Frequently asked questions on Ebola virus disease


1. What is Ebola virus disease?

  • Ebola virus disease (formerly known as Ebola haemorrhagic fever) is a severe, often fatal illness, with a death rate of up to 90%. The illness affects humans and nonhuman primates (monkeys, gorillas, and chimpanzees).

Ebola first appeared in 1976 in two simultaneous outbreaks, one in a village near the Ebola River in the Democratic Republic of Congo, and the other in a remote area of Sudan.

The origin of the virus is unknown but fruit bats (Pteropodidae) are considered the likely host of the Ebola virus, based on available evidence.

2. How do people become infected with the virus?

In the current outbreak in West Africa, the majority of cases in humans have occurred as a result of human-to-human transmission.

Infection occurs from direct contact through broken skin or mucous membranes with the blood, or other bodily fluids or secretions (stool, urine, saliva, semen) of infected people. Infection can also occur if broken skin or mucous membranes of a healthy person come into contact with environments that have become contaminated with an Ebola patient’s infectious fluids such as soiled clothing, bed linen, or used needles.

More than 100 health-care workers have been exposed to the virus while caring for Ebola patients. This happens because they may not have been wearing personal protection equipment or were not properly applying infection prevention and control measures when caring for the patients. Health-care providers at all levels of the health system – hospitals, clinics, and health posts – should be briefed on the nature of the disease and how it is transmitted, and strictly follow recommended infection control precautions.

WHO does not advise families or communities to care for individuals who may present with symptoms of Ebola virus disease in their homes. Rather, seek treatment in a hospital or treatment centre staffed by doctors and nurses qualified and equipped to treat Ebola virus victims. If you do choose to care for your loved one at home, WHO strongly advises you to notify your local public health authority and receive appropriate training, equipment (gloves and personal protective equipment [PPE]) for treatment, instructions on proper removal and disposal of PPE, and information on how to prevent further infection and transmission of the disease to yourself, other family members, or the community.

Additional transmission has occurred in communities during funerals and burial rituals. Burial ceremonies in which mourners have direct contact with the body of the deceased person have played a role in the transmission of Ebola. Persons who have died of Ebola must be handled using strong protective clothing and gloves and must be buried immediately. WHO advises that the deceased be handled and buried by trained case management professionals, who are equipped to properly bury the dead.

People are infectious as long as their blood and secretions contain the virus. For this reason, infected patients receive close monitoring from medical professionals and receive laboratory tests to ensure the virus is no longer circulating in their systems before they return home. When the medical professionals determine it is okay for the patient to return home, they are no longer infectious and cannot infect anyone else in their communities. Men who have recovered from the illness can still spread the virus to their partner through their semen for up to 7 weeks after recovery. For this reason, it is important for men to avoid sexual intercourse for at least 7 weeks after recovery or to wear condoms if having sexual intercourse during 7 weeks after recovery.

Generally, a person must come into contact with an animal that has Ebola and it can then spread within the community from human to human.

3. Who is most at risk?

During an outbreak, those at higher risk of infection are:

  • health workers;
  • family members or others in close contact with infected people;
  • mourners who have direct contact with the bodies of the deceased as part of burial ceremonies.

More research is needed to understand if some groups, such as immuno-compromised people or those with other underlying health conditions, are more susceptible than others to contracting the virus.

Exposure to the virus can be controlled through the use of protective measures in clinics and hospitals, at community gatherings, or at home.

4. What are typical signs and symptoms of infection?

Sudden onset of fever, intense weakness, muscle pain, headache and sore throat are typical signs and symptoms. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding.

Laboratory findings include low white blood cell and platelet counts, and elevated liver enzymes.

The incubation period, or the time interval from infection to onset of symptoms, is from 2 to 21 days. The patients become contagious once they begin to show symptoms. They are not contagious during the incubation period.

Ebola virus disease infections can only be confirmed through laboratory testing.

5. When should someone seek medical care?

If a person has been in an area known to have Ebola virus disease or in contact with a person known or suspected to have Ebola and they begin to have symptoms, they should seek medical care immediately.

Any cases of persons who are suspected to have the disease should be reported to the nearest health unit without delay. Prompt medical care is essential to improving the rate of survival from the disease. It is also important to control spread of the disease and infection control procedures need to be started immediately.

6. What is the treatment?

Severely ill patients require intensive supportive care. They are frequently dehydrated and need intravenous fluids or oral rehydration with solutions that contain electrolytes. There is currently no specific treatment to cure the disease.

Some patients will recover with the appropriate medical care.

To help control further spread of the virus, people that are suspected or confirmed to have the disease should be isolated from other patients and treated by health workers using strict infection control precautions.

7. What can I do? Can it be prevented? Is there a vaccine?

Currently, there is no licensed medicine or vaccine for Ebola virus disease, but several products are under development.

Ways to prevent infection and transmission

While initial cases of Ebola virus disease are contracted by handling infected animals or carcasses, secondary cases occur by direct contact with the bodily fluids of an ill person, either through unsafe case management or unsafe burial practices. During this outbreak, most of the disease has spread through human-to-human transmission. Several steps can be taken to help in preventing infection and limiting or stopping transmission.

  • Understand the nature of the disease, how it is transmitted, and how to prevent it from spreading further. (For additional information, please see the previous questions about Ebola virus disease in this FAQ.)
  • Listen to and follow directives issued by your country’s respective Ministry of Health.
  • If you suspect someone close to you or in your community of having Ebola virus disease, encourage and support them in seeking appropriate medical treatment in a health-care facility.
  • If you choose to care for an ill person in your home, notify public health officials of your intentions so they can train you and provide appropriate gloves and personal protective equipment (PPE) (gloves, impermeable gown, boots/closed shoes with overshoes, mask and eye protection for splashes), as well as instructions as a reminder on how to properly care for the patient, protect yourself and your family, and properly dispose of the PPE after use. N.B. WHO does not recommend home care and strongly advises individuals and their family members to seek professional care in a treatment centre.
  • When visiting patients in the hospital or caring for someone at home, hand washing with soap and water is recommended after touching a patient, being in contact with their bodily fluids, or touching his/her surroundings.
  • People who have died from Ebola should only be handled using appropriate protective equipment and should be buried immediately by public health professionals who are trained in safe burial procedures.

