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Deadliest outbreak of Ebola virus: What you need to know

  By Susannah Cullinane and Nick Thompson

(CNN) -- The deadliest outbreak of Ebola virus on record has sparked fears that the killer virus could spread from West Africa to other regions and continents.
The outbreak began with just a handful of cases in Guinea in March. Since then, that number has grown to 909 confirmed cases and another 414 probable or suspected in that country, Sierra Leone and Liberia and Nigeria, according to the World Health Organization.
Some 729 people of the 1,323 total confirmed and possible infections have died, reports WHO as of July 27.
The WHO says "drastic action is needed" to contain Ebola, warning that previously undetected chains of transmission are boosting the numbers of sick and increasing the chances that the disease spreads from Africa.
"This epidemic is without precedent," said Bart Janssens, director of operations for Médecins Sans Frontières, also known as Doctors Without Borders. "It's absolutely not under control, and the situation keeps worsening. ... There are many places where people are infected but we don't know about it."
What's the latest?
The Ebola outbreak has been centered in Guinea, Sierra Leone and Liberia, where authorities have been working to contain the virus.
In Liberia, President Ellen Johnson Sirleaf announced Wednesday that, "without exceptions, all schools are ordered closed pending further directive from the Ministry of Education." She also declared Friday a nonworking day "to be used for the disinfection and chlorination of all public facilities."
On the same day, the Peace Corps said it was temporarily removing its 340 volunteers from Liberia, Sierra Leone and Guinea due to the outbreak.
The announcement comes as two Peace Corps volunteers were isolated after coming in contact with someone who ended up dying of Ebola, a spokeswoman for the group said. She said these two Americans "are not symptomatic," and the Peace Corps will work to return them to the United States once they get medical clearance to travel.
Concerns about Ebola aren't confined to those three countries.
Last week, a Liberian government official who had contracted the virus died in isolation at a hospital in Lagos, Nigeria.
Patrick Sawyer, a naturalized American citizen who worked in Liberia, flew to Nigeria intending to attend a conference. After exhibiting symptoms upon arrival July 20, he was hospitalized and died on July 25. He's the first American to die in the outbreak, though two other U.S. aid workers in Liberia have contracted Ebola and are being treated.
Sawyer's was the only known case in Nigeria, WHO said.
And the British government convened an emergency meeting to discuss the threat of Ebola to the UK, even though no case has been reported there. Officials discussed what measures could be taken if UK nationals in West Africa should become infected, Foreign Secretary Philip Hammond said.
Why was someone infected with Ebola allowed on a plane?
It is unknown whether Sawyer was displaying symptoms before he flew from Monrovia, Liberia's capital, to Ghana and then to Togo to switch planes to fly to Lagos.
His Minnesota-based widow, Decontee Sawyer, told CNN that he had cared for his ill sister in Liberia, though she said he didn't know at the time that his sister had Ebola. When he arrived in Nigeria, he told officials that he had no direct contact with anyone who had the disease.
Because it takes between two and 21 days before Ebola symptoms to show, there's little health officials can do to stop an asymptomatic person from flying to another country, said CNN Chief Medical Correspondent Sanjay Gupta.
So, serious viruses such as Ebola may be just "a plane ride away" from reaching the developed world, according to Marty Cetron of the U.S. Centers for Disease Control and Prevention (CDC).
Mindful of this, Nigeria-based airline companies ASKY and Arik Airsuspended operations at the end of July into Monrovia and Freetown, the capitals of Liberia and Sierra Leone, respectively. ASKY said passengers departing from Conakry, Guinea, would be screened for signs of the virus.
Cetron says it is unlikely the virus would spread on an airplane unless a passenger were to come into contact with a sick person's bodily fluids.
