EBOLA VIRUS DISEASE (EVD), also known as EBOLA HEMORRHAGIC FEVER
(EHF) or simply EBOLA, is a viral hemorrhagic fever of humans and
other primates caused by ebolaviruses . Signs and symptoms typically
start between two days and three weeks after contracting the virus
with a fever , sore throat , muscular pain , and headaches . Then,
vomiting , diarrhea and rash usually follow, along with decreased
function of the liver and kidneys . At this time, some people begin
to bleed both internally and externally. The disease has a high risk
of death, killing between 25 and 90 percent of those infected, with an
average of about 50 percent. This is often due to low blood pressure
from fluid loss , and typically follows six to sixteen days after
The virus spreads by direct contact with body fluids , such as blood
, of an infected human or other animals. This may also occur through
contact with an item recently contaminated with bodily fluids. Spread
of the disease through the air between primates, including humans, has
not been documented in either laboratory or natural conditions. Semen
or breast milk of a person after recovery from EVD may carry the virus
for several weeks to months. Fruit bats are believed to be the
normal carrier in nature , able to spread the virus without being
affected by it. Other diseases such as malaria , cholera , typhoid
fever , meningitis and other viral hemorrhagic fevers may resemble
Blood samples are tested for viral
RNA , viral antibodies or for
the virus itself to confirm the diagnosis.
Control of outbreaks requires coordinated medical services, alongside
a certain level of community engagement. The medical services include
rapid detection of cases of disease, contact tracing of those who have
come into contact with infected individuals, quick access to
laboratory services, proper healthcare for those who are infected, and
proper disposal of the dead through cremation or burial. Samples of
body fluids and tissues from people with the disease should be handled
with special caution. Prevention includes limiting the spread of
disease from infected animals to humans. This may be done by handling
potentially infected bushmeat only while wearing protective clothing
and by thoroughly cooking it before eating it. It also includes
wearing proper protective clothing and washing hands when around a
person with the disease. No specific treatment or vaccine for the
virus is available, although a number of potential treatments are
being studied. Supportive efforts, however, improve outcomes. This
includes either oral rehydration therapy (drinking slightly sweetened
and salty water) or giving intravenous fluids as well as treating
The disease was first identified in 1976 in two simultaneous
outbreaks, one in
Nzara , and the other in
Yambuku , a village near
Ebola River from which the disease takes its name. EVD outbreaks
occur intermittently in tropical regions of sub-Saharan Africa .
Between 1976 and 2013, the
World Health Organization reports a total
of 24 outbreaks involving 1,716 cases. The largest outbreak to date
was the epidemic in West Africa , which occurred from December 2013 to
January 2016 with 28,616 cases and 11,310 deaths. It was declared
no longer an emergency on 29 March 2016. Another outbreak in Africa
began in May 2017 in the
Democratic Republic of the Congo
Democratic Republic of the Congo .
* 1 Signs and symptoms
* 1.1 Onset
* 1.3 Recovery and death
* 2 Cause
* 2.1 Virology
* 2.2 Transmission
* 2.3 Initial case
* 2.4 Reservoir
* 3 Pathophysiology
* 3.1 Immune system evasion
* 4 Diagnosis
* 4.1 Laboratory testing
* 5 Prevention
* 5.1 Infection control
* 5.2 Putting on protective equipment
* 5.3 Isolation
* 6 Management
* 6.1 Standard support
* 7 Prognosis
* 8 Epidemiology
* 8.1 2013–2016 West African outbreak
* 8.1.1 2014 Ebola spread outside West Africa
* 8.2 1995 to 2014
* 8.3 1976
* 9 Society and culture
* 9.1 Weaponization
* 9.2 Literature
* 10 Other animals
* 10.1 Wild animals
* 10.2 Domestic animals
* 11 Research
* 11.1 Treatments
* 11.2 Vaccines
* 11.3 Diagnostic tests
* 12 See also
* 13 References
* 14 External links
SIGNS AND SYMPTOMS
Signs and symptoms of Ebola
The length of time between exposure to the virus and the development
of symptoms (incubation period ) is between 2 and 21 days, and
usually between 4 and 10 days. However, recent estimates based on
mathematical models predict that around 5% of cases may take greater
than 21 days to develop.
Symptoms usually begin with a sudden influenza -like stage
characterized by feeling tired , fever , weakness , decreased appetite
, muscular pain , joint pain , headache, and sore throat. The
fever is usually higher than 38.3 °C (101 °F). This is often
followed by vomiting, diarrhea and abdominal pain. Next, shortness of
breath and chest pain may occur, along with swelling , headaches and
confusion . In about half of the cases, the skin may develop a
maculopapular rash , a flat red area covered with small bumps, 5 to 7
days after symptoms begin.
In some cases, internal and external bleeding may occur. This
typically begins five to seven days after the first symptoms. All
infected people show some decreased blood clotting .
mucous membranes or from sites of needle punctures has been reported
in 40–50 percent of cases. This may cause vomiting blood , coughing
up of blood , or blood in stool .
Bleeding into the skin may create
petechiae , purpura , ecchymoses or hematomas (especially around
needle injection sites).
Bleeding into the whites of the eyes may
also occur. Heavy bleeding is uncommon; if it occurs, it is usually
located within the gastrointestinal tract .
RECOVERY AND DEATH
Recovery may begin between 7 and 14 days after first symptoms.
Death, if it occurs, follows typically 6 to 16 days from first
symptoms and is often due to low blood pressure from fluid loss . In
general, bleeding often indicates a worse outcome, and blood loss may
result in death. People are often in a coma near the end of life.