Additionally, individuals should reduce contact with high-risk infected animals (i.e. fruit bats, monkeys or apes) in the affected rainforest areas. If you suspect an animal is infected, do not handle it. Animal products (blood and meat) should be thoroughly cooked before eating.

8. What about health workers? How should they protect themselves while caring for patients?

Health workers treating patients with suspected or confirmed illness are at higher risk of infection than other groups. During an outbreak a number of important actions will reduce or stop the spread of the virus and protect health workers and others in the health-care setting. These actions are called “standard and other additional precautions” and are evidence-based recommendations known to prevent the spread of infections. The following questions and answers describe the precautions in detail.

Should patients with suspected or confirmed Ebola virus be separated from other patients?

Isolating patients with suspected or confirmed Ebola virus disease in single isolation rooms is recommended. Where isolation rooms are not available, it is important to assign designated areas, separate from other patients, for suspected and confirmed cases. In these designated areas, suspect and confirmed cases should also be separate. Access to these areas should be restricted, needed equipment should be dedicated strictly to suspected and confirmed EVD treatment areas, and clinical and non-clinical personnel should be exclusively assigned to isolation rooms and dedicated areas.

Are visitors allowed in areas where patients suspected or confirmed Ebola virus disease are admitted?

Stopping visitor access to patients infected with EVD is preferred. If this is not possible, access should be given only to those individuals who are necessary for the patient’s well-being and care, such as a child’s parent.

Is protective equipment required when caring for these patients?

  • In addition to standard health-care precautions, health-care workers should strictly apply recommended infection control measures to avoid exposure to infected blood, fluids, or contaminated environments or objects – such as a patient’s soiled linen or used needles.
  • All visitors and health-care workers should rigorously use what is known as personal protective equipment (PPE). PPE should include at least: gloves, an impermeable gown, boots/closed shoes with overshoes, a mask, and eye protection for splashes (goggles or face shields).

Is hand hygiene important?

Hand hygiene is essential and should be performed:

  • before donning gloves and wearing PPE on entry to the isolation room/area;
  • before any clean or aseptic procedures is being performed on a patient;
  • after any exposure risk or actual exposure with a patient’s blood or body fluids;
  • after touching (even potentially) contaminated surfaces, items, or equipment in the patient’s surroundings; and
  • after removal of PPE, upon leaving the isolation area.

It is important to note that neglecting to perform hand hygiene after removing PPE will reduce or negate any benefits of the PPE.

Either an alcohol-based hand rub or soap and running water can be used for hand hygiene, applying the correct technique recommended by WHO. It is important to always perform hand hygiene with soap and running water when hands are visibly soiled. Alcohol-based hand rubs should be made available at every point of care (at the entrance and within the isolation rooms and areas); running water, soap, and single use towels should also be always available.

What other precautions are necessary in the health-care setting?

Other key precautions are safe injection and phlebotomy procedures, including safe management of sharps, regular and rigorous environmental cleaning, decontamination of surfaces and equipment, and management of soiled linen and of waste.

In addition, it is important to ensure safe processing of laboratory samples from suspected or confirmed patients with EDV and safe handling of dead bodies or human remains for post-mortem examination and burial preparation. Any health-care workers and other professionals undertaking these tasks in connection with suspected or confirmed patients with Ebola virus disease should wear appropriate PPE and follow precautions and procedures recommended by WHO.

9. What about rumours that some foods can prevent or treat the infection?

WHO strongly recommends that people seek credible health advice about Ebola virus disease from their public health authority.

While there is no specific drug against Ebola, the best treatment is intensive supportive treatment provided in the hospital by health workers using strict infection control procedures. The infection can be controlled through recommended protective measures.

10. How does WHO protect health during outbreaks?

WHO provides technical advice to countries and communities to prepare for and respond to Ebola outbreaks.

WHO actions include:

  • disease surveillance and information-sharing across regions to watch for outbreaks;
  • technical assistance to investigate and contain health threats when they occur – such as on-site help to identify sick people and track disease patterns;
  • advice on prevention and treatment options;
  • deployments of experts and the distribution of health supplies (such as personal protection gear for health workers) when they are requested by the country;
  • communications to raise awareness of the nature of the disease and protective health measures to control transmission of the virus; and
  • activation of regional and global networks of experts to provide assistance, if requested, and mitigate potential international health effects and disruptions of travel and trade.

11. During an outbreak, numbers of cases reported by health officials can go up and down? Why?

During an Ebola outbreak, the affected country’s public health authority reports its disease case numbers and deaths. Figures can change daily. Case numbers reflect both suspected cases and laboratory-confirmed cases of Ebola. Sometimes numbers of suspected and confirmed cases are reported together. Sometimes they are reported separately. Thus, numbers can shift between suspected and confirmed cases.

Analyzing case data trends, over time, and with additional information, is generally more helpful to assess the public health situation and determine the appropriate response.

12. Is it safe to travel during an outbreak? What is WHO’s travel advice?

During an outbreak, WHO reviews the public health situation regularly and recommends any travel or trade restrictions, if necessary, and may inform national authorities to implement it. WHO is currently reviewing its recommendations for travel and expects to issue advice in the coming days.

While travellers should always be vigilant with regard to their health and those around them, the risk of infection for travellers is very low since person-to-person transmission results from direct contact with the body fluids or secretions of an infected patient.

Is it safe to travel with persons who have Ebola?

As with any illness or disease, it is always possible that a person who has been exposed to Ebola virus may choose to travel. If the individual has not developed symptoms (see FAQ #4), they cannot transmit EVD to those around them. If the individual does have symptoms, they should seek immediate medical attention at the first sign they are feeling unwell. This may require either notifying the flight crew or ship crew or, upon arrival at a destination, seeking immediate medical attention. Travellers who show initial symptoms of EVD should be isolated to prevent further transmission. Although the risk to fellow travellers in such a situation is very low, contact tracing is recommended under these circumstances.

