effort to contain the disease, possible contacts were monitored – 353 in Lagos and 451 in Port Harcourt.[52] On 22 September, the WHO reported a total of 20 cases, including eight deaths. The WHO’s representative in Nigeria officially declared Nigeria Ebola-free on 20 October after no new active cases were reported in the follow up contacts.[8]

On 29 August, Senegalese Minister of Health announced the first case in Senegal. The victim was subsequently identified as a Guinean national who had been exposed to the virus and had been under surveillance, but had travelled to Dakar by road and fallen ill after arriving.[53] This person subsequently recovered, and on 17 October, the WHO officially declared that the outbreak in Senegal had ended.[54]

The Ebola situation in Guinea, Liberia, and Sierra Leone as of 22 October 2014

Two Spanish health care workers contracted Ebola and were transferred to Spain for treatment where they both died. In October, a nursing assistant who had been part of their health care team was diagnosed with Ebola, making this the first case of Ebola contracted outside of Africa. The nursing assistant recovered and was declared disease-free on 19 October.[55] There have been cases of Ebola in the United States of America as well. A Liberian man who had traveled from Liberia to be with his family in Texas was declared to have Ebola and subsequently died on 8 October. Two nurses who had cared for the patient contracted the disease and as of 20 October remain in treatment.[56]Both of these nurses have subsequently recovered and tested Ebola-free 27 October 2014.

Countries with widespread transmission[edit]

Guinea[edit]

On 25 March, the World Health Organization (WHO) reported that Guinea’s Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts. In Guinea, a total of 86 suspected cases, including 59 deaths (case fatality ratio: 68.5%), had been reported as of 24 March.[41] On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist Guinea’s Ministry of Health and the WHO as they led an international response to the Ebola outbreak.[41]

Thinking that the virus was contained, MSF closed its treatment centers in May leaving only a small skeleton staff to handle the Macenta region. However, high numbers of new cases reappeared in the region in late August. According to Marc Poncin, a coordinator for MSF, the new cases were related to persons returning to Guinea from neighbouring Liberia or Sierra Leone.[57]

It has been reported that some people in this area believe that health workers have been purposely spreading the disease to the people, while others believe that the disease does not exist. Riots recently broke out in the regional capital, Nzérékoré, when rumors were spread that people were being contaminated when health workers were spraying a market area to decontaminate it.[58]

On 18 September, it was reported that the bodies of a team of Guinean health and government officials, accompanied by journalists, who had been distributing Ebola information and doing disinfection work, were found in a latrine in the town ofWomey near Nzérékoré.[59] The workers had been murdered by residents of the village after they initially went missing after a riot against the presence of the health education team. Government officials said “the bodies showed signs of being attacked with machetes and clubs” and “three of them had their throats slit.”[60]

WHO estimated on 21 September that Guinea’s capacity to treat EVD cases falls short by the equivalent of 40 beds.[25] On 13 October, France indicated it would build more treatment centers.[61] On 18 October, Egypt sent three tons of medical aid, consisting of medicine and medical equipment.[62]

On 19 October Guinea have reported two new districts with EBV cases. The Kankan district, on the border with the Côte d’Ivoire and a major trade route to Mali, confirmed 1 case. Kankan also borders the district of Kerouane in this country, one of the areas with the most intense virus transmissions. The Faranah district to the north of the border area of Koinadugu in Sierra Leone in the north also reported a confirmed case. Koinadugu was one on the last EVD free regions in that country. According to the latest WHO report this new developmental highlights the need for increased surveillance of cross border traffic in an effort to contain the disease to the three most affected countries.[9]

Liberia[edit]

Ebola treatment unit in Liberia

In Liberia, the disease was reported in Lofa and Nimba counties in late March.[63] In July, the health ministry implemented measures to improve the country’s response.[64] On 27 July, Ellen Johnson Sirleaf, the Liberian president, announced that Liberia would close its borders, with the exception of a few crossing points such as the airport, where screening centres would be established.[65] Football events were banned,[66] schools and universities were closed,[67][68] and the worst-affected areas in the country were to be placed under quarantine.[69]

In August, President Sirleaf declared a national state of emergency, noting that it might require the “suspensions of certain rights and privileges”.[70] The National Elections Commission announced that it would be unable to conduct the scheduled October 2014 senatorial election and requested postponement,[71] one week after the leaders of various opposition parties had publicly taken different sides on the question.[72] In late August, Liberia’s Port Authority cancelled all “shore passes” for sailors from ships coming into the country’s four seaports.[73] As of 8 September, Ebola had been identified in 14 of Liberia’s 15 counties.[74]

With only 50 physicians in the entire country—one for every 70,000 Liberians—Liberia already faced a health crisis even before the outbreak.[75] In September the US CDC reported that some hospitals had been abandoned while those which were still functioning lacked basic facilities such as running water, rubber gloves, and sanitizing supplies.[76] The WHO estimated that Liberia’s capacity to treat EVD cases fell short by the equivalent of 1,550 beds.[25] In September, a new 150-bed treatment clinic was opened in Monrovia. At the opening ceremony six ambulances were already waiting with potential patients. More patients were waiting by the clinic after making their way on foot with the help of relatives.[77]

In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be “close to collapse”.[75] On 12 October, Liberian nurses threatened a strike over wages.[78] On 14 October, another 100 U.S. troops arrived, bringing the total to 565 to aid in the fight against the disease.[79] On 16 October, U.S. President Obama authorized, via executive order, the use of National Guard and reservists to Liberia.[80] A report of 15 October indicates that Liberia needs 80,000 more body bags and about 1 million protective suits for the next six months.[81] On October 20, the Liberian ambassador to Canada indicated it was time to try the ZMapp drug on the infected in Liberia.[82]

By 19 October only one area in Liberia, Grand Gedeh, has yet to report a EVD case. 14 out of the 15 districts have reported cases. In the capital of Monrovia 305 new cases were reported in the past week alone.[9] On 24 October this district became the last to report cases. Grand Gedeh reported 4 cases of which 2 tested positive.[5] On October 27, U.S. soldiers returning from Liberia were put in isolation upon their arrival in Italy.[83]

Sierra Leone[edit]

Kenema Hospital, Sierra Leone

The first person reported infected in the spread to Sierra Leone was atribal healer. She had treated one or more infected people and died on 26 May. According to tribal tradition, her body was washed for burial and this appears to have led to infections in women from neighbouring towns.[84] On 11 June, Sierra Leone shut its borders for trade with Guinea and Liberia and closed some schools in an attempt to slow the spread of the virus.[85] On 30 July, the government began to deploy troops to enforce quarantines.[86]

On 29 July, well-known physician Sheik Umar Khan, Sierra Leone’s only expert on hemorrhagic fever, died after contracting Ebola at his clinic in Kenema. Khan had long worked with Lassa fever, a disease that kills over 5,000 a year in Africa. He had expanded his clinic to accept Ebola patients. Sierra Leone’s president, Ernest Bai Koroma, celebrated Khan as a “national hero”.[84]

In August, awareness campaigns in Freetown, Sierra Leone’s capital, were delivered over the radio and through loudspeakers.[87] Also in August, Sierra Leone passed a law that subjected anyone hiding someone believed to be infected to two years in jail. At the time the law was enacted, a top parliamentarian criticised failures by neighbouring countries to stop the outbreak.[88]

In an attempt to control the disease, Sierra Leone imposed a three-day lockdown on its population from 19 to 21 September. During this period 28,500 trained community workers and volunteers went door-to-door providing information on how to prevent infection, as well as setting up community Ebola surveillance teams.[89] On 22 September, government officials said that the three-day lockdown had obtained its objective and would not be extended. Eighty percent of targeted households were reached in the operation. A total of around 150 new cases were uncovered, although reports from remote locations had not yet been received.[90]