Stressing the key role that those working at airports play in keeping Ebola in check, the CDC spokesman said: "Being educated, knowing the symptoms, recognizing what to do, having a response to protocol, knowing who to call -- those are really, really important parts of the global containment strategies to deal with threats like this."
What else is being done to stop the spread of the disease?
Ebola patients are being isolated by health officials in West Africa, and those who have come into contact with them are being told to monitor their temperatures.
President Sirleaf has closed most of Liberia's borders with neighboring countries, and the few points of entry that are still open will have Ebola testing centers. The President also placed restrictions on public gatherings and ordered hotels, restaurants and other entertainment venues to play a five-minute video on Ebola safety.
The CDC has issued an alert to health workers in the United States to watch out for any patients who may have recently traveled to West Africa and could have contracted the virus.
Why does Ebola generate such fear?
"It is a highly infectious virus that can kill up to 90% of the people who catch it, causing terror among infected communities," it says. The death rate in this outbreak has dropped to roughly 55% because of early treatment.
There is also no vaccination against it.
Of Ebola's five subtypes, the Zaire strain -- the first to be identified -- is considered the most deadly.
The WHO said preliminary tests on the Ebola virus in Guinea in March suggested that the outbreak there was this strain, though that has not been confirmed.
What is Ebola, and what are its symptoms?
The Ebola virus causes viral hemorrhagic fever, whichaccording to the U.S. Centers for Disease Control and Prevention (CDC), refers to a group of viruses that affect multiple organ systems in the body and are often accompanied by bleeding.
The virus is named after the Ebola River in the Democratic Republic of Congo (formerly Zaire), where one of the first outbreaks occurred in 1976.
Early symptoms include sudden onset of fever, weakness, muscle pain, headaches and a sore throat. These symptoms can appear two to 21 days after infection.
The WHO says these nonspecific early symptoms can be mistaken for signs of diseases such as malaria, typhoid fever, meningitis or even the plague.
MSF says some patients may also develop a rash, red eyes, hiccups, chest pains and difficulty breathing and swallowing.
The early symptoms progress to vomiting, diarrhea, impaired kidney and liver function and sometimes internal and external bleeding.
Ebola can only be definitively confirmed by five different laboratory tests.
How is it treated?
There are no specific treatments for Ebola. MSF says patients are isolated and then supported by health care workers.
"This consists of hydrating the patient, maintaining their oxygen status and blood pressure and treating them for any complicating infections," it says.
There have been cases of healthcare workers contracting the virus from patients, and the WHO has issued guidance for dealing with confirmed or suspected cases of the virus.
Carers are advised to wear impermeable gowns and gloves and to wear facial protection such as goggles or a medical mask to prevent splashes to the nose, mouth and eyes.
MSF says it contained a 2012 outbreak in Uganda by placing a control area around its treatment center. An outbreak is considered over once 42 days -- double the incubation period of the disease -- have passed without any new cases.
How does it spread?
The WHO says it is believed that fruit bats may be the natural host of the Ebola virus in Africa, passing on the virus to other animals.
Humans contract Ebola through contact with the bodily fluids of infected animals or the bodily fluids of infected humans.
MSF says that while the virus is believed to be able to survive for some days in liquid outside an infected organism, chlorine disinfection, heat, direct sunlight, soaps and detergents can kill it.
MSF epidemiologist Kamiliny Kalahne said outbreaks usually spread in areas where hospitals have poor infection control and limited access to resources such as running water.
"People who become sick with it almost always know how they got sick: because they looked after someone in their family who was very sick -- who had diarrhea, vomiting and bleeding -- or because they were health staff who had a lot of contact with a sick patient," she said.

