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Kamis, 09 Oktober 2014

BELAJAR TENTANG SERANGAN VIRUS EBOLA YANG MEMATIKAN PADA MANUSIA

Perpustakaan  Keluarga 
Helmut Todo Tua Simamora dan dr. Olga Y.V Hutapea



Berikut merupakan kutipan ilmiah kedokteran tentang virus ebola yang sangat bermanfaat diketahui sehingga disusun dan digunakan sebagai referensi pribadi.




Coloured transmission electron micro graph of a single Ebola virus, the cause of Ebola fever

A test for Ebola has been carried out on a female passenger who died after arriving in the UK from The Gambia.
The Department for Health said the test on the elderly woman, who landed at Gatwick Airport, came back negative on Sunday afternoon.
Some 728 people have died of Ebola in Guinea, Liberia and Sierra Leone this year, in the worst-ever outbreak of the disease.
Public Health England says the risk to the UK remains very low.
The Ebola virus spreads through human contact with a sufferer's bodily fluids.
Initial flu-like symptoms can lead to external haemorrhaging from areas like eyes and gums, and internal bleeding which can lead to organ failure. The current mortality rate is about 55%.
'No public health risk'
The woman, believed to be in her early 70s, had been a passenger on a Gambia Bird flight that arrived at Gatwick on Saturday morning.
She collapsed at the airport and was later pronounced dead in hospital.
A Department of Health spokeswoman said the passenger's symptoms had not suggested she was an Ebola victim but the test was carried out because she had travelled from West Africa.
Dr Brian McCloskey, director of global public health at Public Health England (PHE), said: "There was no health risk to other passengers or crew, as the passenger did not have symptoms during the flight.
"It was considered very unlikely to be a case of Ebola but testing was done as a precaution, and was negative.
"The correct procedures were followed to confirm there was no reason to quarantine the airplane, the passengers or staff. PHE can confirm there was no public health risk around the sad death of this individual."

A nurse sprays disinfectant at an isolation unit in Liberia

A nurse sprays disinfectant at an isolation unit in Liberia

Ebola virus disease (EVD)
  • Symptoms include high fever, bleeding and central nervous system damage
  • Fatality rate can reach 90%
  • Incubation period is two to 21 days
  • There is no vaccine or cure
  • Supportive care such as rehydrating patients who have diarrhoea and vomiting can help recovery
  • Fruit bats are considered to be virus' natural host
A Gatwick spokeswoman said the aircraft, as well as some airline and airport staff, were isolated "as a precaution" but that the plane was later cleared for its return journey.
Foreign Secretary Philip Hammond has said the government is taking the outbreak, and the threat to the UK, "very seriously".
Ministers have discussed what precautionary measures could be taken if any UK nationals in West Africa become infected with Ebola.
Public Health England has advised UK medical staff to watch out for unexplained illnesses in patients who have visited West Africa.
It said no cases of imported Ebola have ever been reported in the UK.
The US is to send at least 50 public health experts to the region to help fight the disease. They are expected to arrive in the next month.
Meanwhile, American Ebola patient Dr Kent Brantly is improving in hospital after returning to the US from Liberia. Another infected US citizen, aid worker Nancy Writebol, is expected to arrive in the US soon.
A medical official with the U.N. Mission in Liberia who tested positive for Ebola arrived in the German city of Leipzig on Thursday to be treated at a local clinic with specialist facilities, authorities said.
The unidentified medic infected in Liberia is the second member of the U.N. mission, known as UNMIL, to contract the virus. The first died on Sept. 25. He is the third Ebola patient to arrive in Germany for treatment.
"The man will be treated on an isolation ward... with strict security measures," said Dr Iris Minde, head of Leipzig's St Georg clinic in a statement. "There is no danger of infection for other patients, relatives, visitors or the public."
The hospital stressed its doctors and carers were fully prepared and have regular training on how to work in an isolation ward with highly infectious patients. A Spanish nurse became the first person to contract Ebola outside of Africa, while caring for a priest who died of the disease.
The world's worst outbreak of Ebola on record has killed 3,879 people by Oct. 5, most of them in Liberia, Guinea and Sierra Leone, according to the latest figures from the World Health Organisation (WHO).
A WHO employee who arrived in Germany from Sierra Leone for treatment last month was released last weekend after successful treatment at a clinic in Hamburg. Another patient is being treated in Frankfurt. (Reporting by Reuters television; Writing by Alexandra Hudson; Editing by Tom Heneghan)
The current Ebola outbreak sweeping through West Africa likely began at the funeral of a healer in Sierra Leone.
“The funeral was for an herbalist or traditional medicine practitioner in Koindu, a town in Sierra Leone,” says Robert Garry, professor of microbiology and immunology at Tulane University.
“The herbalist had treated several patients from neighboring Guinea, one or more of whom were apparently infected with Ebola virus.”
Scientists were able to sequence 99 Ebola virus genomes using blood samples from 78 patients, painting a record “real-time” snapshot of how the virus rapidly mutated as the outbreak spread.
The analysis, published in the journal Science, shows that the West African Ebola strain was distantly related to a strain that has been circulating in central Africa for decades, but likely migrated to the region in 2004.
Scientists found 300 mutations that differentiate the viral genomes involved in this outbreak from previous outbreaks.
“This is first study to document deep viral genomics during a human outbreak of a hemorrhagic fever like Ebola,” Garry says. “We get a close look at not only how the virus is evolving as it passes from one person to the next, but also how the virus changes as it replicates within a person.”
The results can help researchers as they work to develop antibody-based treatments using the genetic profile of the virus. They also help improve the accuracy of diagnostic tests.
“The diagnostics used in the field are polymerase chain reaction (PCR) based,” Garry says. “PCR depends on finding precise matches between a synthetic primer and the viral genome. If the virus genome mutates, the PCR assay may not work or not work as well.”
Coauthors of the study are from Harvard University, the Broad Institute of MIT, and researchers in Sierra Leone.

