Photo Essay: One family's struggle for survival.

An Ebola story in Guinea.

By Genna Buck

Source: Macleans

Finda Marie Kamano, 33, struggles to walk through her hometown of Gueckedougou in Guinea. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

Kamano is suffering from diarrhoea and vomiting, symptoms of dysentry. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

A doctor with Medecins Sans Frontieres (MSF) examines Kamano. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

Kamano is transported to the clinic in the back of a truck. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

Kamano is led to the treatment centre by a nurse in a protective uniform. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

The MSF team finds Kamano suffering from fever, nosebleeds and symptoms of dysentery. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

After kamano is diagnosed with Ebola, an MSF team disinfects her house and belongings with bleach. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

An MSF team member checks to make sure all of the protective clothing remains in place. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

Items from Kamano's house are removed, to either be disinfected or burned. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

The mattress is burned along with everything that cannot be disinfected with bleach. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

Two days after she tested positive for the Ebola virus disease, Kamano dies. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

Kamano's family members have a coffin ready in which to bury her. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

Kamano is buried steps from her home. She most likely contacted Ebola from helping to prepare the body of an Ebola victim for burial. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

Family members gather for Kamano's funeral. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

Fatou, Finda Maria's sister feels defeated. She was the one who called MSF to come and help her sister.  As a result she is been accused of the death of her sister by some member of the community. (Sylvain Cherkaoui/ Cosmos for MSF/Redux)

The Discovery of Ebola. An Interesting Leisure Read.

The virus detective who discovered Ebola in 1976
By Rob Brown
BBC World Service

Nearly 40 years ago, a young Belgian scientist travelled to a remote part of the Congolese rainforest - his task was to help find out why so many people were dying from an unknown and terrifying disease.

In September 1976, a package containing a shiny, blue thermos flask arrived at the Institute of Tropical Medicine in Antwerp, Belgium. Working in the lab that day was Peter Piot, a 27-year-old scientist and

medical school graduate training as a clinical microbiologist. "It was just a normal flask like any other you would use to keep coffee warm," recalls Piot, now Director of the London School of Hygiene and

Tropical Medicine. But this thermos wasn't carrying coffee - inside was an altogether different cargo. Nestled amongst a few melting ice cubes were vials of blood along with a note. It was from a Belgian doctor based in what was then Zaire, now the Democratic Republic of Congo - his handwritten message explained that the blood was that of a nun, also from Belgium, who had fallen ill with a

mysterious illness which he couldn't identify. 

Piot (right), at Institute of Tropical Medicine, Antwerp in 1976

This unusual delivery had travelled all the way from Zaire's capital city Kinshasa, on a commercial flight, in one of the passengers' hand luggage. "When we opened the thermos, we saw that one of the vials was broken and blood was mixing with the water from the melted ice," says Piot. He and his colleagues were unaware just how dangerous that was. As the blood leaked into the icy water so too did a deadly unknown virus. The samples were treated like numerous others the lab had tested before, but when the scientists placed some of the cells under an electron microscope they saw something they didn't expect. "We saw a gigantic worm like structure - gigantic by viral standards," says Piot. "It's a very unusual shape for a virus, only one other virus looked like that and that was the Marburg virus." The Marburg virus was first recognised in 1967 when 31 people became ill with haemorrhagic fever in the cities of Marburg and Frankfurt in Germany and in Belgrade, the capital of Yugoslavia. This Marburg outbreak was associated with laboratory staff who were working with infected monkeys imported from Uganda - seven people died. Piot knew how serious Marburg could be - but after consulting experts around the world he got confirmation that what he was seeing under the microscope wasn't Marburg - this was something else, something never seen before. 

The Ebola Virus

"It's hard to describe but the main emotion I had was one of real, incredible excitement," says Piot. "There was a feeling of being very privileged, that this was a moment of discovery." News had reached Antwerp that the nun, who was under the care of the doctor in Zaire, had died. The team also learnt that many others were falling ill with this mysterious illness in a remote area in the north of the country - their symptoms included fever, diarrhoea and vomiting followed by bleeding and eventually death. Two weeks later Piot, who had never been to Africa before, was on a flight to Kinshasa. "It was an overnight flight and I couldn't sleep. I was so excited about seeing Africa for the first time, about investigating this new virus and about stopping the epidemic." The journey didn't end in Kinshasa - the team had to travel to the centre of the outbreak, a village in the equatorial rainforest, about 1,000km (620 miles) further north. "The personal physician of President Mobutu, the leader of Zaire at that time, arranged a C-130 transport aircraft for us," recalls Piot. They loaded a Landrover, fuel and all the equipment they needed on to the plane.

C-130 aircraft with the land rover and equipment in Bumba.

 When the C-130 landed in Bumba, a river port situated on the northernmost point of the Congo River, the fear surrounding the mysterious disease was tangible. Even the pilots didn't want to hang around for long - they kept the airplane's engines running as the team unloaded their kit. "As they left they shouted 'Adieu,'" says Piot. "In French, people say 'Au Revoir' to say 'See you again', but when they say 'Adieu' - well, that's like saying, 'We'll never see you again.'" Standing on the tarmac watching the plane leave, facing a deadly unknown virus in an unfamiliar place, some people might have regretted the decision to go there. "I wasn't scared. The excitement of discovery and wanting to stop the epidemic was driving everything. We heard far more people were dying from the disease than we originally thought and we wanted to get to work," Piot says.