Those who survive often have ongoing muscular and joint pain, liver
inflammation , decreased hearing, and may have continued tiredness,
continued weakness, decreased appetite, and difficulty returning to
pre-illness weight. Problems with vision may develop.
Additionally, survivors develop antibodies against Ebola that last at
least 10 years, but it is unclear if they are immune to repeated
EVD in humans is caused by four of five viruses of the genus
Ebolavirus . The four are
Bundibugyo virus (BDBV),
Sudan virus (SUDV),
Taï Forest virus (TAFV) and one simply called
Ebola virus (EBOV,
Zaire Ebola virus). EBOV, species
Zaire ebolavirus , is the
most dangerous of the known EVD-causing viruses, and is responsible
for the largest number of outbreaks. The fifth virus, Reston virus
(RESTV), is not thought to cause disease in humans, but has caused
disease in other primates. All five viruses are closely related to
Ebolavirus (taxonomic group) and
Ebola virus (specific
Electron micrograph of an
Ebola virus virion
Ebolaviruses contain single-stranded, non-infectious
RNA genomes .
Ebolavirus genomes contain seven genes including 3\'-UTR
-NP-VP35-VP40-GP-VP30-VP24-L-5\'-UTR . The genomes of the five
different ebolaviruses (BDBV, EBOV, RESTV, SUDV and TAFV) differ in
sequence and the number and location of gene overlaps. As with all
filoviruses , ebolavirus virions are filamentous particles that may
appear in the shape of a shepherd's crook, of a "U" or of a "6," and
they may be coiled, toroid or branched. In general, ebolavirions are
80 nanometers (nm) in width and may be as long as 14,000 nm.
Their life cycle is thought to begin with a virion attaching to
specific cell-surface receptors such as C-type lectins ,
DC-SIGN , or
integrins , which is followed by fusion of the viral envelope with
cellular membranes . The virions taken up by the cell then travel to
acidic endosomes and lysosomes where the viral envelope glycoprotein
GP is cleaved. This processing appears to allow the virus to bind to
cellular proteins enabling it to fuse with internal cellular membranes
and release the viral nucleocapsid . The
glycoprotein (known as GP1,2) is responsible for the virus' ability to
bind to and infect targeted cells. The viral
RNA polymerase , encoded
by the L gene, partially uncoats the nucleocapsid and transcribes the
genes into positive-strand mRNAs , which are then translated into
structural and nonstructural proteins. The most abundant protein
produced is the nucleoprotein, whose concentration in the host cell
determines when L switches from gene transcription to genome
replication. Replication of the viral genome results in full-length,
positive-strand antigenomes that are, in turn, transcribed into genome
copies of negative-strand virus progeny. Newly synthesized structural
proteins and genomes self-assemble and accumulate near the inside of
the cell membrane . Virions bud off from the cell, gaining their
envelopes from the cellular membrane from which they bud. The mature
progeny particles then infect other cells to repeat the cycle. The
genetics of the
Ebola virus are difficult to study because of EBOV's
Life cycles of the
It is believed that between people, Ebola disease spreads only by
direct contact with the blood or other body fluids of a person who has
developed symptoms of the disease. Body fluids that may contain
Ebola viruses include saliva, mucus, vomit, feces, sweat, tears,
breast milk, urine and semen . The
WHO states that only people who
are very sick are able to spread Ebola disease in saliva , and whole
virus has not been reported to be transmitted through sweat. Most
people spread the virus through blood, feces and vomit. Entry points
for the virus include the nose, mouth, eyes, open wounds, cuts and
abrasions. Ebola may be spread through large droplets ; however, this
is believed to occur only when a person is very sick. This
contamination can happen if a person is splashed with droplets.
Contact with surfaces or objects contaminated by the virus,
particularly needles and syringes, may also transmit the infection.
The virus is able to survive on objects for a few hours in a dried
state, and can survive for a few days within body fluids outside of a
Ebola virus may be able to persist for more than 3 months in the
semen after recovery, which could lead to infections via sexual
intercourse . Virus persistence in semen for over a year has been
recorded in a national screening programme. Ebola may also occur in
the breast milk of women after recovery, and it is not known when it
is safe to breastfeed again. The virus was also found in the eye of
one patient in 2014, two months after it was cleared from his blood.
Otherwise, people who have recovered are not infectious.
The potential for widespread infections in countries with medical
systems capable of observing correct medical isolation procedures is
considered low. Usually when someone has symptoms of the disease,
they are unable to travel without assistance.
Dead bodies remain infectious; thus, people handling human remains in
practices such as traditional burial rituals or more modern processes
such as embalming are at risk. 69% of the cases of Ebola infections
Guinea during the 2014 outbreak are believed to have been
contracted via unprotected (or unsuitably protected) contact with
infected corpses during certain Guinean burial rituals.
Health-care workers treating people with Ebola are at greatest risk
of infection. The risk increases when they do not have appropriate
protective clothing such as masks, gowns, gloves and eye protection;
do not wear it properly; or handle contaminated clothing incorrectly.
This risk is particularly common in parts of Africa where the disease
mostly occurs and health systems function poorly. There has been
transmission in hospitals in some African countries that reuse
hypodermic needles. Some health-care centers caring for people with
the disease do not have running water. In the
United States the
spread to two medical workers treating infected patients prompted
criticism of inadequate training and procedures.
Human-to-human transmission of
EBOV through the air has not been
reported to occur during EVD outbreaks, and airborne transmission has
only been demonstrated in very strict laboratory conditions, and then
only from pigs to primates , but not from primates to primates.
EBOV by water, or food other than bushmeat, has not been
observed. No spread by mosquitos or other insects has been reported.
Other possible methods of transmission are being studied.