Electron micrograph image of Ebola virus

Scientists are racing to understand - and combat - the Ebola virus

The Ebola outbreak in West Africa is unlike anything since the emergence of HIV/Aids, top US medical official Thomas Frieden has said.
The world needed to work fast so it did not become "the next Aids", the director of the Centers for Disease Control and Prevention (CDC) said.
Dr Frieden was addressing a high-level World Bank forum about the crisis.
The outbreak has killed more than 3,860 people, mainly in West Africa, including more than 200 health workers.
On Thursday, a Liberian doctor died of the disease at a treatment centre in Monrovia, health officials said.
Ugandan-born John Taban Dada had been working at the country's largest hospital, the John F Kennedy Memorial Center, his former colleagues said.
His death brings to four the number of doctors who have died in Liberia since the outbreak.
Earlier this week, a Spanish nurse became the first person to contract the deadly virus outside of West Africa.
"I would say that in the 30 years I've been working in public health, the only thing like this has been Aids," Mr Frieden said.
Ebola virus
As the outbreak continues to spread, the fear of catching the disease is rising.
Experts are learning more about how to contain the virus that has infected around 7,500 people in West Africa.
The race is on to stop this deadly disease that kills more than half of those it infects.
Here's what is known.
DON'T TOUCH
Ebola is spread by direct contact with contaminated body fluids. Blood, vomit and saliva can all carry and spread the deadly virus.
View of gloves and boots used by medical staff, drying in the sun, at a centre for victims of the Ebola virus in Guekedou, on 1 April 2014
Medical staff wear rubber gloves that must be regularly disinfected
The relatives of sick patients and the healthcare workers who care for them are at highest risk of infection, but anyone who comes into close proximity potentially puts themselves at risk.
For that reason, contact should only be for essential medical care and always under the full protection of the right clothing.
The virus can't breach protective gear, such as gloves, a mask, goggles, a full body suit and tough rubber wellington boots, but too few have access to state-of-the-art kit.
Those who do get to wear it should keep changing it every 40 minutes to be safe. Inside the suit it can get up to about 40C. Getting into the kit takes about five minutes. Taking it off again takes the wearer and a designated helper "buddy" about 15 minutes.
This is one of the most dangerous times for contamination and people are sprayed with chlorine as this happens.
INTERACTIVE
  • Protective Ebola suit

    ×
    health worker with protective ebola suit
  • Goggles

    ×

    Goggles, or eye visors, are used to provide cover to the eyes, protecting them from splashes. The goggles are sprayed with an anti-fogging solution before being worn.
  • Medical mask

    ×

    Covers the mouth to protect from sprays of blood or body fluids from patients. When wearing a respirator, the medical worker must tear this outer mask to allow the respirator through.
  • Respirator

    ×

    A respirator is worn to protect the wearer from a patient's coughs. According to guidelines from the medical charity Medecins Sans Frontieres (MSF), the respirator should be put on second, right after donning the overalls.
  • Medical Scrubs

    ×

    A surgical scrub suit, durable hospital clothing that absorbs liquid and is easily cleaned, is worn as a baselayer underneath the overalls. It is normally tucked into rubber boots to ensure no skin is exposed.
  • Overalls

    ×

    The overalls are placed on top of the scrubs. These suits are similar to hazardous material (hazmat) suits worn in toxic environments. The team member supervising the process should check that the equipment is not damaged.
  • Double gloves

    ×

    A minimum two sets of gloves are required, placed over the suit sleeves. Medical workers must change gloves between patients, performing thorough hand hygiene before donning a new pair. Heavy duty gloves are used whenever workers need to handle infectious waste.
  • Apron

    ×

    A waterproof apron is placed on top of the overalls as a final layer of protective clothing.
  • Boots

    ×

    Ebola health workers typically wear rubber boots, with the scrubs tucked into the footwear. If boots are unavailable, workers must wear closed, puncture and fluid-resistant shoes.
  • Surgical cap