WHO estimated on 21 September that Sierra Leone’s capacity to treat EVD cases falls short by the equivalent of 532 beds.[25] There have been reports that political interference and administrative incompetence have hindered the flow of medical supplies into the country.[91] On 4 October, Sierra Leone recorded 121 fatalities, the largest number in a single day.[92] On 8 October, Sierra Leone burial crews went on strike.[93] On 12 October, it was reported that the U.K. would begin providing military support to Sierra Leone.[94]

The last district in Sierra Leone untouched by the Ebola virus has declared Ebola cases. According to Abdul Sesay, a local health official, 15 suspected deaths with two confirmed cases of the deadly disease were reported on 16 October in the village of Fakonya. The village is 60 miles from the town of Kabala in the center of a mountainous region of the Koinadugudistrict. All of the districts in this country now have confirmed cases of Ebola.[95] On October 24, U.K. Prime Minister Cameron pledged 80 million (pounds) to Sierra Leone’s fight against the virus,and asked other countries in Europe to donate.[96]

Countries with limited local transmission[edit]

Spain[edit]

On 5 August 2014, the Brothers Hospitallers of St. John of God confirmed that Brother Miguel Pajares, who had been volunteering in Liberia, had become infected. He was evacuated to Spain on 6 August, and died on 12 August.[97] On 21 September it was announced that Brother Manuel García Viejo, another Spanish citizen who was medical director at theSan Juan de Dios Hospital in Lunsar, had been evacuated to Spain from Sierra Leone after being infected with the virus. His death was announced on 25 September.[98]

In October, a nursing assistant, later identified as Teresa Romero, who had cared for these patients became unwell and on 6 October tested positive for Ebola.[99] A second test confirmed the diagnosis,[100] making this the first confirmed case of Ebola transmission outside Africa. On 19 October, it was reported that Romero had recovered and was officially declared to be Ebola free.[55]

United States[edit]

On 30 September, the United States Centers for Disease Control and Prevention (CDC) declared its first case of Ebola virus disease. The CDC disclosed that Thomas Eric Duncan became infected in Liberia and traveled to Texas on 20 September. On 26 September he fell ill and sought medical treatment but was sent home with antibiotics. He returned to the hospital by ambulance on 28 September and was placed in isolation and tested for Ebola.[101][102] Thomas Duncan died on 8 October.[103] On 19 October his four relatives and 44 other people who had had contact with Duncan were released from quarantine.[104]

On 12 October, the CDC confirmed that a health worker who treated Duncan tested positive for the Ebola virus, making this the first known transmission of the disease in the United States. Two days later a second health worker at the same hospital tested positive for Ebola.[105] Nina Pham, the first nurse infected, was transferred to a facility at the National Institutes of Health (NIH) in Bethesda, Maryland on 16 October,[106] while the second, Amber Joy Vinson, was transferred to Emory University Hospital in Atlanta, Georgia.[56] Both patients recovered and were declared free of the virus by October 24.[107] A fourth case of Ebola virus disease was diagnosed on 23 October in New York City. MSF doctor Craig Spencer had recently returned from treating Ebola patients in West Africa where he contracted the disease.[108] On 24 October, New York and New Jersey indicated both states would begin a mandatory 21 day quarantine of all health care workers arriving from west Africa.[109]

Countries with initial cases[edit]

Mali[edit]

On October 23, the first confirmed case of the Ebola virus in Mali was of a two year-old girl who had returned from Guinea.[21] According to a health ministry official, the girl’s mother had died in Guinea a few weeks previously and the child was then brought by relatives to Mali.[20] A local newspaper, MaliJet, reported that she and her grandmother had arrived inBamako on October 20, after attending the funeral of her father, who died of Ebola. They then arrived in Kayes the next day.[110]

On October 24, a health official told Reuters that the girl had died as a result of the disease.[111] 43 contacts have been isolated, of whom ten are health-care workers. Many people may have been exposed during her bus journey from Guinea, when she was already symptomatic.[112][113] On October 25, Mauritania, as a preventive measure, closed its border with Mali.[114] On October 28, WHO raised the number of contacts to 82, stating “the possibility of setting up a treatment center in Kayes” had been discussed.[115]

Countries with contained spread[edit]

Senegal[edit]

In March, the Senegal Ministry of Interior closed the southern border with Guinea,[116] but on 29 August the Senegal health minister announced Senegal’s first case, a university student from Guinea who was being treated in a Dakar hospital.[53]The case was a native of Guinea who had traveled to Dakar, arriving on 20 August. On 23 August, he sought medical care for symptoms including fever, diarrhoea, and vomiting. He received treatment for malaria, but did not improve and left the facility. Still experiencing the same symptoms, on 26 August he was referred to a specialized facility for infectious diseases, and was subsequently hospitalized.[53]

On 28 August, authorities in Guinea issued an alert informing medical services in Guinea and neighbouring countries that a person who had been in close contact with an Ebola infected patient had escaped their surveillance system. The alert prompted testing for Ebola at the Dakar laboratory, and the positive result launched an investigation and triggered urgent contact tracing.[53] On 10 September, it was reported that the student had recovered but health officials would continue to monitor his contacts for 21 days.[117] No further cases were reported.[118] and on 17 October, the WHO officially declared that the outbreak in Senegal had ended.[12]

The WHO have officially commended the Senegalese government, and in particular the President Macky Sall and the Minister of Health Dr Awa Coll-Seck, for their quick response in quickly isolating the patient and tracing and following up 74 contacts as well as for their public awareness campaign. This acknowledgement was also extended to MSF and the CDC for their assistance.[119]

Nigeria[edit]

Health care workers in Nigeria receiving training on 28 August 2014

The first case in Nigeria was a Liberian-American, Patrick Sawyer, who flew from Liberia to Nigeria’s commercial capital Lagos on 20 July. Sawyer became violently ill upon arriving at the airport and died five days later. In response, the Nigerian government observed all of Sawyer’s contacts for signs of infection and increased surveillance at all entry points to the country.[120] On 6 August, the Nigerian health minister told reporters, “Yesterday the first known Nigerian to die of Ebola was recorded. This was one of the nurses that attended to the Liberian. The other five [newly confirmed] cases are being treated at an isolation ward.”[121]

On 9 August, the Nigerian National Health Research Ethics Committee issued a statement waiving the regular administrative requirements that limit the international shipment of any biological samples out of Nigeria[122] and supporting the use of non-validated treatments without prior review and approval by a health research ethics committee.[122] Besides increased surveillance at the country’s borders, the Nigerian government says that they have also made attempts to control the spread of disease by improving tracking, providing education in order to avert disinformation and increase accurate information, and teaching appropriate hygiene measures.[citation needed]

On 19 August, it was reported that the doctor who treated Sawyer, Ameyo Adadevoh, had also died of Ebola disease. Adadevoh was posthumously praised for preventing the index case (Sawyer) from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria.[123][124]

Also on 19 August, the Commissioner of Health in Lagos announced that Nigeria had seen twelve confirmed cases, and that four had died (including the index case) while another five, including two doctors and a nurse, were declared disease-free and released.[citation needed] On 22 September, the Nigeria health ministry announced, “As of today, there is no case of Ebola in Nigeria. All listed contacts who were under surveillance have been followed up for 21 days.”[125]

On 9 October, the European Centre for Disease Prevention and Control (ECDC) acknowledged Nigeria’s positive role in controlling the effort to contain the Ebola outbreak. “We wish to thank the Federal Ministry of Health, Abuja, Nigeria, and the staff of the Ebola Emergency Centre who coordinated the management of cases, containment of outbreaks and treatment protocols in Nigeria.” Nigeria’s quick responses, including intense and rapid contact tracing, surveillance of potential contacts, and isolation of all contacts were of particular importance in controlling and limiting the outbreak, according to the ECDC.[126] Complimenting Nigeria’s successful efforts to control the outbreak, “the usually measured WHO declared the feat ‘a piece of world-class epidemiological detective work’.”[127]