Is it safe to travel to West Africa on business or to visit family and friends?

The risk of a tourist or businessman/woman becoming infected with Ebola virus during a visit to the affected areas and developing disease after returning is extremely low, even if the visit included travel to the local areas from which primary cases have been reported. Transmission requires direct contact with blood, secretions, organs or other body fluids of infected living or dead persons or animal, all of which are unlikely exposures for the average traveller. In any event, tourists are advised to avoid all such contacts.

If you are visiting family or friends in the affected areas, the risk is similarly low, unless you have direct physical contact with a person who is ill or who has died. If this is the case, it is important to notify public health authorities and engage in contact tracing. Contact tracing is used to confirm you have not been exposed to EVD and to prevent further spread of the disease through monitoring.

WHO’s general travel advice

  • Travelers should avoid all contact with infected patients.
  • Health workers traveling to affected areas should strictly follow WHO-recommended infection control guidance.
  • Anyone who has stayed in areas where cases were recently reported should be aware of the symptoms of infection and seek medical attention at the first sign of illness.
  • Clinicians caring for travelers returning from affected areas with compatible symptoms are advised to consider the possibility of Ebola virus disease.

For additional travel advice, please read the Travel and transport risk assessment: Recommendations for public health authorities and transport sector at http://who.int/ith/updates/20140421/en/.

Keeping Ebola in check


After the H1N1 influenza (swine flu) in 2009 and polio in May 2014, the WHO has now declared the Ebola (Ebola virus disease) outbreak in West Africa as an “extraordinary event” and a “public health risk to other countries.” It has also highlighted that the “consequences” of its spread across the world could be “particularly serious” considering the virulence of the virus. After the first outbreak in December 2013 in the Guéckédou region in Guinea’s remote southeastern forest region, the virus has spread to three other West African countries — Liberia, Nigeria and Sierra Leone. As on August 6, as many as 1,779 people (with 1,134 confirmed cases) were infected and the mortality figure was 961. The death toll this time is much more than the combined count of all previous Ebola epidemics. The biggest threat comes from the extremely high virulence of the Zaire Ebola virus species, the most lethal Ebola virus known, with fatality rates going up to 90 per cent; the Zaire virus species is usually restricted to Central Africa. Though the virulence has been lower at 55 per cent, it is still alarmingly high. The incubation period — the time interval from infection to onset of symptoms — of two to 21 days poses a real danger to public health. In this era of global travel, though infected people would not transmit the virus till they develop the disease, they could facilitate virus spread once symptoms show up.

Despite the deadly characteristics of the virus, transmission occurs only when people come into contact with the body fluids of affected people; there is no scientific confirmation of humans getting infected through airborne transmission. Yet, transmission has been rampant both in the community and in health-care settings. Poor handling practices in weak health-care systems are putting doctors and healthworkers at great risk. Currently, no approved drugs or vaccines are available to prevent infections or treat infected people. But an experimental drug tested only in animals has improved the condition of two Ebola-infected U.S. nationals who were flown back to America. It is highly unlikely that the drug would be used to treat those in the four countries. One way to prevent the spread is to stop symptomatic passengers from travelling in normal passenger aircraft, and to screen and follow up those arriving from or transiting through these countries as the infected people act as carriers of the virus. India has its task cut out as nearly 5,000 Indians who live in Guinea, Liberia and Sierra Leone and about 40,000 in Nigeria may return here. The Union Health Minister has held out the assurance that the Ministry has put into operation “the most advanced surveillance and tracking systems”. Utmost care is called for.

 

Ebola virus disease


Key facts

  • Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a severe, often fatal illness in humans.
  • EVD outbreaks have a case fatality rate of up to 90%.
  • EVD outbreaks occur primarily in remote villages in Central and West Africa, near tropical rainforests.
  • The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission.
  • Fruit bats of the Pteropodidae family are considered to be the natural host of the Ebola virus.
  • Severely ill patients require intensive supportive care. No licensed specific treatment or vaccine is available for use in people or animals.

Ebola first appeared in 1976 in 2 simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo. The latter was in a village situated near the Ebola River, from which the disease takes its name.

Genus Ebolavirus is 1 of 3 members of the Filoviridae family (filovirus), along with genus Marburgvirus and genus Cuevavirus. Genus Ebolavirus comprises 5 distinct species:

  • Bundibugyo ebolavirus (BDBV)
  • Zaire ebolavirus (EBOV)
  • Reston ebolavirus (RESTV)
  • Sudan ebolavirus (SUDV)
  • Taï Forest ebolavirus (TAFV).

BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa, whereas RESTV and TAFV have not. The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but no illness or death in humans from this species has been reported to date.

Transmission

Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals. In Africa, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest.

Ebola then spreads in the community through human-to-human transmission, with infection resulting from direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and indirect contact with environments contaminated with such fluids. Burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in the transmission of Ebola. Men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness.

Health-care workers have frequently been infected while treating patients with suspected or confirmed EVD. This has occurred through close contact with patients when infection control precautions are not strictly practiced.

Among workers in contact with monkeys or pigs infected with Reston ebolavirus, several infections have been documented in people who were clinically asymptomatic. Thus, RESTV appears less capable of causing disease in humans than other Ebola species.

However, the only available evidence available comes from healthy adult males. It would be premature to extrapolate the health effects of the virus to all population groups, such as immuno-compromised persons, persons with underlying medical conditions, pregnant women and children. More studies of RESTV are needed before definitive conclusions can be drawn about the pathogenicity and virulence of this virus in humans.

Signs and symptoms

EVD is a severe acute viral illness often characterized by the sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding. Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes.

People are infectious as long as their blood and secretions contain the virus. Ebola virus was isolated from semen 61 days after onset of illness in a man who was infected in a laboratory.

The incubation period, that is, the time interval from infection with the virus to onset of symptoms, is 2 to 21 days.

Diagnosis

Other diseases that should be ruled out before a diagnosis of EVD can be made include: malaria, typhoid fever, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis and other viral haemorrhagic fevers.

