tag:theconversation.com,2011:/us/topics/haemorrhagic-fever-9689/articlesHaemorrhagic fever – The Conversation2017-07-12T14:19:04Ztag:theconversation.com,2011:article/808142017-07-12T14:19:04Z2017-07-12T14:19:04ZAn outbreak of Ebola in the DRC has been contained. What went right this time?<figure><img src="https://images.theconversation.com/files/177678/original/file-20170711-29291-y7mm0b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An elaborate alert system is needed to test for Ebola.</span> <span class="attribution"><span class="source">Baz Ratner/Reuters.</span></span></figcaption></figure><p>The World Health Organisation recently declared the end of the most recent <a href="http://www.who.int/emergencies/ebola-DRC-2017/en/">outbreak</a> of Ebola in the <a href="http://www.who.int/csr/don/13-may-2017-ebola-drc/en/">Democratic Republic of Congo (DRC)</a>.</p>
<p>By the time the outbreak was contained, eight people had been infected. Four survived. The first patient diagnosed in the outbreak (the index case) – a middle aged man who died on his way to hospital - got ill in April. It’s not clear how he became infected. But those who helped transport him to the hospital also became sick. </p>
<p>This outbreak had the second lowest number of patients among all the eight Ebola outbreaks in DRC since 1976. The last one <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1411099?query=featured_home&">in 2014</a> lasted for three months and three quarters of the 66 people diagnosed with the disease died. The outbreak was traced back to a pregnant woman who had <a href="http://time.com/3511101/ebola-congo-contained-spread/">slaughtered a monkey</a> brought home by her husband. The disease spread when she underwent a traditional surgical operation after becoming ill.</p>
<p>The most recent outbreak was controlled more efficiently than the <a href="http://www.who.int/csr/disease/ebola/one-year-report/virus-origin/en/">2014 outbreak</a> and sets an example for other countries. A combination of factors meant that it was possible to stop the disease from spreading. These included a prompt response, immediate diagnosis and treatment, a coordinated approach and the involvement of the community in identifying the case and minimising the spread of the outbreak.</p>
<h2>The logistics</h2>
<p>Following reports that an unknown illness had been identified in a remote community 1400 kilometres from the state capital, a multidisciplinary team of health workers and administrative officers was dispatched. They immediately swung into action conducting field investigations. They traced and collected blood samples from the suspected cases and sent the samples back to the capital for testing. The tests came back positive. </p>
<p>The response team used an <a href="http://www.who.int/csr/resources/publications/ebola/social-mobilization-guidance/en/">alert system</a> to notify members of the community of the cases. It also collected samples and tested them using a mobile laboratory. </p>
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<figcaption><span class="caption">WHO: Testing Ebola samples in the Democratic Republic of the Congo.</span></figcaption>
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<p>The team also succeeded in ensuring that <a href="http://www.who.int/features/ebola/health-care-worker/en/">health workers</a> were not infected. In previous outbreaks in West Africa this had been a problem. Many health workers who came to help contracted the disease and <a href="http://www.who.int/hrh/documents/21may2015_web_final.pdf">transmitted</a> it to patients and community members.</p>
<h2>Tracing the source</h2>
<p>Studies show that bats are the <a href="https://www.nature.com/nature/journal/v438/n7068/full/438575a.html">reservoir</a> of the Ebola virus. Wild animals get infected when they come in contact with infected faeces or body fluids from the bats.</p>
<p>The virus is transmitted to people when they come in direct contact with fluids or when they eat meat from infected bush meat. An infected person then spreads the disease to other people. An outbreak ends when the human to human transmission is interrupted.</p>
<p>The <a href="http://www.who.int/mediacentre/factsheets/fs103/en/">incubation period</a> of the virus ranges from 2 to 21 days which means that an infected person can take up to 21 days to develop <a href="https://www.cdc.gov/vhf/ebola/symptoms/index.html">symptoms</a>. </p>
<p>An outbreak of Ebola is declared over when 42 days have passed since the last confirmed case tests negative for the virus. So, the count of the 42 days starts when the last confirmed case is declared free of the virus. </p>
<p>During these 42 days an elaborate surveillance system is put in place. This includes an alert system that can be activated if a new suspect is identified, as well as testing capability. The surveillance system remains in place for several weeks after the last confirmed case has been declared negative. This is to make that any cases can be identified. An eye is also kept open for possible infections from the wild.</p>
<h2>Lessons learnt</h2>