    ×

    The cap forms part of a protective hood covering the head and neck. It offers medical workers an added layer of protection, ensuring that they cannot touch any part of their face whilst in the treatment centre.
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COVER YOUR EYES
personal protective equipment
If an infected droplet does get on to your skin, it can be washed away immediately with soap and water or an alcohol-based hand sanitiser.
The eyes are a different matter. A spray of droplets from a sneeze directly into the eye, for example, could let the virus in.
Similarly, the mucous membranes of the mouth and inside of the nose are vulnerable areas, as is broken skin.
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LAUNDRY
worker in protective clothing
One of the most shocking symptoms of Ebola is bleeding. Patients can bleed from the eyes, ears, nose, mouth and rectum. Diarrhoea and vomit may also be tainted with blood.
A big infection risk is cleaning up. Any laundry or other clinical waste should be incinerated. Any medical equipment that needs to be kept should be decontaminated.
Without adequate sterilisation, virus transmission can continue and amplify.
Minute droplets on a surface that hasn't been adequately cleaned could, in theory, pose a risk. And it's unclear how long the virus could sit there and remain a threat. Flu viruses and other germs can live two hours or longer on hard environmental surfaces like tables, doorknobs, and desks.
The nurse who recently became infected while caring for two Ebola patients in Spain had twice gone into the room where one of the the patients was being treated - to be directly involved in his care and to disinfect the room after his death. Both times she was wearing protective clothing.
Soap and water or alcohol-based hand sanitisers readily disrupt the envelope of this single-stranded RNA virus, and decontamination with dilute bleach is effective and readily available even in remote settings.
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CONDOMS
condoms
Generally, once someone recovers from Ebola and they have the all-clear, they can no longer spread the virus.
But Ebola virus has been found in semen for up to three months.
For this reason, doctors say that people who recover from Ebola should abstain from sex or use condoms for three months
Health workers in isolation ward, southern Guinea (1 April)
Healthcare workers are among those most at risk of catching Ebola

The Ebola outbreak in West Africa is the world's deadliest to date and the World Health Organization has declared an international health emergency as more than 3,850 people have died of the virus in Guinea, Liberia, Sierra Leone and Nigeria this year.
What is Ebola?
Ebola is a viral illness of which the initial symptoms can include a sudden fever, intense weakness, muscle pain and a sore throat, according to the World Health Organization (WHO). And that is just the beginning: subsequent stages are vomiting, diarrhoea and - in some cases - both internal and external bleeding.
The disease infects humans through close contact with infected animals, including chimpanzees, fruit bats and forest antelope.
It then spreads between humans by direct contact with infected blood, bodily fluids or organs, or indirectly through contact with contaminated environments. Even funerals of Ebola victims can be a risk, if mourners have direct contact with the body of the deceased.
How Ebola spreads
The incubation period can last from two days to three weeks, and diagnosis is difficult. The human disease has so far been mostly limited to Africa, although one strain has cropped up in the Philippines.
Healthcare workers are at risk if they treat patients without taking the right precautions to avoid infection. People are infectious as long as their blood and secretions contain the virus - in some cases, up to seven weeks after they recover.
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Where does it strike?
Ebola outbreaks occur primarily in remote villages in Central and West Africa, near tropical rainforests, says the WHO.
Woman dries bushmeat by the side of the road, Ivory Coast (29 March)
Bushmeat - from animals such as bats, antelopes, porcupines and monkeys - is a prized delicacy in much of West Africa but can also be a source of Ebola
It was first discovered in the Democratic Republic of Congo in 1976 since when it has mostly affected countries further east, such as Uganda and Sudan.
Ebola deaths since 1976
A map showing Ebola outbreaks since 1976
This year's outbreak is unusual because it started in Guinea, which has never before been affected, and it quickly spread to urban areas.
ebola death toll regional map October 4
Figures accurate from 4-6 October, depending on country. Death toll in Liberia includes probable, suspect and confirmed cases, while in Sierra Leone and Guinea only confirmed cases are shown
From Nzerekore, a remote area of south-eastern Guinea, the virus spread to the capital, Conakry, and neighbouring Liberia and Sierra Leone.
There have been 20 cases of Ebola being imported by someone travelling from a country of widespread transmission to Nigeria, with eight confirmed deaths. The US and Senegal have both confirmed one case each. The US Centers for Disease Control and Prevention (CDC) said in September that the virus might have been successfully contained in Nigeria and Senegal.
In October, a nurse in Spain became the first person to contract the deadly virus outside of West Africa, after treating two Spanish missionaries who had eventually died of Ebola in Madrid.