Ebola virus infections can be diagnosed definitively in a laboratory through several types of tests:

  • antibody-capture enzyme-linked immunosorbent assay (ELISA)
  • antigen detection tests
  • serum neutralization test
  • reverse transcriptase polymerase chain reaction (RT-PCR) assay
  • electron microscopy
  • virus isolation by cell culture.

Samples from patients are an extreme biohazard risk; testing should be conducted under maximum biological containment conditions.

Vaccine and treatment

No licensed vaccine for EVD is available. Several vaccines are being tested, but none are available for clinical use.

Severely ill patients require intensive supportive care. Patients are frequently dehydrated and require oral rehydration with solutions containing electrolytes or intravenous fluids.

No specific treatment is available. New drug therapies are being evaluated.

Natural host of Ebola virus

In Africa, fruit bats, particularly species of the genera Hypsignathus monstrosus, Epomops franqueti and Myonycteris torquata, are considered possible natural hosts for Ebola virus. As a result, the geographic distribution of Ebolaviruses may overlap with the range of the fruit bats.

Ebola virus in animals

Although non-human primates have been a source of infection for humans, they are not thought to be the reservoir but rather an accidental host like human beings. Since 1994, Ebola outbreaks from the EBOV and TAFV species have been observed in chimpanzees and gorillas.

RESTV has caused severe EVD outbreaks in macaque monkeys (Macaca fascicularis) farmed in Philippines and detected in monkeys imported into the USA in 1989, 1990 and 1996, and in monkeys imported to Italy from Philippines in 1992.

Since 2008, RESTV viruses have been detected during several outbreaks of a deadly disease in pigs in People’s Republic of China and Philippines. Asymptomatic infection in pigs has been reported and experimental inoculations have shown that RESTV cannot cause disease in pigs.

Prevention and control

Controlling Reston ebolavirus in domestic animals

No animal vaccine against RESTV is available. Routine cleaning and disinfection of pig or monkey farms (with sodium hypochlorite or other detergents) should be effective in inactivating the virus.

If an outbreak is suspected, the premises should be quarantined immediately. Culling of infected animals, with close supervision of burial or incineration of carcasses, may be necessary to reduce the risk of animal-to-human transmission. Restricting or banning the movement of animals from infected farms to other areas can reduce the spread of the disease.

As RESTV outbreaks in pigs and monkeys have preceded human infections, the establishment of an active animal health surveillance system to detect new cases is essential in providing early warning for veterinary and human public health authorities.

Reducing the risk of Ebola infection in people

In the absence of effective treatment and a human vaccine, raising awareness of the risk factors for Ebola infection and the protective measures individuals can take is the only way to reduce human infection and death.

In Africa, during EVD outbreaks, educational public health messages for risk reduction should focus on several factors:

  • Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes and the consumption of their raw meat. Animals should be handled with gloves and other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked before consumption.
  • Reducing the risk of human-to-human transmission in the community arising from direct or close contact with infected patients, particularly with their bodily fluids. Close physical contact with Ebola patients should be avoided. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. Regular hand washing is required after visiting patients in hospital, as well as after taking care of patients at home.
  • Communities affected by Ebola should inform the population about the nature of the disease and about outbreak containment measures, including burial of the dead. People who have died from Ebola should be promptly and safely buried.

Pig farms in Africa can play a role in the amplification of infection because of the presence of fruit bats on these farms. Appropriate biosecurity measures should be in place to limit transmission. For RESTV, educational public health messages should focus on reducing the risk of pig-to-human transmission as a result of unsafe animal husbandry and slaughtering practices, and unsafe consumption of fresh blood, raw milk or animal tissue. Gloves and other appropriate protective clothing should be worn when handling sick animals or their tissues and when slaughtering animals. In regions where RESTV has been reported in pigs, all animal products (blood, meat and milk) should be thoroughly cooked before eating.

Controlling infection in health-care settings

Human-to-human transmission of the Ebola virus is primarily associated with direct or indirect contact with blood and body fluids. Transmission to health-care workers has been reported when appropriate infection control measures have not been observed.

It is not always possible to identify patients with EBV early because initial symptoms may be non-specific. For this reason, it is important that health-care workers apply standard precautions consistently with all patients – regardless of their diagnosis – in all work practices at all times. These include basic hand hygiene, respiratory hygiene, the use of personal protective equipment (according to the risk of splashes or other contact with infected materials), safe injection practices and safe burial practices.

Health-care workers caring for patients with suspected or confirmed Ebola virus should apply, in addition to standard precautions, other infection control measures to avoid any exposure to the patient’s blood and body fluids and direct unprotected contact with the possibly contaminated environment. When in close contact (within 1 metre) of patients with EBV, health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures).

Laboratory workers are also at risk. Samples taken from suspected human and animal Ebola cases for diagnosis should be handled by trained staff and processed in suitably equipped laboratories.

WHO response

WHO provides expertise and documentation to support disease investigation and control.

Recommendations for infection control while providing care to patients with suspected or confirmed Ebola haemorrhagic fever are provided in: Interim infection control recommendations for care of patients with suspected or confirmed Filovirus (Ebola, Marburg) haemorrhagic fever, March 2008. This document is currently being updated.

WHO has created an aide–memoire on standard precautions in health care (currently being updated). Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens. If universally applied, the precautions would help prevent most transmission through exposure to blood and body fluids.

Standard precautions are recommended in the care and treatment of all patients regardless of their perceived or confirmed infectious status. They include the basic level of infection control—hand hygiene, use of personal protective equipment to avoid direct contact with blood and body fluids, prevention of needle stick and injuries from other sharp instruments, and a set of environmental controls.