The WHO’s representative in Nigeria officially declared Ebola free on 20 October after no new active cases were reported in the follow up contacts, stating it was a “spectacular success story”.[8]

A number of people who had become infected with Ebola virus disease have been medically evacuated to treatment in isolation wards in Europe or the US. These are mostly health workers with one of the NGOs in the area. Germany is currently the only country which has agreed to treat non citizens.[128]

Most medical evacuations have been carried out on Gulfstream III planes operated byPhoenix Air.[129]

Countries with medically evacuated cases

France[edit]

A French volunteer health worker, working for MSF in Liberia, contracted EVD and was flown to France on 18 September. After successful treatment at a military hospital near Paris, she was discharged on 4 October.[130]

According to the FujiFilm company, the woman was treated with their drug favipiravir. This fact has not yet been confirmed by the French health authorities.[131]

Germany[edit]

Germany set up an isolation ward to care for six patients at the University Medical Center Hamburg-Eppendorf. On 27 August, a Senegalese epidemiologist working for the WHO in Sierra Leone became the first patient. On 4 October he was discharged after being declared noninfectious.[132]

The WHO requested that a Ugandan doctor working in Sierra Leone who had contracted the disease be treated in Germany. The request was granted by Germany and he was flown to the country on 3 October. The patient is being treated in an isolation unit at the University Hospital in Frankfurt. The doctor was working for an Italian NGO in Sierra Leone, according to Stefan Gruettner, the State Health Minister of Hessen.[133]

On 9 October, a third patient was medevaced to Leipzig, Germany. The 56-year-old Sudanese man, who worked as a UN employee in Liberia, was transferred to St Georg Hospital in Leipzig.[134] He died on 14 October, becoming the first person on German soil to die of Ebola.[135]

Norway[edit]

On 6 October, MSF announced that one of their workers, a Norwegian national, had become infected in Sierra Leone. On 7 October the woman, Silje Lehne Michalsen, was admitted to a special isolation unit at Oslo University Hospital. [136][137] On 20 October, it was announced that she had been successfully treated and had been discharged. It was reported that Michalsen had received an unspecified drug as part of her treatment plan.[138] After discharge Michalsen remarked, “For three months I saw the total absence of an international response. For three months I became more and more worried and frustrated.”[137]

United Kingdom[edit]

An isolation unit at the Royal Free Hospital, London, received its first case on 24 August. William Pooley, a British nurse, was evacuated from Sierra Leone by the Royal Air Force on a specially-equipped C-17 aircraft. He was released from hospital on 3 September.[139][140]

United States[edit]

A number of American citizens who contracted Ebola virus disease while working in the affected areas have been evacuated to the United States for treatment; none have died.

Countries with local transmission[edit]

Nigeria[edit]

Nigeria Ebola areas – 2014
Nigeria Map Ebola 2014.png

Nigeria Situation Map as of 5 September 2014[72]
Date July 2014 – present[73]
Casualties
  • Cases / Deaths (as of 21 September 2014)
  •  Nigeria: 20 / 8 Ebola Free 

The first case in Nigeria was a Liberian-American, Patrick Sawyer, who flew from Liberia to Nigeria’s former capital Lagos on 20 July. Sawyer became violently ill upon arriving at the airport and died five days later. In response, the Nigerian government observed all of Sawyer’s contacts for signs of infection and increased surveillance at all entry points to the country.[74] On 6 August, the Nigerian health minister told reporters, “Yesterday the first known Nigerian to die of Ebola was recorded. This was one of the nurses that attended to the Liberian. The other five [newly confirmed] cases are being treated at an isolation ward.”[75]

On 9 August, the Nigerian National Health Research Ethics Committee issued a statement waiving the regular administrative requirements that limit the international shipment of any biological samples out of Nigeria[76] and supporting the use of non-validated treatments without prior review and approval by a health research ethics committee.[76] Other than increased surveillance at the country’s borders, the Nigerian government states that they have also made attempts to control the spread of disease through an improvement in tracking, providing education to avert disinformation and increase accurate information, and the teaching of appropriate hygiene measures.[72]

On 19 August, it was reported that the doctor who treated Sawyer, Ameyo Adadevoh, had also died of Ebola disease. Adadevoh was posthumously praised for preventing the index case (Sawyer) from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria.[77][78]

On 19 August, the Commissioner of Health in Lagos announced that Nigeria had seen twelve confirmed cases; four died (including the index case) while another five, including two doctors and a nurse, were declared disease-free and released.[72][79] On 22 September, the Nigeria health ministry announced “As of today, there is no case of Ebola in Nigeria. All listed contacts who were under surveillance have been followed up for 21 days.”[80][81] The WHO stated that Nigeria had not reported any new cases since 8 September and if no further cases are reported, Nigeria will be declared Ebola-free on 20 October.[82]

Spain[edit]

On 5 August 2014, the Brothers Hospitallers of St. John of God confirmed that Brother Miguel Pajares, who had been volunteering in Liberia, had become infected. He was evacuated to Spain on 6 August 2014, and subsequently died on 12 August.[83] On 21 September it was announced that Brother Manuel García Viejo, another Spanish citizen who was medical director at the San Juan de Dios Hospital in Lunsar, had been evacuated to Spain from Sierra Leone after being infected with the virus. His death was announced on 25 September.[84] Both of these cases were treated at the Hospital Carlos III in Madrid.[85]

In October 2014, a nurse who had cared for these patients at the Hospital Carlos III became unwell and on 6 October tested positive for Ebola.[86] A second test confirmed the diagnosis,[87] making this the first confirmed case of Ebola transmission outside Africa. There are currently 50 contacts being monitored, with 7 kept in isolation at Hospital Carlos III in Madrid, and an investigation is under way.[88][89] On October 9, the Spanish Health ministry quarantined 3 more people.[90]

Countries with an initial case or cases[edit]

World situation map of the outbreak including local and evacuated cases

Senegal[edit]

In March, the Senegal Ministry of Interior closed the southern border with Guinea,[91] but on 29 August the Senegal health minister announced Senegal’s first case, a university student from Guinea who was being treated in Dakar.[39][40]The WHO was informed on 30 August.[92][93]According to the WHO, the case was a native of Guinea who had traveled by road to Dakar, arriving on 20 August. On 23 August, he sought medical care for symptoms including fever, diarrhoea, and vomiting. He received treatment for malaria, but did not improve and left the facility. Still experiencing the same symptoms, on 26 August he was referred to a specialized facility for infectious diseases, and was subsequently hospitalized.[93]

On 27 August, authorities in Guinea issued an alert informing medical services in Guinea and neighbouring countries that a person who had been in close contact with an Ebola infected patient had escaped their surveillance system. The alert prompted testing for Ebola at the Dakar laboratory, and the positive result launched an investigation and triggered urgent contact tracing.[93] On 10 September, it was reported that the student had recovered but health officials would continue to monitor his contacts for 21 days.[94] On 22 September, the WHO announced that all contacts had completed the 21-day follow-up with no further cases of Ebola in Senegal, however they require a 42 day waiting period before a country can be called disease-free.[82]

United States[edit]

On 30 September, the United States Centers for Disease Control and Prevention (CDC) declared its first case of Ebola disease. A CDC spokesperson said, “The patient is a man who became infected in Liberia and traveled to Texas, where he was hospitalized with symptoms that were confirmed to be caused by Ebola.”[95] The patient, later named as Thomas Eric Duncan, arrived in Dallas on 20 September. Four days later he fell ill and sought medical treatment on 26 September. Despite telling a nurse that he had arrived in the US from West Africa, he was sent home with antibiotics. The hospital later blamed a flaw in their health records system for releasing the man.[96] He returned to the hospital by ambulance on 28 September and was placed in isolation.[97][97][98][99] The patient died on 8 October at around 7:51 am.[100]

On 1 October, the Director of Dallas County’s health department confirmed that a second person is being closely monitored for Ebola. More contacts of the infected patient are under watch and will be monitored for 21 days and placed in isolation if necessary.[101] Four relatives of the patient were placed legally under strict quarantine. Texas health officials have ordered them to stay at home and be available to undergo regular testing until 19 October, the end of the 21-day incubation period.[102]

Countries with medically evacuated cases[edit]

A number of healthcare workers who had become infected with Ebola virus disease have been medically evacuated to treatment in isolation wards in their country of origin.