At least 16 Ebola cases have been treated outside of West Africa in the current outbreak, including a Dallas hospital worker who tested positive for Ebola on Saturday. Most of these involve health and aid workers who contracted Ebola in West Africa and were transported back to their home country for treatment. Three cases were diagnosed outside of West Africa: A Liberian man who began showing symptoms four days after arriving in Dallas, a Spanish nurse who became ill after treating a missionary in a Madrid hospital and the Dallas hospital worker who was involved in the treatment of a Liberian patient infected with Ebola. These cases are compiled from reports by the federal Centers for Disease Control and Prevention, the World Health Organization, Doctors Without Borders and other official agencies.

 Recovered  In treatment  Died
Nebraska Medical Center
A Spanish nurse contracted Ebola while treating
a missionary who died in a Madrid Hospital.
Emory University Hospital
Sunday A hospital worker involved in the treatment of an Ebola patient from Liberia has tested positive for the disease.
Countries with Ebola outbreaks
Cases of Ebola Outside of West Africa
As of Oct. 12, 2014
United States
Arrival date
Arrival date
Aid worker
NBC cameraman
Hospital worker
Aug. 2
Aug. 2
Sept. 5
Sept. 9
Sept. 30*
Oct. 6
Oct. 11*
In treatment
In treatment
In treatment
Aug. 7
Sept. 22
Oct. 6*
In treatment
U.N. medical worker
Aug. 27
Oct. 3
Oct. 9
In treatment
In treatment
Sept. 19
Aid worker
Oct. 6
In treatment
Aug. 24
*Date of Ebola diagnosis.

The Centers for Disease Control and Prevention has sent experts to Texas to trace anyone who may have come in contact with Thomas E. Duncan, a Liberian who traveled to Dallas, while he was contagious.

Health officials use contact tracing to identify and monitor everyone who might have been exposed to the patient during the time he was contagious. If infected, most people develop symptoms within eight to 10 days of being exposed. Anyone who starts running a fever or having symptoms is isolated and tested for Ebola. If the test is positive, that person is kept in isolation and treated, and his or her contacts are then traced for 21 days. The process is repeated until there are no new cases.

Federal officials announced on Oct. 8 that passengers from West Africa arriving at five American airports will be screened for fever. About 90 percent of the people arriving from the main countries stricken with Ebola come through the five airports: Kennedy International, Washington Dulles International, O’Hare International, Hartsfield-Jackson International and Newark Liberty International. Screenings began at Kennedy Airport in New York on Oct 11. The new procedures will begin at the other four airports later this week.

Officials have emphasized that there is no risk of transmission from people who have been exposed to the virus but are not yet showing symptoms. Dr. Thomas R. Frieden, director of the federal Centers for Disease Control and Prevention, said on Oct. 2 that the odds of contracting Ebola in the United States were extremely low.

Ebola spreads through direct contact with body fluids. If an infected person’s blood or vomit gets in another person’s eyes, nose or mouth, the virus may be transmitted. Although Ebola does not cause respiratory problems, a cough from a sick person could infect someone who has been sprayed with saliva. Because of that, being within three feet of a patient for a prolonged time without protective clothing is considered to be direct contact. Specialists at Emory University Medical Center in Atlanta have also found that the virus is present on a patient’s skin after symptoms develop, underlining how contagious the disease is once symptoms set in.

The virus can survive for several hours on surfaces, so any object contaminated with bodily fluids may spread the disease. According to the C.D.C., the virus can survive for a few hours on dry surfaces like doorknobs and countertops and can survive for several days in puddles or other collections of body fluid. Bleach solutions can kill it.

In the current outbreak, most new cases are occurring among people who have been taking care of sick relatives or who have prepared an infected body for burial. Health care workers are at high risk.

Mr. Duncan, who traveled to Dallas from Liberia, was diagnosed with Ebola on Sept. 30. He died on Oct. 8. So far, none of the nearly 50 people who may have been exposed to the virus in Dallas have shown signs of illness.

Sept. 19
After being
checked for
man boards
flight from
Man arrives in
Dallas to visit
Man begins
to develop
Man seeks
care at Dallas
hospital but
is sent home.
Oct. 1
Man is admitted to Dallas hospital and is placed in isolation.
C.D.C. confirms that man’s blood is positive for
Man dies.

There are currently no drugs or vaccines approved by the Food and Drug Administration to treat or prevent Ebola, and in past outbreaks the virus has been fatal in 60 percent to 90 percent of cases. An experimental drug called ZMapp might help infected patients, but the drug is unproven and only available in limited quantities. The World Health Organization suggests that blood from Ebola survivors might be used to treat others, but there is no proof that such a treatment alone would work.