The apparent lack of airborne transmission among humans is believed
to be due to low levels of the virus in the lungs and other parts of
the respiratory system of primates, insufficient to cause new
infections. A number of studies examining airborne transmission
broadly concluded that transmission from pigs to primates could happen
without direct contact because, unlike humans and primates, pigs with
EVD get very high ebolavirus concentrations in their lungs, and not
their bloodstream. Therefore, pigs with EVD can spread the disease
through droplets in the air or on the ground when they sneeze or
cough. By contrast, humans and other primates accumulate the virus
throughout their body and specifically in their blood, but not very
much in their lungs. It is believed that this is the reason
researchers have observed pig to primate transmission without physical
contact, but no evidence has been found of primates being infected
without actual contact, even in experiments where infected and
uninfected primates shared the same air.
Bushmeat being prepared for cooking in
Ghana . In Africa, wild
animals including fruit bats are hunted for food and are referred to
as bushmeat. In equatorial Africa, human consumption of bushmeat has
been linked to animal-to-human transmission of diseases, including
Although it is not entirely clear how Ebola initially spreads from
animals to humans, the spread is believed to involve direct contact
with an infected wild animal or fruit bat. Besides bats, other wild
animals sometimes infected with
EBOV include several monkey species,
chimpanzees, gorillas, baboons and duikers .
Animals may become infected when they eat fruit partially eaten by
bats carrying the virus. Fruit production, animal behavior and other
factors may trigger outbreaks among animal populations.
Evidence indicates that both domestic dogs and pigs can also be
infected with EBOV. Dogs do not appear to develop symptoms when they
carry the virus, and pigs appear to be able to transmit the virus to
at least some primates. Although some dogs in an area in which a
human outbreak occurred had antibodies to EBOV, it is unclear whether
they played a role in spreading the disease to people.
The natural reservoir for Ebola has yet to be confirmed; however,
bats are considered to be the most likely candidate species. Three
types of fruit bats (
Hypsignathus monstrosus ,
Epomops franqueti and
Myonycteris torquata ) were found to possibly carry the virus without
getting sick. As of 2013 , whether other animals are involved in its
spread is not known. Plants, arthropods and birds have also been
considered possible viral reservoirs.
Bats were known to roost in the cotton factory in which the first
cases of the 1976 and 1979 outbreaks were observed, and they have also
been implicated in
Marburg virus infections in 1975 and 1980. Of 24
plant and 19 vertebrate species experimentally inoculated with EBOV,
only bats became infected. The bats displayed no clinical signs of
disease, which is considered evidence that these bats are a reservoir
species of EBOV. In a 2002–2003 survey of 1,030 animals including
679 bats from
Gabon and the
Republic of the Congo
Republic of the Congo , 13 fruit bats were
found to contain
Zaire and Reston
viruses have been found in fruit bats in
Bangladesh , suggesting that
these bats are also potential hosts of the virus and that the
filoviruses are present in Asia.
Between 1976 and 1998, in 30,000 mammals, birds, reptiles, amphibians
and arthropods sampled from regions of
EBOV outbreaks, no Ebola virus
was detected apart from some genetic traces found in six rodents
(belonging to the species
Mus setulosus and
Praomys ) and one shrew
Sylvisorex ollula ) collected from the
Central African Republic
Central African Republic .
However, further research efforts have not confirmed rodents as a
reservoir. Traces of
EBOV were detected in the carcasses of gorillas
and chimpanzees during outbreaks in 2001 and 2003, which later became
the source of human infections. However, the high rates of death in
these species resulting from
EBOV infection make it unlikely that
these species represent a natural reservoir for the virus.
Similar to other filoviruses,
EBOV replicates very efficiently in
many cells , producing large amounts of virus in monocytes ,
macrophages , dendritic cells and other cells including liver cells ,
fibroblasts , and adrenal gland cells . Viral replication triggers
the release of high levels of inflammatory chemical signals and leads
to a septic state .
EBOV is thought to infect humans through contact with mucous
membranes or through skin breaks. Once infected, endothelial cells
(cells lining the inside of blood vessels), liver cells, and several
types of immune cells such as macrophages, monocytes , and dendritic
cells are the main targets of infection. Following infection with the
virus, the immune cells carry the virus to nearby lymph nodes where
further reproduction of the virus takes place. From there, the virus
can enter the bloodstream and lymphatic system and spread throughout
the body. Macrophages are the first cells infected with the virus,
and this infection results in programmed cell death . Other types of
white blood cells , such as lymphocytes , also undergo programmed cell
death leading to an abnormally low concentration of lymphocytes in the
blood. This contributes to the weakened immune response seen in those
infected with EBOV.
Endothelial cells may be infected within three days after exposure to
the virus. The breakdown of endothelial cells leading to blood vessel
injury can be attributed to
EBOV glycoproteins . This damage occurs
due to the synthesis of
Ebola virus glycoprotein (GP), which reduces
the availability of specific integrins responsible for cell adhesion
to the intercellular structure and causes liver damage, leading to
improper clotting . The widespread bleeding that occurs in affected
people causes swelling and shock due to loss of blood volume . The
dysfunction in bleeding and clotting commonly seen in EVD has been
attributed to increased activation of the extrinsic pathway of the
coagulation cascade due to excessive tissue factor production by
macrophages and monocytes.
After infection, a secreted glycoprotein , small soluble glycoprotein
(sGP or GP) is synthesized.
EBOV replication overwhelms protein
synthesis of infected cells and the host immune defenses. The GP forms
a trimeric complex , which tethers the virus to the endothelial cells.
