12 things you need to know about Ebola
12 things you need to know about Ebola
By Julia Belluz
Oct 17 2014, 4:57p
1
The 2014 Ebola outbreak is worse than all other Ebola outbreaks combined
The Ebola virus is a hemorrhagic fever that's fatal in about half of all cases.
Ebola typically strikes like the worst and most humiliating flu you could imagine. People get the sweats, along with body aches and pains. Then they start vomiting and having uncontrollable diarrhea. These symptoms can appear anywhere between two and 21 days after exposure to the virus. Sometimes, they go into shock. Sometimes, they bleed. Again, about half of those infected with the virus die, and this usually happens fairly quickly — within a few days or a couple of weeks of getting sick.
About half of the people who contract Ebola die — usually within a few days or weeks of getting sick. The others return to a normal life after a months-long recovery that can include periods of hair loss, sensory changes, weakness, fatigue, headaches, eye and liver inflammation.
There are five strains of Ebola, four of which have caused the disease in humans: Zaire, Sudan, Taï Forest, and Bundibugyo. The fifth, Reston, has infected nonhuman primates only. Though scientists haven't been able to confirm this, the animal host of Ebola is widely believed to be the fruit bat, and the virus only seldomly makes the leap into humans.
The current outbreak involves the Zaire strain, which was discovered in 1976 — the year Ebola was first identified in what was then Zaire (now the Democratic Republic of the Congo). That same year, the virus was also discovered in South Sudan.
The Ebola virus is extremely rare. Among the leading causes of death in Africa, it only accounts for a tiny fraction. People are much more likely to die from AIDS, respiratory infections, or diarrhea, as you can see.
2
Here's how you can catch Ebola — and how you can't
To get Ebola, you need to have direct contact with the bodily fluids — such as vomit, urine, or blood — of someone who is already sick and symptomatic to get the disease.
But what, exactly, does that mean? Here's a more concrete guide on how the virus can move from one person to another.
How you can get Ebola
1) You can get the virus if you have "direct contact" with a range of bodily fluids from a sick person, including blood, saliva, breast milk, stool, sweat, semen, tears, vomit, and urine. "Direct contact" means these fluids need to get into your broken skin (such as a wound) or touch your mucous membranes (mouth, nose, eyes, vagina).
2) So you can get Ebola by kissing or sharing food with someone who is infectious.
3) Mothers with Ebola can give the disease to their babies. Ebola spreads through breastfeeding — even after recovery from the disease. As one study put it, "It seems prudent to advise breastfeeding mothers who survive (Ebola) to avoid breastfeeding for at least some weeks after recovery and to provide them with alternative means of feeding their infants."THE EBOLA VIRUS HAS BEEN ABLE TO LIVE IN SEMEN FOR UP TO 82 DAYS
4) You can get Ebola through sex with an Ebola patient. The virus has been able to live in semen up to 82 days after a patient became symptomatic, which means sexual transmission — even with someone who has survived the disease for months — is possible.
5) You can get the virus by eating wild animals infected with Ebola or coming into contact with their bodily fluids. The fruit bat is believed to be the animal reservoir for Ebola, and when it's prepared for a meal or eaten raw, people get sick.
So you can get the virus through exposure to bat secretions. However, if you cook a bat infected with Ebola and then eat it, you won't get sick because the virus dies during cooking.
6) You can get Ebola through contact with an infected surface. Though Ebola is easily killed with disinfectants like bleach, if it isn't caught, it can live outside the body on, say, a doorknob or counter top, for several hours. In body fluids, like blood, the virus can survive for several days. So you'd need to touch an infected surface, and then put your hands in your mouth and eyes.
This is why the funerals of Ebola victims are problematic. Someone who has died from the virus will have a very high viral load. Since the virus can live in bodily fluids on their body, if you participate in the ritual washing of an Ebola victim and then touch your hands to your face, you could get the virus.
3
Ebola has never spread to this many countries before
Before 2014, Ebola was a disease that was mostly confined to remote African villages. Health officials didn't worry about it going global.
And then it went global.
THE CURRENT EBOLA EPIDEMIC IS OUTRUNNING OUR ABILITY TO STOP IT
Ebola first appeared in 1976 during twin outbreaks in Zaire (now Democratic Republic of Congo) and South Sudan, likely spread by bats from nearby jungles. Since then, there have been 20 further outbreaks, but they have usually occurred in isolated rural areas and died out quickly. The countries involved — DRC, Gabon, Sudan — have experience in stamping out the virus before it spreads.