Table: Chronology of previous Ebola virus disease outbreaks

 

Year Country Ebolavirus species Cases Deaths Case fatality
2012 Democratic Republic of Congo Bundibugyo 57 29 51%
2012 Uganda Sudan 7 4 57%
2012 Uganda Sudan 24 17 71%
2011 Uganda Sudan 1 1 100%
2008 Democratic Republic of Congo Zaire 32 14 44%
2007 Uganda Bundibugyo 149 37 25%
2007 Democratic Republic of Congo Zaire 264 187 71%
2005 Congo Zaire 12 10 83%
2004 Sudan Sudan 17 7 41%
2003 (Nov-Dec) Congo Zaire 35 29 83%
2003 (Jan-Apr) Congo Zaire 143 128 90%
2001-2002 Congo Zaire 59 44 75%
2001-2002 Gabon Zaire 65 53 82%
2000 Uganda Sudan 425 224 53%
1996 South Africa (ex-Gabon) Zaire 1 1 100%
1996 (Jul-Dec) Gabon Zaire 60 45 75%
1996 (Jan-Apr) Gabon Zaire 31 21 68%
1995 Democratic Republic of Congo Zaire 315 254 81%
1994 Cote d’Ivoire Taï Forest 1 0 0%
1994 Gabon Zaire 52 31 60%
1979 Sudan Sudan 34 22 65%
1977 Democratic Republic of Congo Zaire 1 1 100%
1976 Sudan Sudan 284 151 53%
1976 Democratic Republic of Congo Zaire 318 280 88%

For more information contact:

WHO Media centre
Telephone:  +41 22 791 2222
E-mail: mediainquiries@who.int

Emergence of Zaire Ebola Virus Disease in Guinea .


Outbreaks caused by viruses of the genera ebolavirus and marburgvirus represent a major public health issue in sub-Saharan Africa. Ebola virus disease is associated with a case fatality rate of 30 to 90%, depending on the virus species. Specific conditions in hospitals and communities in Africa facilitate the spread of the disease from human to human. Three ebolavirus species have caused large outbreaks in sub-Saharan Africa: EBOV, Sudan ebolavirus, and the recently described Bundibugyo ebolavirus.1,2Epidemics have occurred in the Democratic Republic of Congo, Sudan, Gabon, Republic of Congo, and Uganda. Reston ebolavirus circulates in the Philippines. It has caused disease in nonhuman primates but not in humans.3 The fifth species, Tai Forest ebolavirus, was documented in a single human infection caused by contact with an infected chimpanzee from the Tai Forest in Ivory Coast.4 Although this event indicated the presence of Tai Forest ebolavirus in West Africa, this subregion was not considered to be an area in which EBOV was endemic.

On March 10, 2014, hospitals and public health services in Guéckédou and Macenta alerted the Ministry of Health of Guinea and — 2 days later — Médecins sans Frontières in Guinea about clusters of a mysterious disease characterized by fever, severe diarrhea, vomiting, and an apparent high fatality rate. (Médecins sans Frontières had been working on a malaria project in Guéckédou since 2010.) In Guéckédou, eight patients were hospitalized; three of them died, and additional deaths were reported among the families of the patients. Several deaths were reported in Macenta, including deaths among hospital staff members. A team sent by the health ministry reached the outbreak region on March 14 (Figure 1FIGURE 1

Map of Guinea Showing Initial Locations of the Outbreak of Ebola Virus Disease.). Médecins sans Frontières in Europe was notified and sent a team, which arrived in Guéckédou on March 18. Epidemiologic investigation was initiated, and blood samples were collected and sent to the biosafety level 4 laboratories in Lyon, France, and Hamburg, Germany, for virologic analysis.

METHODS

Patients

Blood samples were obtained from 20 patients who were hospitalized in Guéckédou, Macenta, and Kissidougou with fever, diarrhea, vomiting, or hemorrhage. Demographic and clinical data for the patients were provided on the laboratory request forms. Clinical data were not collected in a systematic fashion. This work was performed as part of the public health response to contain the outbreak in Guinea; informed consent was not obtained.

Diagnostic Assays

Viral RNA was extracted from 50 to 100 μl of undiluted plasma and 1:10 diluted plasma with the use of the QIAmp viral RNA kit (Qiagen). Nucleic acid amplification tests for detection of filoviruses and arenaviruses were performed with the use of commercially available kits and published primers and probes5-11 (Table S1 in the Supplementary Appendix, available with the full text of this article at NEJM.org).

Viral Sequencing

Fragments amplified by filovirus L gene-specific primers were sequenced with the use of polymerase-chain-reaction (PCR) primers. Complete EBOV genomes were sequenced directly with the use of RNA extracted from serum obtained from three patients with high levels of viral RNA, as measured on real-time reverse-transcriptase–PCR (RT-PCR) analysis. The genome was amplified in overlapping fragments with the use of EBOV-specific primers. The fragments were sequenced from both ends with the use of conventional Sanger techniques. The sequence of the contigs was verified by visual inspection of the electropherograms.

Viral Isolation

About 100 μl of all serum samples was used to inoculate Vero E6 cells maintained in 25-cm2 flasks in Dulbecco’s Modified Eagle’s Medium containing 2 to 5% fetal-calf serum and penicillin–streptomycin. Cells and supernatant were passaged several times. Virus growth in the cells was verified on immunofluorescence with the use of polyclonal mouse anti-EBOV–specific antibodies in serum of mice challenged with EBOV or on the basis of an increase in viral levels in the cell-culture supernatant over several orders of magnitude, as measured on real-time RT-PCR.

Electron Microscopy

Specimens from two patients were prepared for electron microscopy with the use of a conventional negative-staining procedure. In brief, a drop of 1:10 diluted serum was adsorbed to a glow-discharged carbon-coated copper grid and stained with freshly prepared 1% phosphotungstic acid (Agar Scientific). Images were taken at room temperature with the use of a Tecnai Spirit electron microscope (FEI) equipped with an LaB6 filament and operated at an acceleration voltage of 80 kV.