France[edit]

A French volunteer health worker, working for MSF in Liberia, contracted EVD and was flown to France on 18 September. After successful treatment at a military hospital near Paris, she was discharged on 4 October.[103]

Germany[edit]

Germany set up an isolation ward to care for six patients at the University Medical Center Hamburg-Eppendorf. On 27 August, a Senegalese epidemiologist working for the WHO in Sierra Leone became the first patient. On 4 October he was discharged after successful treatment.[104]

The WHO requested that a Ugandan doctor working in Sierra Leone, who contracted the disease, be treated in Germany. The request was granted by Germany and he was flown to the country on 3 October. The patient is being treated in an isolation unit at the University Hospital in Frankfurt. The doctor was working for an Italian NGO in Sierra Leone according to Stefan Gruettner, the State Health Minister of Hessen.[105]

On the 9th October, a third patient was medivaced to Leipzig, Germany. The man, a UN employee, was transferred to St Georg Hospital in Leipzig. The hospital has yet to release a statement.[106]

Norway[edit]

On 6 October, MSF announced that one of their workers, a Norwegian national, had become infected in Sierra Leone. It is understood that she will receive treatment in special facilities at Oslo University Hospital.[107]

Switzerland[edit]

On Monday 22 September a Swiss health worker was flown by a private airline to Geneva. The nurse was bitten by an Ebola-infected child on Saturday, 20 September in Sierra Leone. The unidentified male nurse will remain in isolation for 21 days atGeneva’s University Hospital. The health ministry says it is unlikely that he was infected, but are monitoring him as a potential Ebola patient until the incubation period has passed.[108]

United Kingdom[edit]

An isolation unit at the Royal Free Hospital received its first case on 24 August. William Pooley, a British nurse, was evacuated from Sierra Leone. He was released on 3 September.[109][110]

United States[edit]

A number of American citizens who contracted Ebola virus disease while working in the affected areas have been evacuated to the United States for treatment; see main article.

Democratic Republic of the Congo[edit]

Democratic Republic of Congo – 2014
DRC Ebola Map.png

DRC Ebola area as of 6 September 2014[111]
Casualties
  • Cases / Deaths (as of 23 September 2014)[112]
  •  DR Congo: 70 / 42

In August 2014, the WHO reported an outbreak of Ebola Virus in the Boende District, Democratic Republic of the Congo.[113] They confirmed that the current strain of the virus is the Zaire Ebola species, which is common in the country. The virology results and epidemiological findings indicate no connection to the current epidemic in West Africa. This is the country’s seventh Ebola outbreak since 1976.[114][115]

In August, 13 people were reported to have died of Ebola-like symptoms in the remote northern Équateur province, a province that lies about 1,200 km (750 mi) north of the capital Kinshasa.[115] The initial case was a woman from Ikanamongo Village who became ill with symptoms of Ebola after she had butchered a bush animal that her husband had killed. The following week, relatives of the woman, several health-care workers who had treated the woman, and individuals with whom they had been in contact came down with similar symptoms.[115] On 26 August, the Équateur Province Ministry of Health notified the WHO of an outbreak of Ebola.[115] As of 23 September, the WHO has confirmed the number of cases at 70 and the death toll at 42 from possible or confirmed Ebola cases. Among this group are 8 health care workers.[112]

Virology[edit]

Ebola virus disease is caused by four of five viruses classified in the genus Ebolavirus. Of the four disease-causing viruses,Ebola virus (formerly and often still called the Zaire virus), is the most dangerous and is the strain responsible for the ongoing epidemic in West Africa.[116][117]

Since the discovery of the viruses in 1976 when outbreaks occurred in Sudan and the Democratic Republic of Congo (then called Zaire), Ebola virus disease has been confined to areas in Central Africa, where it is endemic. With the current outbreak, it was initially thought that a new strain endemic to Guinea might be the cause, rather than being imported from central to West Africa.[20][118] However, further studies have shown that the current outbreak is likely caused by an Ebola virus lineage that has spread from Central Africa into West Africa, with the first viral transfer to humans in Guinea.[117][119]

In a study done by the Broad Institute and Harvard University, in partnership with the Sierra Leone Ministry of Health and Sanitation, researchers may have provided information about the origin and transmission of the Ebola virus that sets this outbreak apart from previous outbreaks. For this study, 99 Ebola virus genomes were collected and sequenced from 78 patients diagnosed with the Ebola virus during the first 24 days of the outbreak in Sierra Leone. The team found more than 300 genetic changes that make the 2014 Ebola virus distinct from previous outbreaks. It is still unclear whether these differences are related to the severity of the current outbreak.[28][120] Five members of the research team became ill and died from Ebola before the study was published in August.[28][121]

Transmission[edit]

The life cycles of the Ebolavirus

It is not entirely clear how an Ebola outbreak is initially started.[122] The initial infection is believed to occur after an Ebola virus is transmitted to a human by contact with an infected animal’s body fluids. Evidence strongly implicates bats as the reservoir hosts for ebolaviruses. Bats drop partially eaten fruits and pulp, then land mammals such as gorillas and duikers feed on these fallen fruits. This chain of events forms a possible indirect means of transmission from the natural host to animal populations.[123]

Human-to-human transmission can occur via direct contact with blood or bodily fluids from an infected person or by contact with objects contaminated by the virus.[124] When adequate infection control measures are utilized, the potential for widespread Ebola infections is considered low as the disease is only spread by direct contact with the secretions from someone who is showing signs of infection.[124] Airborne transmission has not been documented during Ebola outbreaks. The time interval from infection with the virus to onset of symptoms is 2 to 21 days. Because dead bodies are still infectious, local traditional burial rituals may spread the disease.[125] Semen and possibly other body fluids (e.g., breast milk) may be infectious in survivors for months.[126][127]

One of the primary reasons for spread is that the health systems in the part of Africa where the disease occurs function poorly.[128] The risk of transmission is increased among those caring for people infected. Recommended measures when caring for those who are infected include isolating them, sterilizing equipment and surfaces, and wearing protective clothing including masks, gloves, gowns, and goggles.[122] However, even with proper isolation equipment available, working conditions such as no running water, no climate control, and no floors, continue to make direct care dangerous. Two American health workers who had contracted the disease and later recovered said that their team of workers had been following “to the letter all of the protocols for safety that were developed by the CDC and WHO”, including a full body coverall, several layers of gloves, and face protection including goggles. One of the two, a physician, had worked with patients, but the other was working to help workers get in and out of their protective gear, while wearing protective gear herself.[129]

Prevention[edit]

Prevention

Contact tracing[edit]

Contact tracing is an essential method of preventing the spread of the disease. It involves finding everyone who has had close contact with an Ebola case and tracking them for 21 days. However, this requires careful record-keeping by properly trained and equipped staff.[159] WHO Assistant Director-General for Global Health Security, Keiji Fukuda, said on 3 September, “We don’t have enough health workers, doctors, nurses, drivers, and contact tracers to handle the increasing number of cases.”[160] There is a massive ongoing effort to train volunteers and health workers. According to reports, 20,419 people from Sierra Leone and 18,699 from Liberia are listed and being traced as of 17 October. Figures for Guinea are not known.[161][162]