Ebola deaths

Up to 4-5 October

3,865
Deaths (probable, confirmed and suspected)
  • 2,210 Liberia
  • 768 Guinea
  • 879 Sierra Leone
  • 8 Nigeria
Getty
The medical charity Medecins Sans Frontieres (MSF) says the outbreak is "unprecedented" in the way the cases were scattered in multiple locations across Guinea, hundreds of kilometres apart, and says it is a "race against time" to check people who come into contact with sick people in neighbouring Sierra Leone.
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Can cultural practices spread Ebola?
Ebola is spread through close physical contact with infected people. This is a problem for many in the West African countries currently affected by the outbreak, as practices around religion and death involve close physical contact.
Hugging is a normal part of religious worship in Liberia and Sierra Leone, and across the region the ritual preparation of bodies for burial involves washing, touching and kissing. Those with the highest status in society are often charged with washing and preparing the body. For a woman this can include braiding the hair, and for a man shaving the head.
Volunteers bury the body of an Ebola victim in Sierra Leone
Strict precautions must be observed when burying those who have died of Ebola
If a person has died from Ebola, their body will have a very high viral load. Bleeding is a usual symptom of the disease prior to death. Those who handle the body and come into contact with the blood or other body fluids are at greatest risk of catching the disease.
MSF has been trying to make people aware of how their treatment of dead relatives might pose a risk to themselves. It is a very difficult message to get across.
All previous outbreaks were much smaller and occurred in places where Ebola was already known - in Uganda and the DR Congo for example. In those places the education message about avoiding contact has had years to enter the collective consciousness. In West Africa, there simply has not been the time for the necessary cultural shift.
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What precautions should I take?
Avoid contact with Ebola patients and their bodily fluids, the WHO advises. Do not touch anything - such as shared towels - which could have become contaminated in a public place.
A Liberian man washes his hands as an extra precaution for the prevention of the spread of the Ebola virus before entering a church service in Monrovia, Liberia -27 July 2014
Washing hands and improving hygiene is one of the best ways to fight the virus
Carers should wear gloves and protective equipment, such as masks, and wash their hands regularly.
The WHO also warns against consuming raw bushmeat and any contact with infected bats or monkeys and apes. Fruit bats in particular are considered a delicacy in the area of Guinea where the outbreak started.
In March, Liberia's health minister advised people to stop having sex, in addition to existing advice not to shake hands or kiss. The WHO says men can still transmit the virus through their semen for up to seven weeks after recovering from Ebola.
INTERACTIVE
  • Protective Ebola suit

    ×
    health worker with protective ebola suit
  • Goggles

    ×

    Goggles, or eye visors, are used to provide cover to the eyes, protecting them from splashes. The goggles are sprayed with an anti-fogging solution before being worn.
  • Medical mask

    ×

    Covers the mouth to protect from sprays of blood or body fluids from patients. When wearing a respirator, the medical worker must tear this outer mask to allow the respirator through.
  • Respirator

    ×

    A respirator is worn to protect the wearer from a patient's coughs. According to guidelines from the medical charity Medecins Sans Frontieres (MSF), the respirator should be put on second, right after donning the overalls.
  • Medical Scrubs

    ×

    A surgical scrub suit, durable hospital clothing that absorbs liquid and is easily cleaned, is worn as a baselayer underneath the overalls. It is normally tucked into rubber boots to ensure no skin is exposed.
  • Overalls

    ×

    The overalls are placed on top of the scrubs. These suits are similar to hazardous material (hazmat) suits worn in toxic environments. The team member supervising the process should check that the equipment is not damaged.
  • Double gloves

    ×

    A minimum two sets of gloves are required, placed over the suit sleeves. Medical workers must change gloves between patients, performing thorough hand hygiene before donning a new pair. Heavy duty gloves are used whenever workers need to handle infectious waste.
  • Apron

    ×

    A waterproof apron is placed on top of the overalls as a final layer of protective clothing.
  • Boots

    ×

    Ebola health workers typically wear rubber boots, with the scrubs tucked into the footwear. If boots are unavailable, workers must wear closed, puncture and fluid-resistant shoes.
  • Surgical cap