The United States government plans to fast-track development of a vaccine shown to protect macaque monkeys, but there is no guarantee it will be effective in humans. Beyond this, all physicians can do is try to nurse people through the illness, using fluids and medicines to maintain blood pressure, and treat other infections that often strike their weakened bodies. A small percentage of people appear to have an immunity to the Ebola virus.

The Ebola virus infects cells by punching into the cell and injecting a small piece of viral RNA. The RNA hijacks the machinery of the cell and uses it to create more copies of the Ebola virus, which in turn infect other cells.
Ebola survivors have antibodies against the Ebola virus in their blood. Antibodies are Y-shaped proteins that can latch on to a specific virus and prevent it from infecting cells. Plasma extracted from the blood of Ebola survivors might be transfused into infected people, possibly helping them fight the infection.
The drug ZMapp is a mixture of three different antibodies that were developed in mice and modified to work in humans. The drug was first tested in humans during the current outbreak, but it is unclear if the drug is effective. ZMapp is made in tobacco plants and there is only limited manufacturing capacity.
Correction: An earlier version of this graphic referred incorrectly to the structure that encloses human cells. It is the cell membrane, not the cell wall.

Symptoms usually begin about eight to 10 days after exposure to the virus, but can appear as late as 21 days after exposure, according to the C.D.C. At first, it seems much like the flu: a headache, fever and aches and pains. Sometimes there is also a rash. Diarrhea and vomiting follow. 

Then, in about half of the cases, Ebola takes a severe turn, causing victims to hemorrhage. They may vomit blood or pass it in urine, or bleed under the skin or from their eyes or mouths. But bleeding is not usually what kills patients. Rather, blood vessels deep in the body begin leaking fluid, causing blood pressure to plummet so low that the heart, kidneys, liver and other organs begin to fail.


Three American health workers, Dr. Kent Brantly, Nancy Writebol and Dr. Rick Sacra, contracted Ebola in Liberia, were treated in the United States and later released. Another American, who has not been identified, contracted Ebola in Sierra Leone and is being treated at Emory University Hospital in Atlanta. The fifth American, Ashoka Mukpo, is a freelance cameraman for NBC who was filming in Liberia. He arrived at the Nebraska Medical Center on Monday.

More than 8,000 people in Guinea, Liberia, Nigeria, Senegal and Sierra Leone have contracted Ebola since March, according to the World Health Organization, making this the biggest outbreak on record.More than 3,800 people have died.
8001,6002,4003,2004,000MAR 21OCT 8768deaths1,298casesGuinea8001,6002,4003,2004,000MAR 21OCT 82,210deaths3,924casesLiberia8001,6002,4003,2004,000MAR 21OCT 8879deaths2,789casesSierra Leone8001,6002,4003,2004,000MAR 218deaths20casesNigeria

The disease continues to spread in Guinea, Liberia and Sierra Leone. The C.D.C. said Tuesday that Nigeria appears to have contained its outbreak.

500 or more
Atlantic Ocean
150 Miles
Source: USAID
Note: Areas affected as of Sept. 29

The Centers for Disease Control and Prevention said on Sept. 23 that in a worst-case scenario, cases could reach 1.4 million in four months. The centers' model is based on data from August and includes cases in Liberia and Sierra Leone, but not Guinea (where counts have been unreliable).

Estimates are in line with those made by other groups like the World Health Organization, though the C.D.C. has projected further into the future and offered ranges that account for underreporting of cases.