Travel restrictions and quarantines[edit]

  21 day mandatory quarantine for people exposed to people with Ebola: New York, New Jersey, Connecticut
  21 day mandatory quarantine for people exposed to people with Ebola without wearing protective gear or otherwise at high risk: Illinois, Virginia
  21 day mandatory twice daily temperature reporting and voluntary in-home quarantine for people exposed to people with Ebola: Maine
  21 day mandatory twice daily health screening or temperature reporting for people who have been in West African Ebola-afflicted countries: Florida, Georgia, Maryland, Pennsylvania

On 8 August, a cordon sanitaire, a disease-fighting practice that forcibly isolates affected regions, was established in the triangular area where Guinea, Liberia, and Sierra Leone are separated only by porous borders and where 70 percent of the known cases had been found. (The cordon sanitaire, a common disease-fighting tactic in the 14th-century Black Death that is considered inhumane today, had apparently not been used in the world since 1918.)[163] By September, the closure of borders had caused a collapse of cross-border trade and was having a devastating effect on the economies of the involved countries. A United Nations spokesperson reported that the price of some food staples had increased by as much as 150% and warned that if they continue to rise widespread food shortages can be expected.[citation needed]

On 2 September, WHO Director-General Margaret Chan advised against travel restrictions, saying that they are not justified and that they are preventing medical experts from entering the affected areas and are “marginalizing the affected population and potentially worsening [the crisis]”. UN officials working on the ground have also criticized the travel restrictions, saying the solution is “not in travel restrictions but in ensuring that effective preventive and curative health measures are put in place”.[31] MSF, also speaking out against the closure of international borders, called it “another layer of collective irresponsibility” and added, “The international community must ensure that those who try to contain the outbreak can enter and leave the affected countries if need be. A functional system of medical evacuation has to be set up urgently.”[33]

The countries of Rwanda, Senegal, Ivory Coast, Chad, South Africa, Cameroon, Cape Verde, Kenya, Australia, and theUnited States all have either banned or restricted travel for people travelling from countries in West Africa afflicted by Ebola.North Korea has banned all foreign tourists from its country in response to the Ebola epidemic. Rwanda also required travelers from the United States and Spain to report their medical condition daily starting October 19, but ended this requirement after 4 days.[164][165][166][167]

On 7 October, the governor of Connecticut, Dannel Malloy, signed an order authorizing the mandatory quarantine for 21 days of anyone, even if asymptomatic, who had direct contact with Ebola patients.[168][169] Nine people were quarantined on 22 October in accordance with the Connecticut order.[170] On 24 October, the governor of New York, Andrew Cuomo, and the governor of New Jersey, Chris Christie, issued similar quarantine authorizations following an Ebola case reported in New York City. It affects people, in particular health care workers, entering the United States through JFK and Newarkairports in New York and New Jersey respectively. Governor Christie said at a news conference with Governor Cuomo that “we are no longer relying on C.D.C. standards.”[171] Illinois Governor Pat Quinn issued a similar quarantine authorization the same day as New York and New Jersey, with Florida Governor Rick Scott on 25 October authorizing mandatory twice daily monitoring for 21 days of people identified as coming from countries affected by Ebola.[172][173] Illinois health officials later said that only people at high risk of Ebola exposure, such as not wearing protective gear near Ebola patients, will be quarantined.[174]

One healthcare worker arriving in the United States at the Newark, New Jersey airport was quarantined on 24 October in accordance with the new policy measures.[175] The healthcare worker called her quarantine in a medical tent “inhumane,” with access to a portable toilet, no shower, no television accessibility, and limited cell phone reception. Obama administration officials have been attempting to persuade New York Governor Cuomo and New Jersey Governor Christie to reverse their mandatory quarantine authorizations since they were ordered.[176] On October 26, New York Governor Andrew Cuomo modified the state’s quarantine procedure, stating that people entering New York who have had contact with Ebola patients in West Africa will be quarantined in their homes, with twice daily checks to ensure their health has not changed and that they are complying with the order.[176] White House spokesmen and National Institute of Health expertAnthony Fauci have both urged against these mandatory quarantines, warning that they would further disincentivize American healthcare workers from traveling to affected areas.[177]

Pennsylvania, Maryland, and Georgia have all authorized mandatory twice daily health monitoring and/or temperature reporting for 21 days for people exposed to people with Ebola. Virginia has also implemented mandatory twice daily temperature reporting and daily monitoring from health authorities, but has also authorized mandatory quarantine for higher risk patients.[178][179] Maine will request people exposed to Ebola patients submit to a voluntary in-home quarantine, but will also require people to report their temperature twice daily for 21 days.[180]

U.S. Army Chief of Staff Ray Odierno also ordered on October 27 a 21-day quarantine of all soldiers returning fromOperation United Assistance in Liberia. Up to 12 soldiers have been quarantined so far in a U.S. base in Italy.[181]

Deaths of healthcare workers[edit]

In August, it was reported that healthcare workers represented nearly 10 percent of the cases and fatalities, significantly impairing the ability to respond to the outbreak in an area which already faces a severe shortage of doctors.[136] In the hardest hit areas there have historically been only one or two doctors available to treat 100,000 people, and these doctors are heavily concentrated in urban areas.[15] Healthcare providers caring for people with Ebola and family and friends in close contact with people with Ebola are at the highest risk of getting infected because they may come in direct contact with the blood or body fluids of the sick person. In some places affected by the current outbreak, care may be provided in clinics with limited resources, and workers could be in these areas for several hours with a number of Ebola infected patients.[137] According to the WHO, the high proportion of infected medical staff can be explained by lack of the number of medical staff needed to manage such a large outbreak, shortages of protective equipment, or improperly using what is available, and “the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe”.[15]

Among the fatalities is Samuel Brisbane, a former advisor to the Liberian Ministry of Health and Social Welfare, described as “one of Liberia’s most high-profile doctors.”[138] In July, leading Ebola doctor Sheik Umar Khan from Sierra Leone died in the outbreak. His death was followed by two more deaths in Sierra Leone: Modupe Cole, a senior physician at the country`s main referral facility,[139] and Sahr Rogers, who worked in Kenema.[140][140][141][142] In August, a well-known Nigerian physician,Ameyo Adadevoh, died. She was posthumously praised for preventing the Nigerian index case from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria.[77]

By 1 October, the WHO reported 382 workers had been infected and 216 had died. Liberia has been especially hard hit with almost half the total cases (188 with 94 deaths) reported. Sierra Leone registered 114 cases with 82 fatalities, thus indicating a death toll of seven out of ten. Guinea reported 69 infected cases with 35 deaths. In Nigeria 11 healthcare workers were also infected and 5 deaths were recorded.[143]

Community[edit]

In order to reduce the spread, the World Health Organization recommends raising community awareness of the risk factors for Ebola infection and the protective measures individuals can take.[144] These include avoiding contact with infected people and regular hand washing using soap and water.[145] A condition of dire poverty exists in many of the areas that have experienced a high incidence of infections. According to the director of the NGO Plan International in Guinea, “The poor living conditionsand lack of water and sanitation in most districts of Conakry pose a serious risk that the epidemic escalates into a crisis. People do not think to wash their hands when they do not have enough water to drink.”[146]

Containment efforts have been hindered because there is reluctance among residents of rural areas to recognize the danger of infection related to person-to-person spread of disease, such as burial practices which include washing of the body of one who has died.[11][12][13][32] A 2014 study found that nearly two thirds of cases of Ebola in Guinea are believed to be due to burial practices.[147]