The sGP forms a dimeric protein that interferes with the signaling of
neutrophils , another type of white blood cell, which enables the
virus to evade the immune system by inhibiting early steps of
neutrophil activation. The presence of viral particles and the cell
damage resulting from viruses budding out of the cell causes the
release of chemical signals (such as TNF-α , IL-6 and IL-8 ), which
are molecular signals for fever and inflammation.
IMMUNE SYSTEM EVASION
Filoviral infection also interferes with proper functioning of the
innate immune system .
EBOV proteins blunt the human immune system's
response to viral infections by interfering with the cells' ability to
produce and respond to interferon proteins such as interferon-alpha ,
interferon-beta , and interferon gamma .
The VP24 and VP35 structural proteins of
EBOV play a key role in this
interference. When a cell is infected with EBOV, receptors located in
the cell's cytosol (such as
MDA5 ) or outside of the cytosol
Toll-like receptor 3 (TLR3) , TLR7 , TLR8 and TLR9 ),
recognize infectious molecules associated with the virus. On TLR
activation, proteins including interferon regulatory factor 3 and
interferon regulatory factor 7 trigger a signaling cascade that leads
to the expression of type 1 interferons . The type 1 interferons are
then released and bind to the
IFNAR2 receptors expressed on
the surface of a neighboring cell. Once interferon has bound to its
receptors on the neighboring cell, the signaling proteins
STAT2 are activated and move to the cell\'s nucleus . This triggers
the expression of interferon-stimulated genes , which code for
proteins with antiviral properties. EBOV's V24 protein blocks the
production of these antiviral proteins by preventing the STAT1
signaling protein in the neighboring cell from entering the nucleus.
The VP35 protein directly inhibits the production of interferon-beta.
By inhibiting these immune responses,
EBOV may quickly spread
throughout the body.
When EVD is suspected in a person, his or her travel and work
history, along with an exposure to wildlife, are important factors to
consider with respect to further diagnostic efforts.
Possible non-specific laboratory indicators of EVD include a low
platelet count ; an initially decreased white blood cell count
followed by an increased white blood cell count ; elevated levels of
the liver enzymes alanine aminotransferase (ALT) and aspartate
aminotransferase (AST); and abnormalities in blood clotting often
consistent with disseminated intravascular coagulation (DIC) such as a
prolonged prothrombin time , partial thromboplastin time , and
bleeding time . Filovirions, such as EBOV, may be identified by their
unique filamentous shapes in cell cultures examined with electron
microscopy , but this method cannot distinguish the various
The specific diagnosis of EVD is confirmed by isolating the virus,
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) are
methods best used in the early stages of the disease and also for
detecting the virus in human remains. Detecting antibodies against the
virus is most reliable in the later stages of the disease and in those
who recover. IgM antibodies are detectable two days after symptom
onset and IgG antibodies can be detected 6 to 18 days after symptom
onset. During an outbreak, isolation of the virus via cell culture
methods is often not feasible. In field or mobile hospitals, the most
common and sensitive diagnostic methods are real-time PCR and ELISA.
In 2014, with new mobile testing facilities deployed in parts of
Liberia, test results were obtained 3–5 hours after sample
submission. In 2015 a rapid antigen test which gives results in 15
minutes was approved for use by WHO. It is able to confirm Ebola in
92% of those affected and rule it out in 85% of those not affected.
Early symptoms of EVD may be similar to those of other diseases
common in Africa, including malaria and dengue fever . The symptoms
are also similar to those of other viral hemorrhagic fevers such as
Marburg virus disease .
The complete differential diagnosis is extensive and requires
consideration of many other infectious diseases such as typhoid fever
, shigellosis , rickettsial diseases , cholera , sepsis , borreliosis
, EHEC enteritis , leptospirosis , scrub typhus , plague ,
Q fever ,
candidiasis , histoplasmosis , trypanosomiasis , visceral
leishmaniasis , measles , and viral hepatitis among others.
Non-infectious diseases that may result in symptoms similar to those
of EVD include acute promyelocytic leukemia , hemolytic uremic
syndrome , snake envenomation , clotting factor deficiencies/platelet
disorders, thrombotic thrombocytopenic purpura , hereditary
hemorrhagic telangiectasia ,
Kawasaki disease , and warfarin
VHF isolation precautions poster Main article: Prevention of
viral hemorrhagic fever
British woman wearing protective gear
People who care for those infected with Ebola should wear protective
clothing including masks, gloves, gowns and goggles. The US Centers
for Disease Control (CDC) recommend that the protective gear leaves no
skin exposed. These measures are also recommended for those who may
handle objects contaminated by an infected person's body fluids. In
2014, the CDC began recommending that medical personnel receive
training on the proper suit-up and removal of personal protective
equipment (PPE); in addition, a designated person, appropriately
trained in biosafety, should be watching each step of these procedures
to ensure they are done correctly. In Sierra Leone, the typical
training period for the use of such safety equipment lasts
approximately 12 days.
The infected person should be in barrier-isolation from other people.
All equipment, medical waste, patient waste and surfaces that may
have come into contact with body fluids need to be disinfected .
During the 2014 outbreak, kits were put together to help families
treat Ebola disease in their homes, which include protective clothing
as well as chlorine powder and other cleaning supplies. Education of
those who provide care in these techniques, and the provision of such
barrier-separation supplies has been a priority of Doctors Without
Ebolaviruses can be eliminated with heat (heating for 30 to 60
minutes at 60 °C or boiling for 5 minutes). To disinfect surfaces,
some lipid solvents such as some alcohol-based products, detergents,
sodium hypochlorite (bleach) or calcium hypochlorite (bleaching
powder), and other suitable disinfectants may be used at appropriate
concentrations. Education of the general public about the risk
factors for Ebola infection and of the protective measures individuals
may take to prevent infection is recommended by the World Health
Organization . These measures include avoiding direct contact with
infected people and regular hand washing using soap and water.