    ×

    The cap forms part of a protective hood covering the head and neck. It offers medical workers an added layer of protection, ensuring that they cannot touch any part of their face whilst in the treatment centre.
Fighting the fear and stigmatisation surrounding Ebola is one of the greatest challenges health workers face.
But health workers themselves are becoming scared of treating patients, and are demanding better protective clothing when exposed to patients.
Ebola has already claimed the lives of dozens of doctors and nurses in the Ebola-hit region, including Sierra Leone's only virologist and Ebola expert, Sheik Umar Khan.
This has put a further strain on the health services of these West African states, which have long faced a shortage of doctors and hospitals.
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What can be done if I catch it?
You must keep yourself isolated and seek professional help. Patients have a better chance of survival if they receive early treatment.
Emergency entrance to a hospital in Conakry treating Ebola patients (March 2014)
The current outbreak is killing between 50% and 60% of people infected
There are no vaccines, though some are being tested, along with new drug therapies. The WHO ruled in August that untested drugs can be used to treat patients in light of the scale of the current outbreak.
The experimental drug ZMapp has been used to treat several people who contracted Ebola: Two US aid workers and a Briton have recovered after taking it but a Liberian doctor and a Spanish priest have died.
But the US pharmaceutical company that makes it says it has for now run out of it.
Patients with Ebola frequently become dehydrated so they should drink solutions containing electrolytes or receive intravenous fluids.
MSF says this outbreak comes from the deadliest and most aggressive strain of the virus.
The current outbreak is killing between 50% and 60% of people infected.
It is not known which factors allow some people to recover while most succumb.
Ebola virus under the microscope
Ebola virus under the microscope
With hundreds of cases of Ebola in Africa, a panel of World Health Organization (WHO) experts has declared it is ethical to use experimental drugs in this current outbreak.
What is the current treatment for Ebola?
There is no licensed treatment or vaccine for the Ebola virus. Hospital treatment is based on giving patients intravenous fluids to stop dehydration and antibiotics to fight infections. Strict medical infection control and rapid burial are regarded as the best means of prevention.
What about experimental treatments?
Several experimental treatments for Ebola are being developed, which have shown promising results in monkeys when given up to five days after infection. However, they have not been tested in more than a handful of people and none has been licensed.
  • Two US aid workers had been given an experimental treatment, known as Zmapp, with "apparently encouraging" signs in one of them, said Prof Tom Solomon, director of the NIHR Health Protection Research Unit in Emerging and Zoonotic infections. The treatment is a mixture of three monoclonal antibodies that attack proteins on the surface of the virus.
  • Another experimental drug, developed by Tekmira Pharmaceuticals in Canada, has been tested on monkeys and in a handful of healthy human volunteers. The drug, TKM-Ebola, is designed to target strands of genetic material of the virus (RNA). The drug interrupts the genetic code of the virus and prevents it from making disease-causing proteins. A small early safety trial on a small number of human volunteers wasput on hold last month when regulators requested further safety data. The Fcompany is hopeful that it may get the go-ahead to continue the trial and is willing to make the drug available.
  • The US-based pharmaceutical company, Sarepta Therapeutics, has developed a similar RNA treatment. It has been tested in healthy human volunteers in early safety trials, but has never been tried in a human patient.
What is serum?
Serum - the part of the blood that contains antibodies that can target and neutralise the disease - has been used in past Ebola outbreaks. Survivors have high levels of antibodies against the virus in their blood. In one outbreak in 1995 in the Democratic Republic of Congo, seven out of eight patients survived after being treated with serum from survivors, according to Prof Solomon. The WHO says serum could be used as a potential treatment in this current outbreak if methods are developed to collect and administer it safely.
What other approaches are being tried?
Scientists have been working on a number of prototype vaccines against Ebola. The WHO says further trials would start soon and potential vaccines may be available in 2016.
The natural host for the virus is the fruit bat
The natural host for the virus is the fruit bat
The Food and Drug Administration in the US says it is fast-tracking a vaccine that has shown encouraging signs in monkeys for phase 1 trials in September.
This type of trial is the earliest study in humans and aims to make sure that drugs are safe and show some chance of working.
What are the chances of success?
Experts say pharmaceutical companies are unlikely to invest the huge resources needed to develop new drugs when these would probably be used only occasionally in relatively small numbers of people. They say investment is needed from international agencies to have any realistic chance of success in the future.
Health workers carry body of woman suspected to have died of Ebola in Clara Town, Monrovia (10 September 2014)
Ebola robs death of its dignity as victims' bodies are quickly burnt with the plastic suits they are wrapped in
With warnings from officials that the Ebola virus is "spreading like wildfire" in Liberia, Sarah Crowe, who works for the UN children's agency (Unicef), describes her week on the Ebola front line:
Flights into disaster zones are usually full of aid workers and journalists. Not this time.
The plane was one of the first in after some 10 airlines stopped flying to Liberia because of Ebola, and still it was empty.
When I was last in Liberia in 2006, it was to work on reintegration of child soldiers in a time of peace. Now the country is fighting a "biological war" from an unseen enemy without foot soldiers.
As we enter the airport, an unnerving sight - a team of health workers kitted out with masks and gloves asks us to wash our hands with a chlorine solution and takes our temperatures.
Health worker being sprayed with disinfectant
Health workers themselves have to be frequently sprayed with disinfectant
It was to be the start of a new routine - the hours and days since, I have had my temperature taken about 15 times and have had to wash my hands with chlorine at the entrance to every building, every office, every store, and every hotel.