This year has, in many ways, changed people's notions about Ebola — not the biology of the virus but how it can move through populations. In December, the virus is believed to have first turned up in the body of a child in Guéckédou, a rainforest region in southeastern Guinea. That geography was unfortunate: Guéckédou happens to share a very porous border with Sierra Leone and Liberia, where people travel in and out every day to go to the market or conduct business.
By the time the Ebola outbreak was identified in March, it had already spread to all three countries along the border.
And it keeps spreading further: In July, a Liberian-American got on a plane bound for Nigeria, bringing the virus with him and spurring 20 cases and eight deaths in Africa's most populous country. Soon, another case turned up in Senegal and, on September 30, the first-ever case was diagnosed in the United States.
There is also an unrelated outbreak of Ebola in the Democratic Republic of the Congo involving a different type of the virus. In October, Spanish officials announced that a nurse who had been caring for a repatriated priest got the virus in Madrid.
That's eight countries hit with Ebola in one year. There's never been an Ebola outbreak like this before.
The usual methods for containing Ebola, like contact tracing, don't scale to an epidemic of this size
The usual methods for containing Ebola, like contact tracing, don't scale to an epidemic of this size. In the past, public-health officials had a playbook for stopping Ebola. Because the disease isn't very contagious and spreads slowly, they just needed to find all those infected, quarantine them, and identify everyone they'd been in contact with. This could be done in sparsely populated rural areas or places with only a few cases.
But an epidemic is much harder to contain when suddenly many countries are dealing with hundreds and then thousands of cases. Since West Africa had never seen Ebola, the virus had a three-month head start before health officials in the countries involved even realized they were harboring an outbreak. It didn't help that the international community was slow to bring aid to the region, only declaring a public health emergency in August, five months after the first international spread.
This is why the current Ebola epidemic in Africa is outpacing health agencies' efforts to contain it — and why the number of infected people keeps growing exponentially.
4
Seven Americans have been diagnosed with Ebola in all
Nina Pham, the Dallas nurse with Ebola. (Nina Pham Facebook community page)
On September 30, 2014, the Centers for Disease Control and Prevention announced that Thomas Eric Duncan, a patient in Dallas, was diagnosed with Ebola — the first time the disease was diagnosed in the US. He died nine days later.
Since then, health workers who cared for him have been getting sick, spreading fear and panic among the health-care community and general population. On October 12, Nina Pham — one of Duncan's nurses — tested positive for the disease. This was the first-ever transmission of the virus in the United States. On October 15, officials announced a second nurse, Amber Vinson, got the virus while caring for Duncan, too.
In addition to Pham and Vinson, five other Americans have been infected with Ebola. All got sick overseas in Africa and later received treatment in the United States. And all of them survived.
Most recently, Nebraska Medical Center took in Ashoka Mukpo, a freelance cameraman who got Ebola while working in Liberia with NBC News. He is in stable condition.
Before him, an unnamed American who worked for the World Health Organization in Sierra Leone returned to Emory University Hospital in Atlanta for treatment.
Three American medical missionaries — Kent Brantly, Nancy Writebol, and Richard Sacra — came down with the illness in Liberia. Brantly and Writebol were treated at Emory. Like Mukpo, Sacra was treated in Nebraska. All of them have survived.
Separately Patrick Sawyer, a Liberian-American, got Ebola in Liberia where he worked at the Ministry of Finance. He died in Lagos, Nigeria in July.
5
Ebola could infect 1.4 million people by January
How bad could the Ebola outbreak get? There are lots of predictions floating around. The World Health Organization projects that 20,000 people will be infected in November. HeathMap, put the number at about 14,000 if there's no improvement in the situation.
But in worst-case scenario, the Centers for Disease Control and Prevention project that up to 1.4 million people could be infected by January.
Behind that projection lurk fears that the supplies and health-care workers needed to bend the epidemic curve downward and save lives won't reach Africa quickly enough. Doctors need to be trained. Hospitals need to be built. There are dire shortages of supplies. (The Liberian government estimates it needs 84,841 body bags, while it has only 4,901.)