Bushmeat , an important source of protein in the diet of some
Africans, should be handled and prepared with appropriate protective
clothing and thoroughly cooked before consumption. Some research
suggests that an outbreak of Ebola disease in the wild animals used
for consumption may result in a corresponding human outbreak. Since
2003, such animal outbreaks have been monitored to predict and prevent
Ebola outbreaks in humans.
If a person with Ebola disease dies, direct contact with the body
should be avoided. Certain burial rituals , which may have included
making various direct contacts with a dead body, require reformulation
such that they consistently maintain a proper protective barrier
between the dead body and the living. Social anthropologists may
help find alternatives to traditional rules for burials.
Transportation crews are instructed to follow a certain isolation
procedure, should anyone exhibit symptoms resembling EVD. As of
August 2014, the
WHO does not consider travel bans to be useful in
decreasing spread of the disease. In October 2014, the CDC defined
four risk levels used to determine the level of 21-day monitoring for
symptoms and restrictions on public activities. In the United States,
the CDC recommends that restrictions on public activity, including
travel restrictions, are not required for the following defined risk
* having been in a country with widespread Ebola disease
transmission and having no known exposure (low risk); or having been
in that country more than 21 days ago (no risk)
* encounter with a person showing symptoms; but not within 3 feet of
the person with Ebola without wearing PPE; and no direct contact of
* having had brief skin contact with a person showing symptoms of
Ebola disease when the person was believed to be not very contagious
* in countries without widespread Ebola disease transmission: direct
contact with a person showing symptoms of the disease while wearing
PPE (low risk)
* contact with a person with Ebola disease before the person was
showing symptoms (no risk).
The CDC recommends monitoring for the symptoms of Ebola disease for
those both at "low risk" and at higher risk.
In laboratories where diagnostic testing is carried out, biosafety
level 4-equivalent containment is required. Laboratory researchers
must be properly trained in BSL-4 practices and wear proper PPE.
PUTTING ON PROTECTIVE EQUIPMENT
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Isolation refers to separating those who are sick from those who are
Quarantine refers to separating those who may have been exposed
to a disease until they either show signs of the disease or are no
longer at risk. Quarantine, also known as enforced isolation, is
usually effective in decreasing spread. Governments often quarantine
areas where the disease is occurring or individuals who may transmit
the disease outside of an initial area. In the United States, the law
allows quarantine of those infected with ebolaviruses.
Contact tracing is considered important to contain an outbreak. It
involves finding everyone who had close contact with infected
individuals and watching for signs of illness for 21 days. If any of
these contacts comes down with the disease, they should be isolated,
tested and treated. Then the process is repeated by tracing the
No specific treatment is currently approved. The Food and Drug
Administration (FDA) advises people to be careful of advertisements
making unverified or fraudulent claims of benefits supposedly gained
from various anti-Ebola products.
A hospital isolation ward in Gulu,
Uganda , during the October
Treatment is primarily supportive in nature. Early supportive care
with rehydration and symptomatic treatment improves survival.
Rehydration may be via the oral or by intravenous route. These
measures may include management of pain , nausea , fever and anxiety .
World Health Organization recommends avoiding the use of aspirin
or ibuprofen for pain due to the bleeding risk associated with use of
Blood products such as packed red blood cells , platelets or fresh
frozen plasma may also be used. Other regulators of coagulation have
also been tried including heparin in an effort to prevent disseminated
intravascular coagulation and clotting factors to decrease bleeding.
Antimalarial medications and antibiotics are often used before the
diagnosis is confirmed, though there is no evidence to suggest such
treatment helps. A number of experimental treatments are being studied
If hospital care is not possible, the
World Health Organization has
guidelines for care at home that have been relatively successful. In
such situations, recommendations include using towels soaked in bleach
solutions when moving infected people or bodies and applying bleach on
stains. It is also recommended that the caregivers wash hands with
bleach solutions and cover their mouth and nose with a cloth.
Intensive care is often used in the developed world. This may
include maintaining blood volume and electrolytes (salts) balance as
well as treating any bacterial infections that may develop. Dialysis
may be needed for kidney failure , and extracorporeal membrane
oxygenation may be used for lung dysfunction.
EVD has a high risk of death in those infected which varies between
25 percent and 90 percent of those infected. As of September 2014 ,
the average risk of death among those infected is 50 percent. The
highest risk of death was 90 percent in the 2002–2003 Republic of
the Congo outbreak.
Death, if it occurs, follows typically six to sixteen days after
symptoms appear and is often due to low blood pressure from fluid loss
. Early supportive care to prevent dehydration may reduce the risk of
If an infected person survives, recovery may be quick and complete.
Prolonged cases are often complicated by the occurrence of long-term
problems, such as inflammation of the testicles , joint pains ,
muscular pain , skin peeling , or hair loss . Eye symptoms, such as
light sensitivity , excess tearing , and vision loss have been
Ebola can stay in some body parts like the eyes, breasts, and
testicles after infection. Sexual transmission after recovery has
been suspected. If sexual transmission occurs following recovery it
is believed to be a rare event. One case of a condition similar to
meningitis has been reported many months after recovery as of Oct.
A study of 44 survivors of the
Ebola virus in
Sierra Leone reported
musculoskeletal pain in 70%, headache in 48% and eye problems in 14%.
Cases of Ebola fever in Africa from 1979 to 2008 For more
about specific outbreaks, see
List of Ebola outbreaks .