Cumulative cases in Liberia and Sierra Leone

Best-case scenario
Worst-case scenario
11,000-27,000 cases through Jan. 20
537,000-1.4 million cases through Jan. 20
Assumes 70 percent of patients are treated in settings that confine the illness and that the dead are buried safely. About 18 percent of patients in Liberia and 40 percent in Sierra Leone are being treated in appropriate settings.
If the disease continues spreading without effective intervention. Dr. Thomas R. Frieden, the C.D.C. director, said, “My gut feeling is, the actions we’re taking now are going to make that worst-case scenario not come to pass. But it’s important to understand that it could happen.”
Source: Centers for Disease Control and Prevention

President Obama announced Sept. 16 an expansion of military and medical resources to combat the outbreak, including the deployment of as many as 4,000 American military personnel to Liberia and Senegal. He said the United States would help Liberia in the construction of more than 17 Ebola treatment centers in the region, with about 1,700 beds, and would also open a joint command operation to coordinate the international effort to combat the disease. But military planners say construction of the centers have been delayed because of the difficulty in getting heavy equipment to the areas.

It is the deadliest, eclipsing an outbreak in 1976, the year the virus was discovered.

Ebola cases and deaths by year, and countries affected
2nd-worst year
Sudan, Democratic Republic of Congo
Democratic Republic of Congo
Uganda, Democratic Republic of Congo
Guinea, Liberia, Nigeria, Senegal and Sierra Leone
602 cases
431 deaths
315 cases
254 deaths
425 cases
224 deaths
413 cases
224 deaths
6,553 cases
3,083 deaths
as of Sept. 26
Source: World Health Organization

The epidemic is growing faster than efforts to keep up with it, and it will take months before governments and health workers in the region can get the upper hand, according to Doctors Without Borders.

In some parts of West Africa, there is a belief that simply saying “Ebola” aloud makes the disease appear. Such beliefs have created major obstacles for physicians trying to combat the outbreak. Some people have even blamed physicians for the spread of the virus, opting to turn to witch doctors for treatment instead. Their skepticism is not without a grain of truth: In past outbreaks, hospital staff members who did not take thorough precautions became unwitting travel agents for the virus.

Ahmed Jallanzo/European Pressphoto Agency
Liberian health workers on the way to bury a woman who died of the Ebola virus.

Ebola was discovered in 1976, and it was once thought to originate in gorillas, because human outbreaks began after people ate gorilla meat. But scientists have since ruled out that theory, partly because apes that become infected are even more likely to die than humans. 

Scientists now believe that bats are the natural reservoir for the virus, and that apes and humans catch it from eating food that bats have drooled or defecated on, or by coming in contact with surfaces covered in infected bat droppings and then touching their eyes or mouths. 

The current outbreak seems to have started in a village near Guéckédou, Guinea, where bat hunting is common, according to Doctors Without Borders.

The biggest headlines have tended to involve outbreaks of deadly viruses that medical workers have few, if any, tools to combat. The four most prominent are compared below. No cure is known for any of them, nor has any vaccine yet been approved for human use.

Emerged / identified1976; latest outbreak in 20141967; latest major outbreak in 20052012-20132002-2003
LocusOriginally, Congo Basin and central Africa; latest strain, West AfricaOriginally, central Europe; latest major outbreak, AngolaArabian peninsulaSouthern China
Suspected sourceFruit bats, by way of monkeys and other animalsFruit bats, sometimes by way of monkeysBats, by way of camelsBats, by way of civets
Type of virusFilovirusFilovirusCoronavirusCoronavirus
Type of illnessHemorrhagic feverHemorrhagic feverRespiratory syndromeRespiratory syndrome
Fatality rate in outbreaks50% to 90%24% to 88%About 30%About 10%
Known cases4,000+570+830+8,200+
Known deaths2700+470+290+775+
Person-to-person transmissionReadily by close contact or fluids; not by aerosolReadily by close contact or fluids; not by aerosolNot very readily; mechanism unclearVery readily by aerosol, fluids or close contact
Note: On Sept. 30, officials with the federal Centers for Disease Control and Prevention said Mr. Duncan first went to the hospital on Sept. 26. On Oct. 1, the Texas Health Presbyterian Hospital issued a statement that he first arrived there after 10 p.m. on Sept. 25.
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