Start Quote

It was a normal pregnancy, but she was turned away by every hospital as staff were too afraid to take her in case she had Ebola”
Even in small villages. And yet ironically, despite all this, few health facilities are properly functioning.
The next morning, the breakfast room at the hotel is buzzing - a large group of scientists from the US Centers for Disease Control and Prevention (CDC) huddle around computers animatedly talking, checking charts and data.
The world's Ebola experts are here - writing the first draft of Ebola history in real time.
The capital, Monrovia, reveals itself as a city branded by Ebola posters shouting out what people know all too well by now - Ebola is deadly, protect yourself, wash your hands.
Human booby traps
The talk in the car, on the radio is only about Ebola - people calling in want to know what to do when their child gets sick, they either fear health centres and hospitals or they are not treated.
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Ebola virus disease (EVD)
Ebola virus
  • Symptoms include high fever, bleeding and central nervous system damage
  • Spread by body fluids, such as blood and saliva
  • Fatality rate can reach 90% - but current outbreak has mortality rate of about 55%
  • Incubation period is two to 21 days
  • There is no proven vaccine or cure
  • Supportive care such as rehydrating patients who have diarrhoea and vomiting can help recovery
  • Fruit bats, a delicacy for some West Africans, are considered to be virus's natural host
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A colleague tells me she has just lost a family member about to give birth.
It was a normal pregnancy, but she was turned away by every hospital as staff were too afraid to take her in case she had Ebola.
She did not have the virus, but she died because of delivery complications. Her baby at least survived.
News of the US obstetrician in Liberia who contracted the deadly disease while delivering a baby has helped fuel such worries.
So far 169 Liberian health care workers have been affected by Ebola and 80 have died - a massive blow to a fragile health system.
Next I prepare to go up country to Lofa county where more warehouse space was needed - Unicef has delivered tonnes of equipment, including personal protective suits, chlorine and oral rehydration salts to Liberia - and more monitoring was required of those other now-neglected childhood killers like measles, diarrhoea and cholera.
Ebola has turned survivors into human booby traps, unexploded ordinance - touch and you die. Ebola psychosis is paralysing.
Liberian health worker disinfects taxi (9 September 2014)
The workers often look like crop sprayers
Heavy rains lash down over the weekend - I shudder to think of Medecins Sans Frontieres and health ministry workers and patients battling under plastic sheeting in such rains.
Luckily the skies over Monrovia clear for the hour-and-a-half helicopter ride to the hot-zone border between Sierra Leone, Guinea, and Liberia.
In Voinjama, I'm out with a team of social mobilisers who interact and educate communities.
They are playing our song - Ebola Is Here - on a megaphone through the village.
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Liberia at a glance:
  • Infrastructure devastated by a 14-year civil war
  • About 250,000 people killed in the conflict that ended in 2003
  • One doctor to treat nearly 100,000 people before Ebola outbreak
  • Ebola cases this year: 2,046
  • Ebola deaths this year: 1,224
  • Population: 4.4 million
Source: WHO
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The jingle has got Liberians jiving and saving lives. We talk to families about protecting themselves from Ebola.
They tell us about a survivor in their community. He came back from the treatment centre, but despite testing negative for the virus infected his girlfriend, who died.
The semen of male Ebola survivors remains contagious for a minimum of seven weeks after infection.
The villagers ask if survivors can be isolated.
Empty hospitals
The doctor at the empty hospital we visit says they suspect any patient who comes with fever, diarrhoea or stomach pains as having Ebola. "Guilty until proven otherwise" is the motto - and people are sent away as medical staff do not have the facilities to cope with the virus.

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Here we dare not touch babies; there are no handshakes, no hugs. It's simply too risky”
In the grounds of the local district health office, a burial team comes in looking like crop sprayers, carrying visors and chlorine spray.
They had just buried three people who died within 10km (6.2 miles) of each other.
We keep a safe distance. Death has no dignity here. The dead are taken and quickly burnt with the plastic suits. Funerals, once a ritual, are now rare.
One of the psycho-social workers tells us she is dealing with 100 children affected by Ebola in Voinjama alone, many of them orphans.
She is not sure what can be done. With schools closed at least until next year, perhaps the country's 26,000 teachers could be used as trained carers?
Back in Monrovia, we hear a bombshell from the World Health Organization - a huge surge in Ebola is expected. The defence minister tells the UN Security Council Ebola threatens his country's existence.
The hard times are far from over. They are stoic and brave but when I speak to ordinary Liberians they say they feel abandoned; they need help to treat other diseases too.
Map: Ebola outbreak in West Africa
In the car with colleagues, they talk almost nostalgically about the long civil war here - a time when the enemy was seen, the rockets were heard, the bullets could be dodged.
We try to focus on what we can do - more hygiene kits, beefing up the messaging, getting basic mother and child health care going again.
This is the most unusual and surreal field assignment I have ever undertaken.
One of the joys of working for Unicef is children, picking up babies, playing with them.
Here we dare not touch babies; there are no handshakes, no hugs. It's simply too risky.
A Liberian woman holds up a pamphlet with guidance on how to prevent the Ebola virus from spreading, in the city of Monrovia, Liberia - 14 August 2014
Ebola is one of the world's most deadly viruses but is not airborne, so cannot be caught like flu. Medical experts say avoiding it should be quite easy if you follow these tips:
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1. Soap and water
A resident washes his hands in chlorinated water at a public bathroom in the West Point slum on 19 August 2014 in Monrovia, Liberia
Wash your hands often with soap and clean water - and use clean towels to dry them. This can be difficult in slum and rural areas where there is not always direct access to clean water - but it is an effective way to kill the virus. Ordinary soap is all that's needed.
Shaking hands should also generally be avoided, Dr Unni Krishnan of Plan International told BBC Africa, because Ebola spreads quickly when people come into contact with an infected person's body fluids and symptoms can take a while to show. Other forms of greeting are being encouraged, he says.
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2. No touching
People walk through the streets of Dolo Town, Liberia, which has been quarantined because of the Ebola outbreak - 23 August 2014
So if you suspect someone of having Ebola, do not touch them. This may seem cruel when you see a loved one in pain and you want to hug and nurse them, but body fluids - urine and stools, vomit, blood, nasal mucus, saliva, tears, sperm and vaginal secretion - can all pass on the virus.
An infected person's symptoms include fever, muscle and joint pain, sore throat, headache and fatigue - followed by nausea, vomiting and diarrhoea, which may include blood.
Encourage them to seek help from a medical professional or health centre as soon as possible. It is also advisable not to touch the clothes or bedclothes of Ebola patients - and Medecins Sans Frontieres advises that such sheets and even mattresses be burnt.
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3. Avoid dead bodies
A team helps dispose of a person who died of Ebola in Liberia - August 2014
If you think someone has died from Ebola, do not touch their body, even as part of a burial ceremony. When someone has died, you can still catch Ebola from their body as it ejects fluids that make it even more contagious than that of a sick person.
Organise for a specialised team to deal with the body as quickly as possible as it is risky to leave a dead body for any length of time in a cramped living area.
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4. No bushmeat
A woman roasts a fresh bushmeat, at the Ajegunle-Ikorodu market in Lagos, Nigeria - 13 August 2014
Avoid hunting, touching and eating bushmeat such as bats, monkeys and chimpanzees, as scientists believe this is how the virus was first transmitted to humans.
Even if a certain wild animal is a delicacy in your region, avoid it as its meat or blood may be contaminated. Make sure all food is cooked properly.
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5. Don't panic
Spreading rumours increases fear. Do not be scared of health workers - they are there to help and a clinic is the best place for a person to recover - they will be rehydrated and receive pain relief.
About half of the people infected in the current outbreak have died. There have been cases of medics being attacked and people being abandoned when they are suspected of having Ebola - even when they are suffering from something else.
Angry people quarantined in the West Point township in Liberia's capital, Monrovia, wait for relatives to deliver them food and personal items - 23 August  2014
A belief in irrational traditional remedies has also exacerbated the spread of the virus.
"Prevention is the best way to deal with Ebola, so stop rumours and do not panic; it is possible to reduce the suffering and save lives," Dr Krishnan says.
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Ebola Virus Disease (EVD):
  • Symptoms include high fever, bleeding and central nervous system damage
  • Fatality rate can reach 90% - but current outbreak has mortality rate of about 55%
  • Incubation period is two to 21 days
  • There is no proven vaccine or cure
  • Supportive care such as rehydrating patients who have diarrhoea and vomiting can help recovery
  • Fruit bats, a delicacy for some West Africans, are considered to be virus's natural host
Dead body removed from home