The disease typically occurs in outbreaks in tropical regions of
Sub-Saharan Africa . From 1976 (when it was first identified) through
World Health Organization reported 1,716 confirmed cases.
The largest outbreak to date was the
Ebola virus epidemic in West
Africa , which had caused a large number of deaths in
Guinea , Sierra
Leone , and
2013–2016 WEST AFRICAN OUTBREAK
Main article: West African
Ebola virus epidemic Cases and
deaths from April 2014 to July 2015 during the 2013–2015 outbreak
Ebola virus epidemic in West Africa
In March 2014, the
World Health Organization (WHO) reported a major
Ebola outbreak in
Guinea , a western African nation. Researchers
traced the outbreak to a one-year-old child who died December 2013.
The disease then rapidly spread to the neighboring countries of
Sierra Leone . It is the largest Ebola outbreak ever
documented, and the first recorded in the region. On 8 August 2014,
WHO declared the epidemic to be an international public health
emergency. Urging the world to offer aid to the affected regions, the
Director-General 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." By mid-August 2014, Doctors
Without Borders reported the situation in Liberia's capital Monrovia
as "catastrophic" and "deteriorating daily". They reported that fears
of Ebola among staff members and patients had shut down much of the
city’s health system, leaving many people without treatment for
other conditions. 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."
Checking for symptoms of Ebola in Sierra Leone, November 2014
Intense contact tracing and strict isolation techniques largely
prevented further spread of the disease in the countries that had
imported cases; this disease is still ongoing in Guinea. As of 8 May
2016 , 28,616 suspected cases and 11,310 deaths have been reported;
WHO has said that these numbers may be underestimated.
Because they work closely with the body fluids of infected patients,
healthcare workers have been especially vulnerable to catching the
disease; in August 2014, the
WHO reported that ten percent of the dead
have been healthcare workers.
In September 2014, it was estimated that the countries' capacity for
treating Ebola patients was insufficient by the equivalent of 2,122
beds; by December there were a sufficient number of beds to treat and
isolate all reported Ebola cases, although the uneven distribution of
cases was resulting in serious shortfalls in some areas. On 28
January 2015, the
WHO reported that for the first time since the week
ending 29 June 2014, there had been fewer than 100 new confirmed cases
reported in a week in the three most-affected countries. The response
to the epidemic then moved to a second phase, as the focus shifted
from slowing transmission to ending the epidemic. On 8 April 2015,
WHO reported a total of only 30 confirmed cases, the lowest weekly
total since the third week of May 2014.
On 29 December 2015, 42 days after the last person tested negative
for a second time,
Guinea was declared free of Ebola transmission. At
that time, a 90-day period of heightened surveillance was announced by
that agency. "This is the first time that all three countries –
Sierra Leone – have stopped the original chains
of transmission ...", the organization stated in a news release. A
new case was detected in
Sierra Leone on 14 January 2016. However,
the outbreak was declared no longer an emergency on 29 March 2016.
2014 Ebola Spread Outside West Africa
Ebola virus cases in the
United States , Ebola virus
disease in Spain , and
Ebola virus disease in the United Kingdom
As of 15 October 2014, there have been 17 cases of Ebola treated
outside Africa, four of whom have died.
In early October, Teresa Romero, a 44-year-old Spanish nurse,
contracted Ebola after caring for a priest who had been repatriated
from West Africa. This was the first transmission of the virus to
occur outside Africa. On 20 October, it was announced that Teresa
Romero had tested negative for the Ebola virus, suggesting that she
may have recovered from Ebola infection.
On 19 September, Eric Duncan flew from his native
Liberia to Texas; 5
days later he began showing symptoms and visited a hospital but was
sent home. His condition worsened and he returned to the hospital on
28 September, where he died on 8 October. Health officials confirmed
a diagnosis of Ebola on 30 September – the first case in the United
States. On 12 October, the CDC confirmed that a nurse in Texas, Nina
Pham , who had treated Duncan was found to be positive for the Ebola
virus, the first known case of the disease to be contracted in the
United States. On 15 October, a second Texas health-care worker who
had treated Duncan was confirmed to have the virus. Both of these
people have since recovered.
On 23 October, a doctor in New York City, who returned to the United
Guinea after working with Doctors Without Borders, tested
positive for Ebola. His case is unrelated to the Texas cases. The
person has recovered and was discharged from Bellevue Hospital Center
on 11 November. On 24 December 2014, a laboratory in
Georgia reported that a technician had been exposed to Ebola.
On 29 December 2014,
Pauline Cafferkey , a British nurse who had just
Glasgow from Sierra Leone, was diagnosed with Ebola at
Gartnavel General Hospital . After initial treatment in
Glasgow, she was transferred by air to
RAF Northolt , then to the
specialist high-level isolation unit at the
Royal Free Hospital
Royal Free Hospital in
London for longer-term treatment.
1995 TO 2014
The second major outbreak occurred in
Zaire (now the Democratic
Republic of the Congo
Republic of the Congo ) in 1995, affecting 315 and killing 254.
Uganda had an outbreak affecting 425 and killing 224; in
this case, the
Sudan virus was found to be the Ebola species
responsible for the outbreak.
In 2003 there was an outbreak in the
Republic of the Congo
Republic of the Congo that
affected 143 and killed 128, a death rate of 90 percent, the highest
death rate of a genus
Ebolavirus outbreak to date.
In 2004 a Russian scientist died from Ebola after sticking herself
with an infected needle.
Between April and August 2007, a fever epidemic in a four-village
region of the
Democratic Republic of the Congo
Democratic Republic of the Congo was confirmed in
September to have cases of Ebola. Many people who attended the recent
funeral of a local village chief died. The 2007 outbreak eventually
affected 264 individuals and resulted in the deaths of 187.