<p>The DRC experience underscores the fact that there are a number of areas that need special attention in an Ebola outbreak.</p>
<p>First, governments should have efficient nationwide surveillance systems to monitor priority health conditions, beginning at the community level. This early warning system can detect deviations from the norm, including suspected Ebola cases. </p>
<p>The surveillance systems should be linked to laboratory diagnostics for rapid confirmation of cases. This is especially possible today with the advent of field ready technologies reducing the turnaround time for diagnosis.</p>
<p>Secondly, an outbreak response team with regional operation centres should be established and tested before an outbreak begin. It requires coordination among the different stakeholders to enable a rapid response. They should also be in touch with international agencies in case of cross-border emergencies.</p>
<p>Thirdly, public health education plays a pivotal role because the quick spread of the disease is often fuelled by <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a2.htm">community practice</a> like burial rites and acceptance of disease survivors. This means that appropriate <a href="http://www.who.int/csr/disease/ebola/messages/en/">communication</a> on the risks of the disease, infection, treatment and management should be delivered to the public in a culturally appropriate way.</p>
<p>And finally, a resourceful public health system is necessary for a timely response. Governments should improve primary health care facilities by hiring and training more health workers and having efficient infrastructure, logistics, health information, governance and drug supply systems.</p>
<p>In all, we need to remain vigilant because we’re dealing with “when” rather than “if” the next large outbreak happens.</p><img src="https://counter.theconversation.com/content/80814/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eric Osoro does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When an Ebola outbreak is detected, surveillance, community engagement , laboratory services and tracing infected persons should be activated to prevent rapid spread of the disease.Eric Osoro, Medical Epidemiologist , Washington State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/320422014-11-03T04:08:31Z2014-11-03T04:08:31ZHealth Check: what does my blood group mean?<figure><img src="https://images.theconversation.com/files/63478/original/j4dfy3fj-1414973884.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Blood is categorised by the naturally occurring proteins and sugars on the surface of red blood cells.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/jooon/2432064925">Jon Åslund/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Few discoveries have revolutionised the practice of medicine as much as the discovery of human red blood cell groups.</p>
<p>Unlike modern vampire and Time Lord mythologies, blood groups don’t have a particular flavour (<a href="http://trueblood.wikia.com/wiki/Tru_Blood">Tru blood</a>) or make humans susceptible to hypnotic mind control (<a href="http://tardis.wikia.com/wiki/Blood_control">Dr Who</a>). Rather, blood is categorised by the naturally occurring <a href="http://www.sciencedirect.com/science/article/pii/S0037196304000022">proteins and sugars</a> on the surface of red blood cells. </p>
<p>For most people, which blood group you are does not matter one jot, unless your life is at risk and you need a blood transfusion. In this case, the proteins and sugars can act as a barrier to safe transfusion of red blood cells from one person to another. </p>
<h2>The ABO blood group system</h2>
<p>Prior to the 20th century, early attempts at transfusing blood into humans could be unpredictable and lead to death. Looking for a solution, immunologist <a href="http://www.pbs.org/wnet/redgold/innovators/bio_landsteiner.html">Karl Landsteiner</a> found that the blood of two people could be either “compatible” or “incompatible” in a predictable way: “incompatible” blood led to “clumping” (agglutination) of red blood cells in a test tube, while “compatible blood” did not.</p>
<p>Along with Alfred von Decastello and Adriano Sturli, Landsteiner identified the four major blood groups: O, A, B and AB or what is known as the <a href="http://www.donateblood.com.au/about-blood/types">ABO blood group system</a>. </p>
<p>Landsteiner realised what made blood types compatible or incompatible were antibodies produced against specific red blood cell <a href="http://www.ncbi.nlm.nih.gov/books/NBK2267/">sugar molecules</a>, causing agglutination of the red cells in the test tube and destruction of the red cells in the circulation. For this work, Landsteiner was awarded the <a href="http://www.nobelprize.org/nobel_prizes/medicine/laureates/1930/landsteiner-lecture.pdf">Nobel Prize in Medicine</a>.</p>