The death toll has passed 2,000 and shows every sign of getting worse
This isn't just the worst single Ebola outbreak in history, it has now killed more than all the others combined.
Healthcare workers are visibly struggling, the response to the outbreak has been damned as "lethally inadequate" and the situation is showing signs of getting considerably worse.
The outbreak has been running all year, but the latest in a stream of worrying statistics shows 40% of all the deaths have been in just the past three weeks.
So what can we expect in the months, and possibly years, to come?
Taking off
Crystal-ball gazing can be a dangerous affair, particularly as this is uncharted territory.
Previous outbreaks have been rapidly contained, affecting just dozens of people; this one has already infected more than 3,900.
But the first clues are in the current data.
Dr Christopher Dye, the director of strategy in the office of the director general at the World Health Organization, has the difficult challenge of predicting what will happen next.
He told the BBC: "We're quite worried, I have to say, about the latest data we've just gathered."
Ebola patient
Man outside his home just outside the Liberian capital Monrovia
Up until a couple of weeks ago, the outbreak was raging in Liberia especially close to the epicentre of the outbreak in Lofa County and in the capital Monrovia.
However, the two other countries primarily hit by the outbreak, Sierra Leone and Guinea, had been relatively stable. Numbers of new cases were not falling, but they were not soaring either.
That is no longer true, with a surge in cases everywhere except some parts of rural Sierra Leone in the districts of Kenema and Kailahun.
"In most other areas, cases and deaths appear to be rising. That came as a shock to me," said Dr Dye.
Cumulative deaths - up to 5 September
Ebola deaths
Only going up
The stories of healthcare workers being stretched beyond breaking point are countless.
A lack of basic protective gear such as gloves has been widely reported.