On 30 November 2007, the
Uganda Ministry of Health confirmed an
outbreak of Ebola in the
Bundibugyo District in Western Uganda. 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 genus
Ebolavirus, which was tentatively named Bundibugyo. The
149 cases of this new strain and 37 of those led to deaths.
WHO confirmed two small outbreaks in
Uganda in 2012. The first
outbreak affected 7 people and resulted in the death of 4 and the
second affected 24, resulting in the death of 17. The
was responsible for both outbreaks.
On 17 August 2012, the Ministry of Health of the Democratic Republic
of the Congo reported an outbreak of the Ebola-Bundibugyo variant in
the eastern region. Other than its discovery in 2007, this was the
only time that this variant has been identified as responsible for an
WHO revealed that the virus had sickened 57 people and
claimed 29 lives. The probable cause of the outbreak was tainted bush
meat hunted by local villagers around the towns of
Isiro and Viadana.
In 2014, an outbreak of
Ebola virus disease occurred in the
Democratic Republic of the Congo
Democratic Republic of the Congo (DRC). Genome-sequencing has shown
that this outbreak was not related to the 2014–15 West Africa Ebola
virus outbreak , but was the same
EBOV species, the
Zaire species. It
began in August 2014 and was declared over in November of that year
with a total of 66 cases and 49 deaths. This is the 7th outbreak in
the DRC, three of which occurred during the period when the country
was known as
CDC worker incinerates medical waste from Ebola patients in
Zaire in 1976.
Cotton factory in
Nzara, South Sudan where the first outbreak
The first known outbreak of EVD was identified only after the fact,
occurring between June and November 1976 in
Nzara, South Sudan ,
(then part of
Sudan ) and was caused by
Sudan virus (SUDV). The Sudan
outbreak infected 284 people and killed 151. The first identifiable
Sudan occurred on 27 June in a storekeeper in a cotton factory
Nzara , who was hospitalized on 30 June and died on 6 July.
WHO medical staff involved in the
Sudan outbreak were
aware that they were dealing with a heretofore unknown disease, the
actual "positive identification" process and the naming of the virus
did not occur until some months later in the Democratic Republic of
the Congo .
Yambuku § Ebola outbreak
On 26 August 1976, a second outbreak of EVD began in
Yambuku , a
small rural village in
Mongala District in northern
Zaire (now known
Democratic Republic of the Congo
Democratic Republic of the Congo ). This outbreak was caused
by EBOV, formerly designated
Zaire ebolavirus, which is a different
member of the genus
Ebolavirus than in the first
Sudan outbreak. The
first person infected with the disease was village school headmaster
Mabalo Lokela , who began displaying symptoms on 26 August 1976.
Lokela had returned from a trip to Northern
Zaire near the Central
African Republic border, having visited the
Ebola River between 12 and
22 August. He was originally believed to have malaria and was given
quinine . However, his symptoms continued to worsen, and he was
Yambuku Mission Hospital on 5 September. Lokela died on 8
September 14 days after he began displaying symptoms.
Soon after Lokela's death, others who had been in contact with him
also died, and people in the village of
Yambuku began to panic. This
led the country's Minister of Health along with
Zaire President Mobutu
Sese Seko to declare the entire region, including
Yambuku and the
Kinshasa , a quarantine zone. No one was permitted
to enter or leave the area, with roads, waterways, and airfields
placed under martial law . Schools, businesses and social
organizations were closed. Researchers from the CDC , including Peter
Piot , co-discoverer of Ebola, later arrived to assess the effects of
the outbreak, observing that "the whole region was in panic." Piot
concluded that the Belgian nuns had inadvertently started the epidemic
by giving unnecessary vitamin injections to pregnant women, without
sterilizing the syringes and needles. The outbreak lasted 26 days,
with the quarantine lasting 2 weeks. Among the reasons that
researchers speculated caused the disease to disappear, were the
precautions taken by locals, the quarantine of the area, and
discontinuing the injections.
During this outbreak, Dr. Ngoy Mushola recorded the first clinical
description of EVD in
Yambuku , where he wrote the following in his
daily log: "The illness is characterized with a high temperature of
about 39 °C (102 °F), hematemesis , diarrhea with blood,
retrosternal abdominal pain, prostration with 'heavy' articulations,
and rapid evolution death after a mean of 3 days."
The virus responsible for the initial outbreak, first thought to be
Marburg virus , was later identified as a new type of virus related to
marburgviruses. Virus strain samples isolated from both outbreaks were
named as the "Ebola virus" after the
Ebola River , located near the
originally identified viral outbreak site in Zaire. Reports conflict
about who initially coined the name: either Karl Johnson of the
American CDC team or Belgian researchers. Subsequently, a number of
other cases were reported, almost all centered on the
hospital or having close contact with another case. 318 cases and 280
deaths (an 88 percent fatality rate) occurred in Zaire. Although it
was assumed that the two outbreaks were connected, scientists later
realized that they were caused by two distinct ebolaviruses, SUDV and
Zaire outbreak was contained with the help of the World
Health Organization and transport from the Congolese air force, by
quarantining villagers, sterilizing medical equipment, and providing
SOCIETY AND CULTURE
Cultural effects of the Ebola crisis
Ebolavirus 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 , and was investigated by
Biopreparat for such
use, but might be difficult to prepare as a weapon of mass destruction
because the virus becomes ineffective quickly in open air. Fake
emails pretending to be Ebola information from the
WHO or the Mexican
Government have in 2014 been misused to spread computer malware. The
BBC reported in 2015 that, "North Korean state media has suggested the
disease was created by the US military as a biological weapon."