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<img alt="" src="https://images.theconversation.com/files/63465/original/zcknf4z3-1414973123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/63465/original/zcknf4z3-1414973123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/63465/original/zcknf4z3-1414973123.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/63465/original/zcknf4z3-1414973123.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/63465/original/zcknf4z3-1414973123.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/63465/original/zcknf4z3-1414973123.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/63465/original/zcknf4z3-1414973123.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Blood transfusions are no longer analogous to medical ‘Russian roulette’.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-215905168/stock-photo-blood-transfusion-in-the-icu.html?src=JQNLZtiJKOey1OkQKGDSwg-1-14">sfam_photo/Shutterstock</a></span>
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<p>Ludwig Hektoen developed rigorous <a href="http://www.pbs.org/wnet/redgold/innovators/bio_ottenberg.html">testing procedures</a> of blood grouping and cross matching in 1907 which were first performed by <a href="http://www.pbs.org/wnet/redgold/innovators/bio_ottenberg.html">Reuben Ottenberg</a>. These methods have been used to reliably select the correct donor blood ever since. </p>
<h2>Beyond the ABO blood group</h2>
<p>In general, everyone can be classified within ABO blood group system, based on the ABO sugars. Red blood cells also contain many other proteins and sugars, known as red cell antigens. Researchers have discovered more than <a href="http://www.transfusion.com.au/blood_basics/antigens/red_cell">300</a> blood group antigens, each representing different proteins on the red blood cell that perform different <a href="http://asheducationbook.hematologylibrary.org/content/2002/1/445.full">functions</a>. </p>
<p>The importance of these red cell blood groups, however, is not necessarily what they do; you could live without several blood group antigens and be none the wiser. Their importance of lies in how they elicit an immune antibody response, and whether these new antibodies can destroy foreign red cells against which they are targeted. </p>
<p>The immune system of person who doesn’t have these antigens can be stimulated to make antibodies against red cell antigens that aren’t their own. This can cause red cell destruction (<a href="http://www.transfusion.com.au/adverse_transfusion_reactions/acute_haemolytic_reaction">haemolysis</a>) which, in its most immediate and dramatic form, can lead to severe stress to the heart and circulation, kidney failure and death. It can also lead to a delayed form of red cell destruction that occurs a week or so after a blood transfusion.</p>
<h2>Positive or negative</h2>
<p>One of the most important non-ABO blood groups is the Rhesus blood group system, which Landsteiner discovered in 1940 in collaboration with <a href="http://www.scienceheroes.com/index.php?option=com_content&view=article&id=195&Itemid=195">Alexander Weiner</a>. This system categorises people as either positive or negative, depending on whether they have Rhesus D antigen on their red cells (O- or O+ for example). </p>
<p>Since the late 1800s, physicians had noted that following a successful first pregnancy, some mothers could lose their subsequent babies through a disease called <a href="http://www.transfusion.com.au/disease_therapeutics/fetomaternal/HDN">haemolytic disease of the fetus and newborn</a>. For the majority of babies, this condition was attributable to the Rhesus D antigen.</p>
<p>Researchers realised that Rhesus D-negative mothers were exposed to Rhesus D antigen through the course of their pregnancy. The baby had inherited this red cell antigen from their father. The mother’s immune system therefore reacted against this foreign red cell antigen by producing antibodies which could cross the placenta and destroy the red cells of the baby in subsequent pregnancies.</p>
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<img alt="" src="https://images.theconversation.com/files/63469/original/sr3mp8qg-1414973317.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/63469/original/sr3mp8qg-1414973317.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=341&fit=crop&dpr=1 600w, https://images.theconversation.com/files/63469/original/sr3mp8qg-1414973317.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=341&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/63469/original/sr3mp8qg-1414973317.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=341&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/63469/original/sr3mp8qg-1414973317.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=429&fit=crop&dpr=1 754w, https://images.theconversation.com/files/63469/original/sr3mp8qg-1414973317.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=429&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/63469/original/sr3mp8qg-1414973317.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=429&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">ABO and Rhesus are the most important red cell blood groups.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/ianhumes/3263620112">Ian Humes/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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<p>The understanding of the Rhesus system led to strategies that have dramatically reduced haemolytic disease among newborns. Rhesus D-negative women of child-bearing age are only given blood transfusions of Rhesus D-negative blood to prevent stimulating the immune system against this antigen. </p>