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If current trends persist we would be seeing not hundreds of cases per week, but thousands of cases per week and that is terribly disturbing”
Dr Christopher DyeWorld Health Organization
The charity Medecins Sans Frontieres has an isolation facility with 160 beds in Monrovia. But it says the queues are growing and they need another 800 beds to deal with the number of people who are already sick.
This is not a scenario for containing an epidemic, but fuelling one.
Dr Dye's tentative forecasts are grim: "At the moment we're seeing about 500 new cases each week. Those numbers appear to be increasing.
"I've just projected about five weeks into the future and if current trends persist we would be seeing not hundreds of cases per week, but thousands of cases per week and that is terribly disturbing.
"The situation is bad and we have to prepare for it getting worse."
The World Health Organization is using an educated guess of 20,000 cases before the end, in order to plan the scale of the response.
But the true potential of the outbreak is unknown and the WHO figure has been described to me as optimistic by some scientists.
International spread?
Map: Ebola outbreak in West Africa
The outbreak started in Gueckedou in Guinea, on the border with Liberia and Sierra Leone.
But it has spread significantly with the WHO reporting that "for the first time since the outbreak began" that the majority of cases in the past week were outside of that epicentre with the capital cities becoming major centres of Ebola.
Additionally one person took the infection to Nigeria, where it has since spread in a small cluster and there has been an isolated case in Senegal.
Prof Simon Hay, from the University of Oxford, will publish his scientific analysis of the changing face of Ebola outbreaks in the next week.
He warns that as the total number of cases increases, so does the risk of international spread.
He told me: "I think you're going to have more and more of these individual cases seeding into new areas, continued flows into Senegal, Cote d'Ivoire, and all the countries in between, so I'm not very optimistic at the moment that we're containing this epidemic."
Children
Children watch as another dead body is taken from their village
There is always the risk that one of these cases could arrive in Europe or North America.
However, richer countries have the facilities to prevent an isolated case becoming an uncontrolled outbreak.
The worry is that other African countries with poor resources would not cope and find themselves in a similar situation to Guinea, Liberia and Sierra Leone.
"Nigeria is the one I look at with great concern. If things started to get out of control in Nigeria I really think that, because of its connectedness and size, that could be quite alarming," said Prof Hay.
End game?
It is also unclear when this outbreak will be over.
Officially the World Health Organization is saying the outbreak can be contained in six to nine months. But that is based on getting the resources to tackle the outbreak, which are currently stretched too thinly to contain Ebola as it stands.
There have been nearly 4,000 cases so far, cases are increasing exponentially and there is a potentially vulnerable population in Sierra Leone, Liberia and Guinea in excess of 20 million.

Ebola deaths

Up to 4-5 October

3,865
Deaths (probable, confirmed and suspected)
  • 2,210 Liberia
  • 768 Guinea
  • 879 Sierra Leone
  • 8 Nigeria
Getty
Prof Neil Ferguson, the director of the UK Medical Research Council's centre for outbreak analysis and modelling at Imperial College London, is providing data analysis for the World Health Organization.
He is convinced that the three countries will eventually get on top of the outbreak, but not without help from the rest of the world.
"The authorities are completely overwhelmed. All the trends are the epidemic is increasing, it's still growing exponentially, so there's certainly no reason for optimism.
"It is hard to make a long-term prognosis, but this is certainly something we'll be dealing with in 2015.
"I can well imagine that unless there is a ramp-up of the response on the ground, we'll have flare-ups of cases for several months and possibly years."
It is certainly a timeframe that could see an experimental Ebola vaccine, which began safety testing this week, being used on the front line.
If the early trials are successful then healthcare workers could be vaccinated in November this year.
Here forever
But there are is also a fear being raised by some virologists that Ebola may never be contained.
Prof Jonathan Ball, a virologist at the University of Nottingham, describes the situation as "desperate".
His concern is that the virus is being given its first major opportunity to adapt to thrive in people, due to the large number of human-to-human transmissions of the virus during this outbreak of unprecedented scale.
Map showing Ebola outbreaks since 1976
Ebola is thought to come from fruit bats; humans are not its preferred host.
But like HIV and influenza, Ebola's genetic code is a strand of RNA. Think of RNA as the less stable cousin of DNA, which is where we keep our genetic information.
It means Ebola virus has a high rate of mutation and with mutation comes the possibility of adapting.
Prof Ball argues: "It is increasing exponentially and the fatality rate seems to be decreasing, but why?
"Is it better medical care, earlier intervention or is the virus adapting to humans and becoming less pathogenic? As a virologist that's what I think is happening."
There is a relationship between how deadly a virus is and how easily it spreads. Generally speaking if a virus is less likely to kill you, then you are more likely to spread it - although smallpox was a notable exception.
Prof Ball said "it really wouldn't surprise me" if Ebola adapted, the death rate fell to around 5% and the outbreak never really ended.
"It is like HIV, which has been knocking away at human-to-human transmission for hundreds of years before eventually finding the right combo of beneficial mutations to spread through human populations."
Collateral damage
Malaria carrying mosquito
Malaria season is starting in West Africa
It is also easy to focus just on Ebola when the outbreak is having a much wider impact on these countries.
The malaria season, which is generally in September and October in West Africa, is now starting.
This will present a number of issues. Will there be capacity to treat patients with malaria? Will people infected with malaria seek treatment if the nearest hospital is rammed with suspected Ebola cases? How will healthcare workers cope when malaria and Ebola both present with similar symptoms.
And that nervousness about the safety of Ebola-rife hospitals could damage care yet further. Will pregnant women go to hospital to give birth or stay at home where any complications could be more deadly.
The collateral damage from Ebola is unlikely to be assessed until after the outbreak.
No matter where you look there is not much cause for optimism.
The biggest unknown in all of this is when there will be sufficient resources to properly tackle the outbreak.
Prof Neil Ferguson concludes: "This summer has there have been many globally important news stories in Ukraine and the Middle East, but what we see unfolding in West Africa is a catastrophe to the population, killing thousands in the region now and we're seeing a breakdown of the fragile healthcare system.
"So I think it needs to move up the political agenda rather more rapidly than it has."


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