Denial in some affected countries has often made containment efforts difficult.[148] Language barriers and the appearance of medical teams in protective suits has sometimes increased fears of the virus.[149] There are reports that some people believe that the disease is caused by sorcery and that doctors are killing patients.[150] In late July, the former Liberian health minister, Peter Coleman, stated that “people don’t seem to believe anything the government now says.”[47]

Acting on a rumor that the virus was invented to conceal “cannibalistic rituals” (due to medical workers preventing families from viewing the dead), demonstrations were staged outside of the main hospital treating Ebola patients in Kenema, Sierra Leone. The demonstrations were broken up by the police and resulted in the need to use armed guards at the hospital.[151] In Liberia, a mob attacked an Ebola isolation centre stealing equipment and “freeing” patients while shouting, “There’s no Ebola.”[152] Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives.[153] In the town of Womey in Guinea, at least eight aid workers were murdered by suspicious inhabitants with machetes and their bodies dumped in a latrine on September 18.[154]

Treatment[edit]

Treatment facilities in West Africa
WHO ebola response map.jpg

Treatment facilities and responses in the West African region as of 1 October 2014[155]

No proven Ebola virus-specific treatment exists as of August 2014.[156] Treatment is primarily supportive in nature and includes minimizing invasive procedures, balancing fluids andelectrolytes to counter dehydration, administration ofanticoagulants early in infection to prevent or controldisseminated intravascular coagulation, administration ofprocoagulants late in infection to control bleeding, maintaining oxygen levels, pain management, and the use of medications to treat bacterial or fungal secondary infections.[157][158][159][160][161]Early treatment may increase the chance of survival.[162]

Level of care[edit]

Local authorities have not had resources to contain the disease, with health centres closing and hospitals overwhelmed.[163] In late June, the Director-General of Médecins Sans Frontières said, “Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible.”[134] Adequate equipment has not been provided for medical personnel,[164] with even a lack of soap and water for hand-washing and disinfection.[165]

In late August, Médecins Sans Frontières (MSF) called the situation “chaotic” and the medical response “inadequate”. They reported that they had expanded their operations but were unable to keep up with the rapidly increasing need for assistance which had forced them to reduce the level of care they were able to offer: “It is not currently possible, for example, to administer intravenous treatments.” Calling the situation “an emergency within the emergency”, MSF reported that many hospitals have had to shut down due to lack of staff or fears of the virus among patients and staff which has left people with other health problems without any care at all. Speaking from a remote region, a MSF worker said that a shortage of protective equipment was making the medical management of the disease difficult and that they had limited capacity to safely bury bodies.[166]

By September, treatment for Ebola patients had become unavailable in some areas. Speaking on 12 September, WHO director-general Margaret Chan said, “In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centers. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia.”[167] According to a WHO report released on 19 September, Sierra Leone is currently meeting only 25% of its need for patient beds, and Liberia is meeting only 20% of its need.[168]

Current bed capacity for patients in countries with active cases as at 21 Sep 2014.[41]
Countries Existing beds Beds to be set up with partner Additional beds required
Guinea 180 0 40
Liberia 345 440 1,550
Sierra Leone 323 297 532
Total 848 763 2,122

Healthcare settings[edit]

A number of Ebola Treatment Centres have been set up in the area, supported by international aid organisations and staffed by a combination of local and international staff. Each treatment centre is divided into a number of distinct and rigorously separate areas. For patients, there is a triage area, and low & high risk care wards. For staff, there are areas for preparation and decontamination. An important part of each centre is an arrangement for safe burial or cremation of bodies, required to prevent further infection.[169][170]

Although the WHO does not advise caring for Ebola patients at home, it is an option and even a necessity when no hospital treatment beds are available. For those being treated at home, the WHO advises informing the local public health authority and acquiring appropriate training and equipment.[171] UNICEF, USAID and the NGO Samaritan’s Purse have begun to take measures to provide support for families that are forced to care for patients at home by supplying caregiver kits intended for interim home-based interventions. The kits include protective clothing, hydration items, medicines, and disinfectant, among other items.[172][173] Even where hospital beds are available, it has been debated whether conventional hospitals are the best place to care for Ebola patients, as the risk of spreading the infection is high.[174] The WHO and non-profit partners have launched a program in Liberia to move infected people out of their homes into Ad Hoc Centers that will provide rudimentary care.[175]

Experimental treatments[edit]

There is as yet no known effective medication or vaccine. According to the director of the US National Institute of Allergy and Infectious Diseases, “it is important to recognise that we[who?] are still in the early stages of understanding how infection with the Ebola virus can be treated and prevented.” [227] The unavailability of treatments in the most-affected regions has spurred controversy, with some calling for experimental drugs to be made more widely available in Africa on a humanitarian basis, and others warning that making unproven drugs widely available would be unethical, especially in light of past experimentation conducted in developing countries by Western drug companies.[228][229] As a result of the controversy, on 12 August an expert panel of the WHO endorsed the use of interventions with as-yet-unknown effects for both treatment and prevention of Ebola, and also said that deciding which treatments should be used and how to distribute them equitably were matters that needed further discussion.[230]

Known as a promising method since the early 1970s days of Ebola research,[231] the WHO has recognised that transfusion of whole blood or purified serum from Ebola survivors is the therapy with the greatest potential to be implemented immediately although there is little information on its efficacy.[232] At the end of September, WHO issued an interim guideline for this therapy.[233] During September, there were reports of blood from survivors of the disease being offered for sale on the black market. Health professionals have warned that patients buying blood on the black market could expose themselves to a number of risks, including infection with HIV or hepatitis.[234]

A number of experimental treatments are being considered for use in the context of this outbreak, and are currently or will soon undergo clinical trials,[235] but it will still be some time before sufficient quantities have been produced for widespread trials.[227]

  • ZMapp, a combination of monoclonal antibodies. The limited supply of the drug has been used to treat 7 individuals infected with the Ebola virus.[236] Although some of them have recovered, the outcome is not considered to bestatistically significant.[237] ZMapp has proved highly effective in a trial involving rhesus macaque monkeys.[238] Texas A&M stated on 8 October that it was ready to mass-produce the drug, pending final approval.[239]
  • TKM-Ebola, an RNA interference drug.[240] The drug started Phase 1 trial in early 2014 and has since has received limited approval from the FDA for emergency use.[241] The drug disrupts the virus replication process, “allowing the body’s immune system to catch up with the virus and destroy it”.[242]
  • Favipiravir (Avigan), a drug approved in Japan for stockpiling against influenza pandemics. The drug appears to be useful in a mouse model of the disease[243][244] and a clinical trial is being planned for Ebola patients in Guinea, due November.[245] The French Health ministry has authorized its use.[246] Treatments that use small interfering RNAs protected macaque monkeys that were exposed to the virus.[247]
  • BCX4430 is a broad-spectrum antiviral drug developed by BioCryst Pharmaceuticals and currently being researched as a potential treatment for Ebola by USAMRIID.[248] The drug has been approved to progress to Phase 1 trials, expected late in 2014.[249] BCX4430 attempts to disrupt viral replication or the pathogenic mechanism. Stated simply, “it tries to stop … the virus by directly acting on the virus”.[250]
  • Brincidofovir, another broad-spectrum antiviral drug, has been granted an emergency FDA approval as an investigational new drug for the treatment of Ebola after it was found to be effective against Ebola virus in in vitrotests.[251] It has subsequently been used to treat the first patient diagnosed with Ebola in the USA after he had recently returned from Liberia.[252] On 16 October, it was cleared to start clinical trials. The drug is based on injectable antiviral Cidofovir.[253]
  • JK-05 is a small molecule drug, and its pharmacological mechanism inhibits the RNA polymerase of the Ebola virus.[254][255] The drug can selectively inhibit virus replication by inhibiting the RNA polymerase of the Ebola virus, meaning that it blocks an enzyme that the virus needs to replicate its genes.[256][257]