Scarier yet, experts believe there has been widespread under-reporting of actual Ebola cases, since people have been turned away from overflowing hospitals and others have been hiding in their homes, afraid that coming out with Ebola will mean they never see their families again or that they are ostracized by their neighbors. One estimate holds that for every four known cases of Ebola, there are six unknown cases.
No matter the precise figure, all these models assume the growth in cases will continue to rise for some time. "We're nine months into an exponential growth process," says infectious disease modeler David Fisman. "This is an impossibly huge epidemic, and it's been allowed to reach a point where it's basically the biggest infectious-disease forest fire one could imagine."
6
For every four cases of Ebola we know of, there might be six that we don't
While official estimates suggest there are already more than 8,000 cases of Ebola this year, the real number is likely much, much higher. The Centers for Disease Control and Prevention estimate that the actual number of Ebola cases is roughly 2.5 times higher than the reported figures — so for every four Ebola cases we know of, there could be six that we don't.
The CDC isn't alone in this. "There is widespread under-reporting of new cases," warns the World Health Organization. The WHO has continually said that even its current dire numbers don't reflect the full reality. The estimated 8,000-plus Ebola cases in West Africa could just be the tip of the iceberg.
Health workers sterilize the house and prepare a body for burial in Lango village, Kenema, Sierra Leone. (Photo courtesy of Andalou Agency)
To understand how an Ebola case could be missed, you need to understand what it takes to actually find and count a case.
Often times, potential cases are communicated through dedicated hot-lines, which citizens can call in to report on themselves or their neighbors. Health workers or doctors can call in cases, too. These reports are forwarded to local surveillance response teams.
All these cases need to be followed up on and verified to be counted. To do that, a team of two to four investigators is dispatched to hunt for the suspected Ebola victim.
Tracking down Ebola cases is difficult in places where the roads and communication infrastructure are poor.
Actually tracking these people down isn't straightforward, especially in areas where the roads and communication infrastructure are poor. Investigators can spend days chasing a rumor.
These health teams also work under constant stress and uncertainty. During this outbreak, they've faced violence, angry crowds, and blockaded roads. They can't wear protective gear because they'll scare off locals.
When they finally locate an Ebola victim, he or she may not always be lucid enough to talk or even still alive. So the investigators need to interview friends, family or community members to determine whether it's Ebola that struck — always keeping a distance.
If this chase appears to have led to an Ebola patient, the health team notifies a dispatcher to have that person transported by ambulance to a nearby clinic or Ebola treatment center for testing and isolation.
If the person is already dead, they notify a burial team, which arrives in full personal protective gear. They put the body in a body bag, decontaminate the house, swab the corpse for Ebola testing, and transport the body to the morgue.
But confirming the cause of death doesn't always happen. There have been reports that mass graves hold uncounted Ebola cases. With limited resources, too, saving people who are alive tends to take precedent over managing and testing dead bodies.
Reported cases are then communicated to the ministry of health in the country. These reports are combined with counts from NGOs and other aid organizations working in the region. The numbers come in three forms: lab-test confirmed cases, suspected cases, and probable cases. The WHO classifies a suspected case as an illness in any person, dead or alive, who had Ebola-like symptoms. A probable case is any person who had symptoms and contact with a confirmed or probable case.
The ministry of health compiles and crunches this information and sends it to the WHO country office. They then report that to the WHO's regional Africa office in Brazzaville, Congo and that message is passed along to Geneva, home to WHO's headquarters.
"At each step along the way the case can fall out of the pool of 'counteds.'"
To get to this point, Dr. David Fisman, an infectious disease modeler working on Ebola, summed up: "A person needs to have recognized symptoms, seek care, be correctly diagnosed, get lab testing — if they're going to be a confirmed case — have the clerical and bureaucratic apparatus actually transmit that information to the people doing surveillance. At each step along the way the case can fall out of the pool of 'counteds.'"
7
The majority of Ebola deaths may not be from Ebola
Of this epidemic, the World Bank said Ebola may deal a "potentially catastrophic blow" to the West African countries reeling with the virus. Businesses are shutting down, people aren't working, kids aren't going to school.
The epidemic has also led to widespread food insecurity. "The fertile fields of Lofa County, once Liberia's breadbasket, are now fallow. In that county alone, nearly 170 farmers and their family members have died from Ebola," the WHO director warned. "In some areas, hunger has become an even greater concern than the virus."