Phylogenetic Analysis

We obtained all 48 complete genome sequences of filoviruses that are currently available from GenBank and aligned them with the new EBOV Guinea sequences (18,959 nucleotides). We used software designed to perform statistical selection of best-fit models of nucleotide substitution (jModelTest12) to identify the general time-reversible model of sequence evolution with gamma-distributed rate variation among sites (GTR+gamma) as the model that best describes the phylogenetic data. We used the Bayesian Markov Chain Monte Carlo method, as implemented in MrBayes 3.1.2 software,13 to infer the composition of one phylogenetic tree, using two runs of four chains with 1 million steps with a burn-in rate of 25% and the GTR+gamma model. A second tree was inferred for the same alignment with a maximum-likelihood method implemented in PhyML software14 under the GTR+gamma model with 1000 bootstrap replications.

Epidemiologic Investigations

We gathered data on possible transmission chains from hospital records and through interviews with patients in whom EBOV infection was suspected and their contacts, affected families, inhabitants of villages in which deaths occurred, attendants of funerals, public health authorities, and hospital staff members.

RESULTS

Identification of the EBOV Strain

To detect the causative agent, we used conventional Filoviridae-specific RT-PCR assays targeting a conserved region in the L gene to test samples obtained from 20 hospitalized patients who were suspected of being infected with a hemorrhagic fever virus.5,6,9 In addition, we performed EBOV-specific real-time RT-PCR assays targeting the glycoprotein (GP) or nucleoprotein (NP) gene.7,10 Samples from 15 of 20 patients tested positive in the conventional L gene PCR assay and the real-time assays (Table 1TABLE 1

Demographic, Clinical, and Virologic Characteristics of 15 Patients with Confirmed Ebola Virus Disease during the 2014 Outbreak in Guinea.). EBOV was identified in the serum of one patient on electron microscopy (Figure 2FIGURE 2

Transmission Chains in the Outbreak of Ebola Virus Disease in Guinea., inset) and was isolated in cell culture from 5 patients. None of the samples were positive for Lassa virus on Lassa virus–specific RT-PCR assays.8,11 Sequencing of the fragments amplified by the L gene RT-PCR assays revealed EBOV sequences. The partial L gene sequences were identical for all confirmed cases, except for a synonymous T-to-C polymorphism at position 13560, which was found in Patients C12 and C14.

Sequencing of Samples from Patients

The EBOV in samples obtained from three patients was completely sequenced with the use of conventional Sanger techniques (GenBank accession numbers, KJ660346, KJ660347, and KJ660348). The three sequences, each 18,959 nucleotides in length, were identical with the exception of a few polymorphisms at positions 2124 (G→A, synonymous), 2185 (A→G, NP552 glycine→glutamic acid), 2931 (A→G, synonymous), 4340 (C→T, synonymous), 6909 (A→T, sGP291 arginine→tryptophan), and 9923 (T→C, synonymous). The Guinean EBOV strain showed 97% identity to EBOV strains from the Democratic Republic of Congo and Gabon. Phylogenetic analysis of the full-length sequences by means of Bayesian and maximum-likelihood methods revealed a separate, basal position of the Guinean EBOV within the EBOV clade (Figure 3FIGURE 3Phylogenetic Analysis of the Ebolavirus Genus, Including the EBOV Strains from Guinea.).

Clinical and Epidemiologic Analysis

The prominent clinical features of the EBOV infection in the confirmed cases were fever, severe diarrhea, and vomiting; hemorrhage was less frequent. The case fatality rate in the initial cases was 86% (12 of 14 patients with a known outcome died). Confirmed cases originated from hospitals in Guéckédou, Macenta, Nzérékoré, and Kissidougou prefectures (Figure 1). We performed an epidemiologic look-back investigation of the transmission chains by reviewing hospital documentations and interviews with affected families, patients with suspected disease, and inhabitants of villages in which cases occurred. According to the current state of the epidemiologic investigation, the suspected first case of the outbreak was a 2-year-old child who died in Meliandou in Guéckédou prefecture on December 6, 2013 (Figure 2). Patient S14, a health care worker from Guéckédou with suspected disease, seems to have triggered the spread of the virus to Macenta, Nzérékoré, and Kissidougou in February 2014. As the virus spread, 13 of the confirmed cases could be linked to four clusters: the Baladou district of Guéckédou, the Farako district of Guéckédou, Macenta, and Kissidougou. Eventually, all clusters were linked with several deaths in the villages of Meliandou and Dawa between December 2013 and March 2014.

Current Status of the Ongoing Outbreak

This report is focused on the initial phase and geographic origin of the EBOV outbreak. Before the end of March 2014 (week 13), a total of 111 clinically suspected cases with 79 deaths (71% case fatality rate on the basis of clinical suspicion) had been recorded in the prefectures of Guéckédou, Macenta, and Kissidougou. According to the timeline of the transmission chains (Figure 2), the outbreak of confirmed disease started in the prefecture Guéckédou and then spread to Macenta and Kissidougou (Figure 4FIGURE 4

Number of Suspected Cases of Ebola Virus Disease, According to Prefecture and Week.). The male-to-female ratio among patients who died was 41:59; the median age was 35 years (interquartile range, 25 to 51).

DISCUSSION

This study demonstrates the emergence of EBOV in Guinea. The high degree of similarity among the 15 partial L gene sequences, along with the three full-length sequences and the epidemiologic links between the cases, suggest a single introduction of the virus into the human population. This introduction seems to have happened in early December 2013 or even before. Further epidemiologic investigation is ongoing to identify the presumed animal source of the outbreak. It is suspected that the virus was transmitted for months before the outbreak became apparent because of clusters of cases in the hospitals of Guéckédou and Macenta. This length of exposure appears to have allowed many transmission chains and thus increased the number of cases of Ebola virus disease.

The clinical picture of the initial cases was predominantly fever, vomiting, and severe diarrhea. Hemorrhage was not documented for most of the patients with confirmed disease at the time of sampling but may have developed during the later course of the disease. The term Ebola virus disease (rather than the earlier term Ebola hemorrhagic fever) takes into account that hemorrhage is not seen in all patients15and may help clinicians and public health officials in the early recognition of the disease. The case fatality rate was 86% among the early confirmed cases and 71% among clinically suspected cases, which is consistent with the case fatality rates observed in previous EBOV outbreaks.15-17

Phylogenetic analysis of the full-length sequences established a separate clade for the Guinean EBOV strain in sister relationship with other known EBOV strains. This suggests that the EBOV strain from Guinea has evolved in parallel with the strains from the Democratic Republic of Congo and Gabon from a recent ancestor and has not been introduced from the latter countries into Guinea. Potential reservoirs of EBOV, fruit bats of the species Hypsignathus monstrosus, Epomops franqueti, and Myonycteris torquata, are present in large parts of West Africa.18 It is possible that EBOV has circulated undetected in this region for some time. The emergence of the virus in Guinea highlights the risk of EBOV outbreaks in the whole West African subregion.