Prognosis

Statistical measures

Calculating an accurate case fatality rate (CFR) is difficult for an ongoing epidemic due to differences in testing policies, the inclusion of probable and suspected cases, and the inclusion of new cases that have not run their course. In late August, the WHO made an initial CFR estimate of 53% though this included suspected cases.[198][199] On 23 September, the WHO released a revised and more accurate CFR of 70.8%, derived using data from patients with definitive clinical outcomes.[5]

The basic reproduction number (R0) is a statistical measure of the number of people who are expected to be infected by one person who has the disease in question. If the rate is less than 1, the infection will die out in the long run and if the rate is greater than 1, the infection will continue to spread in a population.[200] The BRN of the current outbreak is estimated to be between 1.71 and 2.02.[5]

Projections of future cases[edit]

On 28 August, the WHO released its first estimate of the possible total cases (20,000) from the outbreak as part of its roadmap for stopping the transmission of the virus.[201][202] The WHO roadmap states “[t]his Roadmap assumes that in many areas of intense transmission the actual number of cases may be two- to fourfold higher than that currently reported. It acknowledges that the aggregate case load of EVD could exceed 20,000 over the course of this emergency. The Roadmap assumes that a rapid escalation of the complementary strategies in intense transmission, resource-constrained areas will allow the comprehensive application of more standard containment strategies within 3 months.”[202] It includes an assumption that some country or countries will pay the required cost of their plan, estimated at half a billion dollars.[202]

When the WHO released its first estimated projected number of cases, a number of epidemiologists presented data to show that the WHO’s projection of a total of 20,000 cases was likely an underestimate. On August 31, the journal Science quoted Christian Althaus, a mathematical epidemiologist at the University of Bern in Switzerland, as saying that if the epidemic were to continue in this way until December, the cumulative number of cases would exceed 100,000 in Liberia alone.[203] According to a research paper released in early September, in the hypothetical worst-case scenario, if a BRN of over 1.0 continues for the remainder of the year we would expect to observe a total of 77,181 to 277,124 additional cases within 2014.[204] On 9 September, Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine controversially announced that the containment fight in Sierra Leone and Liberia has already been “lost” and that the disease would “burn itself out”.[205] Writing in the New York Times on 12 September, Bryan Lewis, an epidemiologist at the Virginia Bioinformatics Institute at Virginia Tech, said that researchers at various universities who have been using computer models to track the growth rate say that at the virus’s present rate of growth, there could easily be close to 20,000 cases in one month, not in nine.[206]

On 8 September, the WHO warned that the number of new cases in Liberia was increasing exponentially, and would increase by “many thousands” in the following three weeks. In a 23 September WHO report, the WHO revised their previous projection, stating that they expect there to be an excess of 20,000 Ebola cases in West Africa by 2 November.[5] They further stated, that if the disease is not adequately contained it could become endemic in Guinea, Sierra Leone and Liberia,[206] “spreading as routinely as malaria or the flu”,[207] and according to an editorial in the New England Journal of Medicine, eventually to other parts of Africa and beyond.[208]

In a 23 September CDC report, a projection calculates a potential underreporting which is corrected by a factor of 2.5. With this correction factor, approximately 21,000 total cases are the estimate for the end of September 2014 in Liberia and Sierra Leone alone. The same report predicted that total cases, including unreported cases, could reach 1.4 million in Liberia and Sierra Leone by 20 January 2015 if no improvement in intervention or community behaviour occurred.[209]

On 2 September, an assessment of the probability of Ebola virus disease case importation in countries across the world was published in PLOS Currents Outbreaks.[210] The projections are based on simulations of epidemic spread worldwide. The analysis was updated with simulations based on new data on 6 October, and the updated results are available online.[211]

Economic effects[edit]

In addition to the loss of life, the outbreak is having a number of significant economic impacts.

  • Markets and shops are closing, due to travel restrictions, cordon sanitaire, or fear of human contact, leading to loss of income for producers and traders.[212]
  • Movement of people away from affected areas has disturbed agricultural activities.[213][214] The UN Food and Agriculture Organisation (FAO) has warned that the outbreak could endanger harvest and food security in West Africa.[215]
  • Tourism is directly impacted in affected countries.[216] Other countries in Africa which are not directly affected by the virus have also reported adverse effects on tourism.[217] * Many airlines have suspended flights to the area.[218]
  • Foreign mining companies have withdrawn non-essential personnel, deferred new investment, and cut back operations.[214][219][220]
  • The outbreak is straining the finances of governments, with Sierra Leone using Treasury bills to fund the fight against the virus.[221]
  • The IMF is considering expanding assistance to Guinea, Sierra Leone, and Liberia as their national deficits are ballooning and their economies contract sharply.[222]
  • On 8 October, the World Bank issued a report which estimated overall economic impacts of between $3.8 billion and $32.6 billion, depending on the extent of the outbreak and the speed with which it can be contained. The economic impact would be felt most severely in the 3 affected countries, but with wider impact felt across the broader West African region.[223][224]

Responses[edit]

In July, the World Health Organization convened an emergency meeting with health ministers from eleven countries and announced collaboration on a strategy to co-ordinate technical support to combat the epidemic. In August they published a roadmap to guide and coordinate the international response to the outbreak, aiming to stop ongoing Ebola transmission worldwide within 6–9 months and formally designated the outbreak as a Public Health Emergency of International Concern.[225] This is a legal designation used only twice before (for the 2009 H1N1 (swine flu) pandemic and the 2014 resurgence of polio) which invokes legal measures on disease prevention, surveillance, control, and response, by 194 signatory countries.[226][227]

In September, the United Nations Security Council declared the Ebola virus outbreak in West Africa a “threat to international peace and security” and unanimously adopted a resolution urging UN member states to provide more resources to fight the outbreak; the WHO stated that the cost for combating the epidemic will be a minimum of $1 billion.[228][229] The Economic Community of West African States and the World Bank Group have pledged aid money and the World Food Programmeannounced plans to mobilize food assistance for an estimated 1 million people living in restricted access areas. Several Non-Governmental Organizations have provided assistance in the efforts to control the spread of the disease. The humanitarian aid organisation Médecins Sans Frontières (Doctors Without Borders) is the leading organization responding to the crisis. Currently it has five treatment centers in the area.[168] Samaritan’s Purse is providing direct patient care in multiple locations in Liberia.[230] Many nations and charitable organizations, foundations, and individuals have also pledged assistance to control the epidemic.

Timeline of cases and deaths[edit]

Data comes from reports by the Centers for Disease Control and Prevention[231] and the WHO.[232] All numbers are correlated with United Nations Office for the Coordination of Humanitarian Affairs (OCHA) if available.[233] The table includes suspected cases that have not yet been confirmed. The reports are sourced from official information from the affected countries’ health ministries. WHO has stated the reported numbers “vastly underestimate the magnitude of the outbreak”,[234] saying there may be 2.5 times as many cases as officially reported.[235] Cases in remote areas may also be missed.[236]

The case numbers reported may include probable or suspected cases. Numbers are revised downward if a case is later found to be negative. (Numbers may differ from reports as per respective Government reports. See notes at the bottom for stated source file.)