A wall bearing information about Ebola in Monrovia, Liberia. (Photo by Pascal Guyot/AFP)
There's also the fact that people are going to suffer and die more from other diseases as the scarce health resources in the region go to Ebola. Speaking at the United Nations, Dr. Joanne Liu, international president of Médecins Sans Frontières, said, "Mounting numbers are dying of other diseases, like malaria, because health systems have collapsed."
Jimmy Whitworth, the head of population health at Britain's Wellcome Trust, told the Independent in an interview, "People aren't going to hospitals or clinics because they're frightened, there aren't any medical or nursing staff available."
"West Africa will see much more suffering and many more deaths during childbirth and from malaria, tuberculosis, HIV-AIDS, enteric and respiratory illnesses, diabetes, cancer, cardiovascular disease, and mental health during and after the Ebola epidemic," wrote disease researchers Jeremy Farrar, of the Wellcome Trust, and Peter Piot, of the London School of Hygiene and Tropical Medicine in an article in the New England Journal of Medicine.
So this virus has wreaked incalculable damage on not only the bodies of those infected, but on others who are not getting health care they need, and the health systems and economies of West Africa.
Dr. Ezie Patrick, with the World Medical Association who is based in Nigeria, focused on the simple and disquieting fact that Ebola has also taken the lives of health workers in places where the ratio of doctors per population is abysmally low. "Sadly Ebola is claiming the lives of the few doctors who have decided to work in these challenging health systems thereby worsening the dearth and also increasing the brain drain leading to far fewer doctors in the region."
The disaster could last longer than the epidemic itself. Before the Ebola outbreak, West African nations were seeing promising signs of economic growth. Sierra Leone, for example had the second highest real GDP growth rate in the world. Liberia was 11th in 2013.
Now, there's worry that Ebola will slam the brakes on that development. "A prolonged outbreak could undercut the growth that these countries were finally starting to experience, taking away the resources that would be necessary for improving the health and education systems," says Jeremy Youde, a professor of political science at the University of Minnesota Duluth.
"These countries are generally not starting from a great position as it is, so they don't have much of a cushion to absorb long-term economic losses. If the international economy turns away from West Africa and brands it as diseased, that could be very problematic."
8
Over 230 health-care workers have died from Ebola
One disturbing feature of the current epidemic is that so many health workers have lost their lives while caring for the sick or trying to spread public-health messages about Ebola.
This is partly because Ebola is transmitted through bodily fluids, and no one has more contact with the bodily fluids of an Ebola patient than his or her nurse. The only two people who have contracted Ebola in the US are nurses.
In Africa, the situation is much more dire. In total, over 230 health-care workers have died from Ebola, according to the World Health Organization. To put that into context, in the second biggest outbreak in history — in Zaire in 1976 — 11 medical personnel died. And that was the first recorded outbreak, when measures to prevent transmission of the virus weren't well established.
There are several causes for the death toll.
The first is that health workers haven't had access to the supplies they need. Since the disease is transmitted through direct exposure to bodily fluids, they are advised to wear face masks, goggles, gowns and gloves while caring for patients. But doctors and nurses in the developing-country context don't always have that protective gear.
A hospital guard waits to greet patients, some suspected of suffering from the Ebola virus, in Monrovi. (Photo by Pascal Guyot/AFP)
Or if they do, they want to use their scarce supplies when absolutely necessary, which brings us to another reason for the alarming loss of health workers: many doctors caring for Ebola patients in West Africa had no idea they were seeing Ebola patients. The disease had never appeared in this part of Africa, and it's difficult to diagnose, sometimes masquerading as malaria or the flu until symptoms worsen. So doctors and nurses weren't always protecting themselves as they would from a deadly virus.
A third reason for the outsized health-worker death toll is that the total number of people infected with the virus this year is so much greater. In 1976, the death toll was 280 and there were 318 reported cases. In this 2014 outbreak, that denominator is nearly twenty times larger.
9
Poverty is one big reason why Ebola is spreading so quickly
(Joss Fong / Vox)
Ebola can be stopped. But it takes resources, and a working health-care system.
The three countries hardest hit by the Ebola epidemic — Guinea, Sierra Leone, and Liberia — all have very weak health systems and little money to spend on health care. That has constrained their ability to stop the epidemic.