Ebola virus disease.


Key facts

The Ebola virus causes Ebola virus disease (EVD; formerly known as Ebola haemorrhagic fever) in humans.
EVD outbreaks have a case fatality rate of up to 90%.
EVD outbreaks occur primarily in remote villages in Central and West Africa, near tropical rainforests.
The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission.
Fruit bats of the Pteropodidae family are considered to be the natural host of the Ebola virus.
No specific treatment or vaccine is available for use in people or animals.
The Ebola virus causes Ebola virus disease (EVD) in humans, with a case fatality rate of up to 90%.

Ebola first appeared in 1976 in 2 simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo. The latter was in a village situated near the Ebola River, from which the disease takes its name.

Genus Ebolavirus is 1 of 3 members of the Filoviridae family (filovirus), along with genus Marburgvirus and genus Cuevavirus. Genus Ebolavirus comprises 5 distinct species:

Bundibugyo ebolavirus (BDBV)
Zaire ebolavirus (EBOV)
Reston ebolavirus (RESTV)
Sudan ebolavirus (SUDV)
Taï Forest ebolavirus (TAFV).
BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa, whereas RESTV and TAFV have not. The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but no illness or death in humans from this species has been reported to date.

Transmission

Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals. In Africa, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the rainforest.

Ebola then spreads in the community through human-to-human transmission, with infection resulting from direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and indirect contact with environments contaminated with such fluids. Burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in the transmission of Ebola. Men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness.

Health-care workers have frequently been infected while treating patients with suspected or confirmed EVD. This has occurred through close contact with patients when infection control precautions are not strictly practiced.

Among workers in contact with monkeys or pigs infected with Reston ebolavirus, several infections have been documented in people who were clinically asymptomatic. Thus, RESTV appears less capable of causing disease in humans than other Ebola species.

However, the only available evidence available comes from healthy adult males. It would be premature to extrapolate the health effects of the virus to all population groups, such as immuno-compromised persons, persons with underlying medical conditions, pregnant women and children. More studies of RESTV are needed before definitive conclusions can be drawn about the pathogenicity and virulence of this virus in humans.

Signs and symptoms

EVD is a severe acute viral illness often characterized by the sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding. Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes.

People are infectious as long as their blood and secretions contain the virus. Ebola virus was isolated from semen 61 days after onset of illness in a man who was infected in a laboratory.

The incubation period, that is, the time interval from infection with the virus to onset of symptoms, is 2 to 21 days.

Diagnosis

Other diseases that should be ruled out before a diagnosis of EVD can be made include: malaria, typhoid fever, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis and other viral haemorrhagic fevers.

Ebola virus infections can be diagnosed definitively in a laboratory through several types of tests:

enzyme-linked immunosorbent assay (ELISA)
antigen detection tests
serum neutralization test
reverse transcriptase polymerase chain reaction (RT-PCR) assay
virus isolation by cell culture.
Samples from patients are an extreme biohazard risk; testing should be conducted under maximum biological containment conditions.

Prevention and treatment

No vaccine for EVD is available. Several vaccines are being tested, but none are available for clinical use.

Severely ill patients require intensive supportive care. Patients are frequently dehydrated and require oral rehydration with solutions containing electrolytes or intravenous fluids.

No specific treatment is available. New drug therapies are being evaluated.

Natural host of Ebola virus

In Africa, fruit bats, particularly species of the genera Hypsignathus monstrosus, Epomops franqueti and Myonycteris torquata, are considered possible natural hosts for Ebola virus. As a result, the geographic distribution of Ebolaviruses may overlap with the range of the fruit bats.

Ebola virus in animals

Although non-human primates have been a source of infection for humans, they are not thought to be the reservoir but rather an accidental host like human beings. Since 1994, Ebola outbreaks from the EBOV and TAFV species have been observed in chimpanzees and gorillas.

RESTV has caused severe EVD outbreaks in macaque monkeys (Macaca fascicularis) farmed in Philippines and detected in monkeys imported into the USA in 1989, 1990 and 1996, and in monkeys imported to Italy from Philippines in 1992.

Since 2008, RESTV viruses have been detected during several outbreaks of a deadly disease in pigs in Philippines and China. Asymptomatic infection in pigs has been reported and experimental inoculations have shown that RESTV cannot cause disease in pigs.

Prevention

Controlling Ebola Reston in domestic animals
No animal vaccine against RESTV is available. Routine cleaning and disinfection of pig or monkey farms (with sodium hypochlorite or other detergents) should be effective in inactivating the virus.

If an outbreak is suspected, the premises should be quarantined immediately. Culling of infected animals, with close supervision of burial or incineration of carcasses, may be necessary to reduce the risk of animal-to-human transmission. Restricting or banning the movement of animals from infected farms to other areas can reduce the spread of the disease.

As RESTV outbreaks in pigs and monkeys have preceded human infections, the establishment of an active animal health surveillance system to detect new cases is essential in providing early warning for veterinary and human public health authorities.

Reducing the risk of Ebola infection in people
In the absence of effective treatment and a human vaccine, raising awareness of the risk factors for Ebola infection and the protective measures individuals can take is the only way to reduce human infection and death.