Ebola cases and deaths by country – 22 March to 30 July

Date Total Guinea Liberia Sierra Leone Nigeria
Ca De Ca De Ca De Ca De Ca De
27 Jul 2014 1,323 729 460 339 329 156 533 233 1 1
23 Jul 2014 1,201 672 427 319 249 129 525 224
20 Jul 2014 1,093 660 415 314 224 127 454 219
17 Jul 2014 1,048 632 410 310 196 116 442 206
14 Jul 2014 982 613 411 310 174 106 397 197
12 Jul 2014 964 603 406 304 172 105 386 194
8 Jul 2014 888 539 409 309 142 88 337 142
6 Jul 2014 844 518 408 307 131 84 305 127
2 Jul 2014 779 481 412 305 115 75 252 101
30 Jun 2014 759
(6/25)+22
467
+14
413
+3
303
+5
107
+8
65
+7
239
+11
99
+2
22 Jun 2014 599 338 51 34
20 Jun 2014 581 328 390
+0
270
+3
158
+0
34
+4
17 Jun 2014 528 337 97
(6/15)+31
49
+4
16 Jun 2014 526 334 398 264 33
(6/11)+9
24
+5
15 Jun 2014 522 333 394 263 33 24 95 46
10 Jun 2014 474 252 372 236
6 Jun 2014 453 245 89
+8
7
+1
5 Jun 2014 445 244 351
+7
226
+6
5 Jun 2014 438 233 81
+9
6
3 Jun 2014 436 233 344
+11
215
+3
1 Jun 2014 383 211 328 208
+21
79
+13
6
29 May 2014 354 211
+1

+1
50
+34
6
+1
28 May 2014 319 209 291 193
27 May 2014 309 202 281 186 16 5
23 May 2014 270 185 258 174
18 May 2014 265 187 253 176
12 May 2014 260 182 248 171
10 May 2014 245 168 233 157 12 11
7 May 2014 249 169 236 158
3 May 2014 244 166 231 155 0 0
2 May 2014 239 160 13 11
1 May 2014 237 158 226 149
30 Apr 2014 233 155 221 146
24 Apr 2014 253 152 35
23 Apr 2014 252 152 218 141
21 Apr 2014 242 147 34
↓26?
11
-2
20 Apr 2014 235 149 208 136
17 Apr 2014 230 142 203 129 27 13
16 Apr 2014 224 135 197 122 27 13 (1)
14 Apr 2014 194 121 168 108
11 Apr 2014 184 114 26 13
10 Apr 2014 183 113 25 12
9 Apr 2014 179 111 158 101
7 Apr 2014 172 105 151 95 21 10
(-2)
1 Apr 2014 135 88 127 83 8
+0
5
+1
31 Mar 2014 130 82 122 80 8 2
29 Mar 2014 114 71 2
↓5
1
↓1
28 Mar 2014 120 76 112 70 (2) (2)
27 Mar 2014 111 72 103 66 8 6 (6) (5)
26 Mar 2014 86 62 86 62
25 Mar 2014 86 60 86 60
24 Mar 2014 86 59 86 59
22 Mar 2014 49 29 49 29

References

History

For more about the outbreak in Virginia, US, see Reston virus.

Cases of ebola fever in Africa from 1979 to 2008.

Ebola virus was first isolated in 1976 during outbreaks of Ebola hemorrhagic fever in Zaire[117] andSudan.[118] The strain of Ebola that broke out in Zaire has one of the highest case fatality rates of any human virus, roughly 90%.[119]

The name of the disease originates from one of those first recorded outbreaks in 1976 in Yambuku, Democratic Republic of the Congo (then Zaire), which lies on the Ebola River.[117]

While investigating an outbreak of Simian hemorrhagic fever virus (SHFV) in November 1989, an electron microscopist from USAMRIID discovered filoviruses similar in appearance to Ebola in tissue samples taken from crab-eating macaque imported from the Philippines to Hazleton Laboratories Reston, Virginia.[120] Blood samples were taken from 178 animal handlers during the incident.[121] Of those, six animal handlers eventually seroconverted. When the handlers did not become ill, the CDC concluded that the virus had a very low pathogenicity to humans.[122]

In 1990, Hazelton Research Products’ Reston Quarantine Unit in Reston, Virginia suffered a mysterious outbreak of fatal illness among a shipment of crab-eating macaque monkeys imported from the Philippines. The company’s veterinary pathologist sent tissue samples from dead animals to the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick, Maryland, where a laboratory test known as an ELISA assay showed antibodies to Ebola virus.

Shortly afterward, a US Army team headquartered at USAMRIID went into action to euthanize the monkeys which had not yet died, bringing those monkeys and those which had already died of the disease to Ft. Detrick for study by the Army’s veterinary pathologists and virologists, and eventual disposal under safe conditions.

The Philippines and the United States had no previous cases of Ebola infection, and upon further isolation researchers concluded it was another strain of Ebola, or a new filovirus of Asian origin, which they named Reston ebolavirus (REBOV) after the location of the incident.[123]

Some scientists also believe that the Plague of Athens, which wiped out about a third of its inhabitants during the Peloponnesian War, may have been caused by Ebola. However, these studies are conflicting, and point to other possible diseases such as typhoid.[124]

Society and culture

Given the lethal nature of Ebola, and since no approved vaccine or treatment is available, it is classified as a biosafety level 4 agent, as well as a Category A bioterrorism agent by the Centers for Disease Control and Prevention. It has the potential to be weaponized for use in biological warfare.[125][126]

Other animals

In general, outbreaks of EVD among human populations result from handling infected wild animal carcasses. In general, declines in animal populations precede outbreaks among human populations. Since 2003, such declines have been monitored through surveillance of animal populations with the aim of predicting and preventing EVD outbreaks in humans.[127] Recovered carcasses from gorillas contain multiple Ebola virus strains, which suggest multiple introductions of the virus. Bodies decompose quickly and carcasses are not infectious after three to four days. Contact between gorilla groups is rare, suggesting transmission among gorilla groups is unlikely, and that outbreaks result from transmission between viral reservoir and animal populations.[128]

Ebola has a high mortality among primates.[129] Frequent outbreaks of Ebola may have resulted in the deaths of 5,000 gorillas.[130] Outbreaks of EVD may have been responsible for an 88% decline in tracking indices of observed chimpanzee populations in 420 square kilometer Lossi Sanctuary between 2002 and 2003.[128]Transmission among chimpanzees through meat consumption constitutes a significant risk factor, while contact between individuals, such as touching dead bodies and grooming is not.[131]

Domestic animals

Ebola virus can be transmitted to dogs and pigs.[132] While dogs may be asymptomatic, pigs tend to develop symptomatic disease.

Research

Medications

Favipiravir looks like it may be useful in a mouse model of the disease.[13] Estrogen receptor drugs used to treat infertility and breast cancer (clomiphene andtoremifene) inhibit the progress of Ebola virus in infected mice.[133] Ninety percent of the mice treated with clomiphene and fifty percent of those treated with toremifene survived the tests.[133] Given their oral availability and history of human use, these drugs would be candidates for treating Ebola virus infection in remote geographical locations, either on their own or together with other antiviral drugs.

Human antibodies

Researchers looking at slides of cultures of cells that make monoclonal antibodies. These are grown in a lab and the researchers are analyzing the products to select the most promising of them.

During an outbreak 1999 in the Democratic Republic of the Congo, seven of eight people who received blood transfusions from individuals who had previously survived the infection survived themselves.[134] However, this potential treatment is considered controversial.[135] Intravenous antibodies appear to be protective in non-human primates who have been exposed to large doses of ebola.[136]

ZMapp antibody treatment

In August of 2014 an experimental treatment based on plants was used for the first time in two humans. The treatment drug was referred to as ZMapp, an antibody response related therapy. The initially response appears positive. ZMapp was produced by MAPP Biopharmaceutical Inc. using a three-mouse monoclonal antibody, manufactured in genetically modified tobacco plants (of the genus Nicotiana).[137][138] In the three-mouse drug production process, mice were exposed to three different fragments of the virus strain and antibodies were harvested to create the medicine.[139][140] In 2013, these antibodies, were effective when given within a day of exposure primates other than humans.[141]

Other treatments

Other promising treatments rely on antisense technology. Both small interfering RNAs (siRNAs) and phosphorodiamidate morpholino oligomers (PMOs) targeting the Zaire Ebola virus (ZEBOV) RNA polymerase L protein could prevent disease in nonhuman primates.[142][143]