Richard Preston 's 1995 best-selling book,
The Hot Zone , dramatized
the Ebola outbreak in Reston, Virginia.
William Close 's 1995 Ebola: A Documentary Novel of Its First
Explosion and 2002 Ebola: Through the Eyes of the People focused on
individuals' reactions to the 1976 Ebola outbreak in Zaire.
Tom Clancy 's 1996 novel,
Executive Orders , involves a Middle
Eastern terrorist attack on the
United States using an airborne form
of a deadly
Ebola virus strain named "Ebola Mayinga" (see Mayinga
Ebola virus epidemic in West Africa developed in 2014, a
number of popular self-published and well-reviewed books containing
sensational and misleading information about the disease appeared in
electronic and printed formats. The authors of some such books
admitted that they lacked medical credentials and were not technically
qualified to give medical advice. The
World Health Organization and
the United Nations stated that such misinformation had contributed to
the spread of the disease.
Ebola has a high mortality among primates. Frequent outbreaks of
Ebola may have resulted in the deaths of 5,000 gorillas. Outbreaks of
Ebola may have been responsible for an 88 percent decline in tracking
indices of observed chimpanzee populations in 420 square kilometer
Lossi Sanctuary between 2002 and 2003. Transmission among chimpanzees
through meat consumption constitutes a significant risk factor,
whereas contact between the animals, such as touching dead bodies and
grooming, is not.
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 3 to 4 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.
In 2012 it was demonstrated that the virus can travel without contact
from pigs to nonhuman primates, although the same study failed to
achieve transmission in that manner between primates.
Dogs may become infected with
EBOV but not develop symptoms. Dogs in
some parts of Africa scavenge for food, and they sometimes eat
EBOV-infected animals and also the corpses of humans. A 2005 survey of
dogs during an
EBOV outbreak found that although they remain
asymptomatic, about 32 percent of dogs closest to an outbreak showed a
EBOV versus 9 percent of those farther away. The
authors concluded that there were "potential implications for
preventing and controlling human outbreaks."
For more about the outbreak in Virginia, US, see
Reston virus .
In late 1989, Hazelton Research Products' Reston
Quarantine Unit in
Reston, Virginia , suffered an outbreak of fatal illness amongst
certain lab monkeys. This lab outbreak was initially diagnosed as
simian hemorrhagic fever virus (SHFV) and occurred amongst a shipment
of crab-eating macaque monkeys imported from the Philippines.
Hazelton'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 an
ELISA test indicated the antibodies present in the tissue were a
Ebola virus and not SHFV. An electron microscopist from
USAMRIID discovered filoviruses similar in appearance to Ebola in the
tissue samples sent from Hazelton Research Products' Reston Quarantine
US Army team headquartered at USAMRIID euthanized the surviving
monkeys, and brought all the monkeys to
Ft. Detrick for study by the
Army's veterinary pathologists and virologists, and eventual disposal
under safe conditions.
Blood samples were taken from 178 animal
handlers during the incident. Of those, six animal handlers
eventually seroconverted , including one who had cut himself with a
bloody scalpel. Despite its status as a Level‑4 organism and its
apparent pathogenicity in monkeys, when the handlers did not become
ill, the CDC concluded that the virus had a very low pathogenicity to
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
Reston ebolavirus (RESTV) after the location of the
Reston virus (RESTV) can be transmitted to pigs. Since the
initial outbreak it has since been found in nonhuman primates in
Pennsylvania, Texas, and Italy, where the virus had infected pigs.
According to the WHO, routine cleaning and disinfection of pig (or
monkey) farms with sodium hypochlorite or detergents should be
effective in inactivating the Reston ebolavirus. Pigs that have been
infected with RESTV tend to show symptoms of the disease.
Ebola virus disease treatment research
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.
As of July 2015, there is no medication which has been proven to be
safe and effective in treating Ebola. By the time the Ebola virus
epidemic in West Africa began in 2013, there were at least nine
different candidate treatments. Several trials were conducted in late
2014 and early 2015, but some were abandoned due to lack of efficacy
or lack of people to study.
Ebola vaccine candidates had been developed in the decade prior
to 2014, but as of November 2014, none had been approved for use in
humans in the United States. In December 2016,
Ebola virus disease
was found to be 70–100% prevented by rVSV-Z
EBOV vaccine , making it
the first proven vaccine against the disease.
One issue which hinders control of Ebola is that diagnostic tests
which are currently available require specialized equipment and highly
trained personnel. Since there are few suitable testing centers in
West Africa, this leads to delay in diagnosis. In December 2014, a
conference in Geneva will aim to work out which diagnostic tools could
be to identify Ebola reliably and more quickly. The meeting, convened
WHO and the non-profit Foundation for Innovative New
Diagnostics , seeks to identify tests that can be used by untrained
staff, do not require electricity or can run on batteries or solar
power and use reagents that can withstand temperatures of 40 °C.
On 29 November 2014, a new 15-minute Ebola test was reported that if
successful, "not only gives patients a better chance of survival, but
it prevents transmission of the virus to other people." The new
equipment, about the size of a laptop and solar-powered, allows
testing to be done in remote areas. The equipment is currently being
tested in Guinea.
On 29 December 2014, the FDA approved LightMix (R) Ebola Zaire
rRT-PCR Test on patients with symptoms of Ebola. The report indicates
it could help health care authorities around the world.
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V · T · D
* ICD -10 : A98.4
* ICD -9-CM : 078.89
* MESH : D019142
* DISEASESDB : 18043
* MEDLINEPLUS : 001339
* EMEDICINE : med/626