In Africa, during EVD outbreaks, educational public health messages for risk reduction should focus on several factors:

Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes and the consumption of their raw meat. Animals should be handled with gloves and other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked before consumption.
Reducing the risk of human-to-human transmission in the community arising from direct or close contact with infected patients, particularly with their bodily fluids. Close physical contact with Ebola patients should be avoided. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. Regular hand washing is required after visiting patients in hospital, as well as after taking care of patients at home.
Communities affected by Ebola should inform the population about the nature of the disease and about outbreak containment measures, including burial of the dead. People who have died from Ebola should be promptly and safely buried.
Pig farms in Africa can play a role in the amplification of infection because of the presence of fruit bats on these farms. Appropriate biosecurity measures should be in place to limit transmission. For RESTV, educational public health messages should focus on reducing the risk of pig-to-human transmission as a result of unsafe animal husbandry and slaughtering practices, and unsafe consumption of fresh blood, raw milk or animal tissue. Gloves and other appropriate protective clothing should be worn when handling sick animals or their tissues and when slaughtering animals. In regions where RESTV has been reported in pigs, all animal products (blood, meat and milk) should be thoroughly cooked before eating.

Controlling infection in health-care settings
Human-to-human transmission of the Ebola virus is primarily associated with direct or indirect contact with blood and body fluids. Transmission to health-care workers has been reported when appropriate infection control measures have not been observed.

It is not always possible to identify patients with EBV early because initial symptoms may be non-specific. For this reason, it is important that health-care workers apply standard precautions consistently with all patients – regardless of their diagnosis – in all work practices at all times. These include basic hand hygiene, respiratory hygiene, the use of personal protective equipment (according to the risk of splashes or other contact with infected materials), safe injection practices and safe burial practices.

Health-care workers caring for patients with suspected or confirmed Ebola virus should apply, in addition to standard precautions, other infection control measures to avoid any exposure to the patient’s blood and body fluids and direct unprotected contact with the possibly contaminated environment. When in close contact (within 1 metre) of patients with EBV, health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures).

Laboratory workers are also at risk. Samples taken from suspected human and animal Ebola cases for diagnosis should be handled by trained staff and processed in suitably equipped laboratories.

WHO response

WHO provides expertise and documentation to support disease investigation and control.

Recommendations for infection control while providing care to patients with suspected or confirmed Ebola haemorrhagic fever are provided in: Interim infection control recommendations for care of patients with suspected or confirmed Filovirus (Ebola, Marburg) haemorrhagic fever, March 2008. This document is currently being updated.

WHO has created an aide–memoire on standard precautions in health care (currently being updated). Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens. If universally applied, the precautions would help prevent most transmission through exposure to blood and body fluids.

Standard precautions are recommended in the care and treatment of all patients regardless of their perceived or confirmed infectious status. They include the basic level of infection control—hand hygiene, use of personal protective equipment to avoid direct contact with blood and body fluids, prevention of needle stick and injuries from other sharp instruments, and a set of environmental controls.

Table: Chronology of previous Ebola virus disease

Year Country Ebolavirus species Cases Deaths Case fatality
2012 Democratic Republic of Congo Bundibugyo 57 29 51%
2012 Uganda Sudan 7 4 57%
2012 Uganda Sudan 24 17 71%
2011 Uganda Sudan 1 1 100%
2008 Democratic Republic of Congo Zaire 32 14 44%
2007 Uganda Bundibugyo 149 37 25%
2007 Democratic Republic of Congo Zaire 264 187 71%
2005 Congo Zaire 12 10 83%
2004 Sudan Sudan 17 7 41%
2003 (Nov-Dec) Congo Zaire 35 29 83%
2003 (Jan-Apr) Congo Zaire 143 128 90%
2001-2002 Congo Zaire 59 44 75%
2001-2002 Gabon Zaire 65 53 82%
2000 Uganda Sudan 425 224 53%
1996 South Africa (ex-Gabon) Zaire 1 1 100%
1996 (Jul-Dec) Gabon Zaire 60 45 75%
1996 (Jan-Apr) Gabon Zaire 31 21 68%
1995 Democratic Republic of Congo Zaire 315 254 81%
1994 Cote d’Ivoire Taï Forest 1 0 0%
1994 Gabon Zaire 52 31 60%
1979 Sudan Sudan 34 22 65%
1977 Democratic Republic of Congo Zaire 1 1 100%
1976 Sudan Sudan 284 151 53%
1976 Democratic Republic of Congo Zaire 318 280 88%

Ebola outbreak in Uganda kills two.


Up to 90% of those who contract Ebola die from the virus.

A fresh outbreak of the deadly Ebola virus in Uganda has killed at least two people, the health minister has said.

Christine Ondoa said two members of the same family died over the weekend not far from the capital – and a third person was also suspected to have died in that area of the haemorrhagic fever.

An estimated 17 people died in western Uganda during an outbreak in July.

According to the medical charity Medecins Sans Frontieres (MSF), there had been no cases since August.

‘Avoid gatherings’

Dr Ondoa said that investigators had found conclusive evidence of Ebola in Luweero, about 60km (37 miles) from the capital, Kampala.

A third man had also died in the area late last month after showing symptoms of Ebola however no samples were taken from the victim and the case was not reported to health officials at the times, she said.

Five people who came into contact with those who died are being monitored. Two of them have been admitted to an isolation unit at Kampala’s main Mulago hospital, the minister said.

 

There is no known cure for Ebola, but patients can be treated for their symptoms with antibiotics, drugs for pain relief and for other diseases such as malaria, to strengthen their resistance.

The virus causes death in 90% of human cases.

Dr Ondoa said the disease is “very infectious” and kills “in a short time”, but is “easily” preventable.

Among precautionary measures she urged people to take were:

  • Avoid public gatherings, including funerals, in affected districts
  • Bury victims immediately under the supervision of health officials
  • Avoid direct contact with body fluids of Ebola patients by using gloves and masks
  • Disinfect the bedding and clothing of an infected person and
  • Avoid eating dead animals, especially monkeys.

Uganda has seen several major Ebola outbreaks over the past 12 years.

The deadliest was in 2000 when 425 people were infected. More than half of them died.

The BBC’s Catherine Byaruhanga in Kampala says many Ugandans are wondering why the country is so prone to Ebola outbreaks.

The government has said it is because its systems are getting better at detecting them.

Source:BBC