<p>Pregnant Rhesus D-negative women are also given special <a href="http://www.sahealth.sa.gov.au/wps/wcm/connect/9a96ba804eedaf06b1b9b36a7ac0d6e4/Red-cell-allo-immunisation-WCHN-PPG-21092010.pdf?MOD=AJPERES&CACHEID=9a96ba804eedaf06b1b9b36a7ac0d6e4">anti-D immunoglobulin</a> during their pregnancy, after delivery and following any trauma or pregnancy-related procedure. Again, this helps prevent foreign Rhesus D-positive red cells from stimulating the mother’s immune system.</p>
<h2>Rare blood groups</h2>
<p>What ultimately determines our blood group is our genetics: our parents, our ancestors and also their migration patterns.</p>
<p>Rare blood groups arise from inheritable <a href="http://www.ncbi.nlm.nih.gov/projects/gv/rbc/xslcgi.fcgi?cmd=bgmut/systems">mutations of red blood cell genes</a> in different populations. This can make it very difficult to find correctly “matched” blood donor units for people with rare blood groups simply because they are uncommon in the usual volunteer blood donor population. </p>
<p>The red cell blood group Kidd(null) phenotype (Jka-b-) which is more common in <a href="http://www.ncbi.nlm.nih.gov/books/NBK2272/">Finnish and Polynesian populations</a>, for instance, is very rare in Australian blood donors. Unless a correctly matched Jka-b- blood is found, there is a risk of developing a haemolytic transfusion reaction or haemolytic disease of the newborn, as patients develop antibodies that are acquired to Kidd red cell blood groups on the transfused blood.</p>
<p>People with the <a href="http://www.ncbi.nlm.nih.gov/books/NBK2268/">Bombay</a> red cell phenotype have only a one in a million chance of finding a suitable blood donor. In this setting, transfusion may be sought from a family member, who is much more likely to have the correct blood phenotype.</p>
<p>It’s likely that <a href="http://www.donateblood.com.au/why-donate/blood-use">you or someone you know</a> will require a blood transfusion at some stage in life. One of the simplest things we can do as individuals is to become a <a href="http://www.donateblood.com.au/why-donate/faq#faq_314">volunteer blood donor</a>.</p><img src="https://counter.theconversation.com/content/32042/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ashley Ng currently receives funding from The National Health and Medical Research Council.
He has previously received funding from the Leukaemia Foundation Australia and Cure Cancer Australia.
He has previously been the Lions Fellow of the Cancer Council of Victoria and has been awarded a Sir Edward Dunlop Fellowship.</span></em></p>Few discoveries have revolutionised the practice of medicine as much as the discovery of human red blood cell groups. Unlike modern vampire and Time Lord mythologies, blood groups don’t have a particular…Ashley Ng, Post Doctoral Fellow and Haematologist, Walter and Eliza Hall InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/250712014-04-01T04:04:18Z2014-04-01T04:04:18ZExplainer: what is Ebola virus?<p>An outbreak of the <a href="http://www.who.int/mediacentre/factsheets/fs103/en/">Ebola virus</a>, which started in a rural region of Guinea in West Africa, has now spread to the nation’s capital Conakry. It now <a href="http://www.theguardian.com/world/2014/mar/31/guinea-ebola-epidemic-medecins-sans-frontieres">reportedly involves</a> 122 people, of which 78 have died. Additional cases have been reported in Liberia and Sierra Leone, which border Guinea. </p>
<p>The <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC224575/">disease caused by the virus</a> is dramatic and awful. It starts with flu-like symptoms – a fever, sore throat, extreme tiredness and muscle pain. Within a few days, nausea, vomiting and diarrhoea develop. </p>
<p>While all this is happening, the virus is also attacking the internal organs, particularly the liver and kidneys. As these organs start to fail, the patient starts to bleed and eventually succumbs to dehydration and blood loss. Of the <a href="http://www.who.int/mediacentre/factsheets/fs103/en/">roughly</a> 2,200 recorded cases of Ebola to date, around 1,500 infected people have died.</p>
<h2>A family of viruses</h2>
<p>The Ebola virus itself was <a href="http://www.ncbi.nlm.nih.gov/pubmed/65661">first discovered</a> in 1976, but it’s one of a group of viruses that cause a similar syndrome known as <a href="http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/vhf.htm">viral hemorrhagic fevers</a>. </p>
<p>While Ebola virus is mainly found in Central Africa (the current outbreak in Guinea is far west of previous outbreaks), other viruses that cause viral haemorrhagic fever are distributed more widely – Lassa fever (West Africa), hantavirus (east Asia), Junin (Argentina), Crimean-Congo (mainly Central Asia and eastern Europe). Dengue virus, commonly found across the tropics (particularly Asia), can, on rare occasions, cause a similar syndrome.</p>