In most of West Africa, health spending amounts to less than $100 per person per year (in the United States, it's about $8,000). What's more, Guinea, Sierra Leone, and Liberia all have some of the worst maternal and child mortality rates on the planet — an indicator of a failing health system.
Experts point out that scarce resources make it extremely difficult to contain the Ebola epidemic: "If you're in a hospital in Sierra Leone or Guinea, it might not be unusual to say, 'I need gloves to examine this patient,' and have someone tell you, 'We don't have gloves in the hospital today,' or 'We're out of clean needles,' — all the sorts of things you need to protect against Ebola," says Daniel Bausch, associate professor at the Tulane University School of Public Health and Tropical Medicine, who is working with the WHO and MSF on the outbreak.
Bausch would walk into the hospital in the morning and find patients on the floor in pools of vomit, blood, and stool. They had fallen out of their beds during the night, and they were delirious. "What should happen is that a nursing staff or sanitation officer would come and decontaminate the area," he said. "But when you don't have that support, obviously it gets more dangerous."
Along with poverty and a health system too weak to combat the virus, illiteracy has contributed to the problem. As you can see in the map below, Guinea, Liberia, and Sierra Leone (circled in green) have some of the lowest literacy rates in the world.
Adult literacy by country. (Map courtesy of Unesco.)
Poor literacy has made it much harder for aid workers to mount a public-health information campaign and explain to people how they can stop the spread of Ebola. It also helped to fuel a rumor mill about supposed cures. One persistent myth has been that hot water and salt can stop Ebola. Others suggest faith healing or hot chocolate, coffee and raw onions will stamp out the virus.
This has, in turn, fueled Ebola's spread in the region.
10
Global health agencies were too slow in responding to the Ebola crisis
"Ebola is a very preventable disease," said Lawrence Gostin, a health law professor at Georgetown University. "We've had over 20 previous outbreaks and we managed to contain all of them."It could take months for a full response to get off the ground But
this time, the international response just wasn't there. "There was no mobilization," Gostin said. "The World Health Organization didn't call a public health emergency until August — five months after the first international spread [in March]."
It took three months for health officials to identify Ebola as the cause of the epidemic, another five months to declare a public health emergency, and two more months to mount a humanitarian response. In reality, a full response could take several more months still to get off the ground.
Part of the reason for the slow response can be attributed to budget cuts at the WHO that have left the agency understaffed and under-resourced. The WHO also now sees itself as a "technical agency," providing analysis and data, and not as a first responder.
But, as an editorial in the journal Nature pointed out: "If the WHO is not the first responder to an emergency such as this, then who is?"
The International Health Regulations governing disease responses are also flawed and broken, leaving us unprepared for outbreaks. So this Ebola epidemic has served as a reminder of just how slow and poorly coordinated our global responses to outbreaks are, and this is a problem because any infectious diseases expert will tell you that the best way to stop an outbreak is to contain it early.
A Liberian health worker interviews family members of a woman suspected of dying of the Ebola virus in Monrovia, Liberia. (John Moore/Getty Images)
Health is not free from politics, either. Sadly, the world only seemed to wake up to Ebola after two American missionaries got infected in Liberia. One of them, Dr. Kent Brantly, testified before the Senate in the US to make that point: "This unprecedented outbreak began nine months ago but received very little attention from the international community until the events of mid-July when my friend and colleague, Nancy Writebol, and I became infected." He added: "The response, however, is still unacceptably out-of-step with the size and scope of the problem now before us."
"(Ebola) could establish itself as an endemic infection because of a highly inadequate and late global response."
This awakening came too late. Preeminent disease researchers, in an article in the New England Journal of Medicine, wrote, "Ebola has reached the point where it could establish itself as an endemic infection because of a highly inadequate and late global response."
Still, the global health community is now moving aggressively. The director of the World Health Organization called this Ebola epidemic "the greatest peacetime challenge" the world has ever faced. President Barack Obama called the epidemic "not just a threat to regional security… [but] a potential threat to global security." For this reason, the United States will send more than 3,000 troops to fight Ebola and has now funded the largest international response in the history of the CDC.
The United Nations Security Council has also characterized the virus as a threat to international peace and security, holding its second-ever disease-focused meeting and setting up a special UN mission to deal with the epidemic. The Security Council unanimously passed a resolution asking countries around the world to urgently send medical workers and supplies to stop the epidemic.