<p>There are five strains of Ebola and they vary in terms of how infective and lethal they are. The most significant outbreaks are associated with the Sudan and Zaire strains; the latter is implicated in this outbreak. </p>
<p>The largest outbreak involved 425 people in 2000 in Uganda, and the 2003 outbreak in Congo had a mortality of 90%, making it one of the most dangerous viral infections described. Nonetheless, in absolute numbers Ebola is regarded as uncommon, even compared to some other viral haemorrhagic fevers. And it’s almost insignificant compared to some of the major health problems in the region. </p>
<p>Ebola is thought to originate in fruit bats and initial cases in humans result from contact with infected animals, including chimpanzees, gorillas and monkeys. But outbreaks like the current one occur because of human-to-human spread.</p>
<h2>How it spreads</h2>
<p>The good news, if there is any, is that spread of the virus is controllable, and it’s probably not as infectious as you might think from watching films about virus outbreaks.</p>
<p>Unlike SARS (severe acute respiratory syndrome), which spread quickly from contact with droplets and contamination of the environment and was <a href="http://pmj.bmj.com/content/80/945/373.full">difficult to control</a> even in developed countries such as Singapore and Canada, Ebola requires contact with infected body fluids. This means it only generally spreads to close contacts of infected people – mainly family members, health-care workers and people involved with preparing bodies for burial. </p>
<p>The World Health Organization only <a href="http://www.who.int/csr/bioriskreduction/interim_recommendations_filovirus.pdf?ua=1">recommends</a> “standard precautions” to stop people coming into close contact with the secretions of infected patients. This includes wearing gloves, gown, face mask and eye protection, ensuring hand disinfection and setting up systems to manage assessment, patient care, and cleaning and waste disposal.</p>
<p>All this may sound rather simple – after all, <a href="http://www.nhmrc.gov.au/book/australian-guidelines-prevention-and-control-infection-healthcare-2010/b1-standard-precautions">standard precautions</a> are what’s generally recommended for all patients in Australian hospitals. But the challenges involved in caring for patients in outbreaks are significant. </p>
<p>People with viral haemorrhagic fever bleed and vomit, and these fluids are potentially infectious. Training for health-care workers, particularly in areas where Ebola has previously been unknown, is unlikely to adequately prepare them for recognising or caring for infected patients, or for the strict infection control procedures required to prevent spread.</p>
<h2>Containing the outbreak</h2>
<p>And there’s a bigger problem still; Ebola infections tend to occur in places where the health infrastructure is extremely limited. </p>
<p>I was once told that no patient with Ebola had ever had a chest X-ray. Not because it wasn’t relevant (in some haemorrhagic fevers, leakage of fluid into the lungs can be an important finding) but because infections always occur in places without the capacity to do a chest X-ray, one of the most basic of medical tests. </p>
<p>That lack of capacity tends to affect all efforts to control disease outbreaks. Guinea, where the current outbreak is occurring, is also <a href="http://www.bbc.com/news/world-africa-26717490">reportedly</a> battling measles, cholera and meningitis.</p>
<p>But all is not lost. The medical aid organisation, Médecins Sans Frontières (MSF), is airlifting in teams and resources to control this Ebola outbreak. It has <a href="http://www.msf.org/article/guinea-mobilisation-against-unprecedented-ebola-epidemic">expertise</a> in these areas through involvement with previous such emergencies. </p>
<p>The organisation has noted that this outbreak poses particular difficulties as cases are being recognised in <a href="http://www.smh.com.au/world/liberia-confirms-ebola-cases-as-deadly-virus-spreads-20140331-zqour.html">multiple places in the region</a>, which are also far apart, complicating efforts to control the epidemic. And because the virus’ incubation period can range up to three weeks, we won’t know how successful the current control measures are doing for a while.</p>
<p>Let’s hope current local and international efforts to control the spread of Ebola will stop more people getting infected. </p><img src="https://counter.theconversation.com/content/25071/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Allen Cheng receives funding from the NHMRC.</span></em></p>An outbreak of the Ebola virus, which started in a rural region of Guinea in West Africa, has now spread to the nation’s capital Conakry. It now reportedly involves 122 people, of which 78 have died. Additional…Allen Cheng, Associate Professor in Infectious Diseases Epidemiology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.