11
The key to stopping Ebola in the US is stopping it in Africa
(Graphic courtesy of PLoS Currents: Outbreaks)
The longer this epidemic rages on in West Africa, the more people get infected, the more chance there is of the virus finding new hosts to infect and spreading further around the world.
AIR TRAVEL IS ONE LIKELY METHOD OF TRANSPORT
Beth Bell, director of the National Center for Emerging and Zoonotic Infectious Diseases at the CDC, testified before the Senate on this point: "In the worst case scenario, we continue to see an exponential rise in cases that we're currently seeing. And an important corollary to that is exportation to other countries." The outbreak that originated in Guinea in December has already spread to seven countries as of October and the Democratic Republic of the Congo has been battling a separate outbreak.
For Ebola to continue to move, travelers are the most likely method of transport. Infectious-disease researchers recently looked at flight patterns out of West Africa and local transmission dynamics to figure out how likely it would be that an Ebola-positive person gets on a plane with the virus and brings it to a new setting.
While countries in Africa are most at risk, as the Ebola epidemic continues to over the coming the months, the risk of Ebola going international grows, too.
Unfortunately, restricting the movement of people because of Ebola, while politically expedient in a time of panic, isn't economically viable or effective at stopping its spread. In fact, it could have the opposite of the desire effect. As Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said, "To completely seal off and don't let planes in or out of the West African countries involved, then you could paradoxically make things much worse in the sense that you can't get supplies in, you can't get help in, you can't get the kinds of things in there that we need to contain the epidemic."
12
There's no cure for Ebola — but a number of candidates are being studied
Even though Ebola has been known for almost 40 years, vaccine and drug development for the disease has been slow at best. Notably, most of the investment in Ebola cures has come from government agencies (such as the US Department of Defense) interested in researching potential biological terrorism weapons — not in helping Africa.
But the Ebola epidemic burning in West Africa has sparked unprecedented focus on finding an Ebola cure and speeding up the drug testing and approval process for the current therapies being developed.
In September 2014, the drug company GlaxoSmithKline announced it took the unprecedented step of starting mass production on an Ebola vaccine that has just begun being tested in humans.
THE USUAL DRUG APPROVAL PROCESSES ARE BEING CONDENSED OR SKIPPED
That news followed a decision by the World Health Organization to allow unproven and experimental treatments on people in this public health emergency — which means the usual drug approvals process will be condensed or phases of clinical testing potentially skipped.
One such drug is ZMapp, an antibody therapy that was used in the two American medical missionaries infected with Ebola in Liberia. The drug was developed by several stakeholders — Mapp Biopharmaceutical, Inc. and Leaf Bio in San Diego, Defyrus Inc. from Toronto, the U.S. government and the Public Health Agency of Canada — to treat Ebola. It's made up of a cocktail of monoclonal antibodies, which are essentially lab-produced molecules manufactured from tobacco plants that mimic the body's immune response to theoretically help it attack the Ebola virus.
But the truth is, while these patients did improve after receiving the drug, a third patient who got ZMapp died. We won't know whether the drug worked or whether it's harmful on the basis of data from three patients, especially since half of those infected with this strain of the virus live anyway.
Kent Brantly, one of the American medical missionaries infected with Ebola. (Photo by Jessica McGowan)
Another experimental therapy now being tried in humans is TKM-Ebola, developed by the Canadian pharmaceutical company Tekmira (with the help of US Department of Defense funding). After being shown to reduce mortality in Ebola-infected monkeys, the FDA froze and then re-started clinical trials recently.
Whether this Ebola drug development actually turns out to be the silver lining of the worst epidemic in history remains to be seen. For every 5,000 compounds discovered at this stage, only about five are allowed to be tried in humans. These Ebola therapies are at only the earliest stage of drug testing, and they have a long way to go before proving useful. What's more, an Ebola drug won't fix all the health systems issues that allowed the disease to spread in Africa.
As Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, wrote in the New England Journal of Medicine: "While these interventions remain on accelerated development paths, public health measures are available today that have a proven record of controlling (Ebola) outbreaks. Premature deployment of unproven interventions could cause inadvertent harm, compromising an already strained relationship between health care professionals and patients in West Africa."
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