Piot (second from left) and the team in Yambuku in 1976

 The curiosity and sense of adventure that brought Piot to this point had been ignited many years earlier when he was a young boy growing up in a small rural village in the Flanders region of Belgium. A museum near Piot's home was dedicated to a local saint who worked with leprosy patients, and it was here that he got his first glimpse into the world of disease and microbiology. "I decided one day to cycle to the museum. The old pictures I saw there of those suffering from leprosy fascinated me," he says. "That sparked my interest in medicine - it gave me a thirst for scientific knowledge, a desire to help people and I hoped it would give me a passport to the world." It did give Piot a passport to the world. The team's final destination was the village of Yambuku - about 120km (75 miles) from Bumba, where the plane had left them. Yambuku was home to an old Catholic mission - it had a hospital and a school run by a priest and nuns, all of them from Belgium. "The area was beautiful. The mission was surrounded by lush rainforest and the earth was red - the nature was incredibly rich but the people were so poor," says Piot. "Joseph Conrad called that place 'The Heart of Darkness', but I thought there was a lot of light there." The beauty of Yambuku belied the horror that was unfolding for the people that lived there. When Piot arrived, the first people he met were a group of nuns and a priest who had retreated to a guesthouse and established their own cordon sanitaire - a barrier used to prevent the spread of disease.

There was a sign on the cord, written in the local Lingala language that read, "Please stop, anybody who crosses here may die." "They had already lost four of their colleagues to the disease," says Piot. "They were praying and waiting for death." Piot jumped over the cordon and told them that the team would help them and stop the epidemic. "When you are 27, you have all this confidence," he says. 

A Belgian nun

The nuns told the newly arrived scientists what had happened, they spoke about their colleagues and those in the village who had died and how they tried to help as best they could. The priority was to stop the epidemic, but first the team needed to find out how this virus was moving from person to person - by air, in food, by direct contact or spread by insects. "We had to start asking questions. It was really like a detective story," says Piot. 

To investigate the spread of the virus the team drew maps and plotted each village they visited.

These were the three questions they asked:

•How did the epidemic evolve? Knowing when each person caught the virus

gave clues to what kind of infection this was - from here the story of

the virus began to emerge.

•Where did the infected people come from? The team visited all the

surrounding villages and mapped out the number of infections - it was

clear that the outbreak was closely related to areas served by the local

hospital.

•Who gets infected? The team found that more women than men caught

the disease and particularly women between 18 and 30 years old - it

turned out that many of the women in this age group were pregnant and

many had attended an antenatal clinic at the hospital.

The mystery of the virus was beginning to unravel.

The team then discovered that the women who attended the antenatal clinic all received a routine injection. Each morning, just five syringes would be distributed, the needles would be reused and so the virus was spread between the patients. "That's how we began to figure it out," recalls Piot. "You do it by talking, looking at the statistics and using logical deduction." 

Many people were interviewed and detailed notes were taken during the investigation 

The team also noticed that people were getting ill after attending funerals. When someone dies from Ebola, the body is full of the virus - any direct contact, such as washing or preparation of the deceased without protection can be a serious risk.

The next step was to stop the transmission of the virus. "We systematically went from village to village and if someone was ill they would be put into quarantine," says Piot. "We would also quarantine anyone in direct contact with those infected and we would ensure everyone knew how to correctly bury those who had died from the virus." The closure of the hospital, the use of quarantine and making sure the community had all the necessary information eventually brought an end to the epidemic - but nearly 300 people died. Piot and his colleagues had learned a lot about the virus during three months in Yambuku, but it still lacked a name. "We didn't want to name it after the village, Yambuku, because it's so stigmatising. You don't want to be associated with that," says Piot. The team decided to name the virus after a river. They had a map of Zaire, although not a very detailed one, and the closest river they could see was the Ebola River. From that point on, the virus that arrived in a flask in Antwerp all those months earlier would be known as the Ebola virus.

The Ebola River in 1976

In February 2014, Piot returned to Yambuku for only the second time since 1976, to mark his 65th birthday. He met Sukato Mandzomba, one of the few who caught the virus in 1976 and survived. "It was fantastic to meet him again, it was a very moving moment," says Piot. Back then, Mandzomba was a nurse in the local hospital and could speak French so the pair had managed to build up a rapport. "He's still living in Yambuku and still working in the hospital - he's now running the lab there and it's impeccable. I was really impressed," Piot says.

Piot and Mandzomba in Yambuku, February 2014

It's 38 years since that initial outbreak and the world is now experiencing its worst Ebola epidemic ever. So far more than 600 people have died in the West African countries of Guinea, Liberia and Sierra Leone. The current situation has been called unprecedented, the spread of the disease across three countries making it more complicated to deal with than ever before. In the absence of any vaccine or cure, the advice for this outbreak is much the same as it was in the 1970s. "Soap, gloves, isolating patients, not reusing needles and quarantining the contacts of those who are ill - in theory it should be very easy to contain Ebola," says Piot. In practice though, other factors can make fighting an Ebola outbreak a difficult task. People who become ill and their families may be stigmatised by the community - resulting in a reluctance to come forward for help. Cultural beliefs lead some to think the disease is caused by witchcraft, while others are hostile towards health workers. "We shouldn't forget that this is a disease of poverty, of dysfunctional health systems - and of distrust," says Piot. For this reason, information, communication and involvement of community leaders are as important as the classical medical approach, he argues. Ebola changed Piot's life - following the discovery of the virus, he went on to research the Aids epidemic in Africa and became the founding executive director of the UNAIDS organisation. "It led me to do things I thought only happened in books. It gave me a mission in life to work on health in developing countries," he says.

"It was not only the discovery of a virus but also of myself."

Peter Piot spoke to World Update on the BBC World Service

Ebola Outbreak. An Overview.

On March 10^th 2014, hospitals and public health services in Gueckedou and Macenta districts alerted the Guinea Ministry of Health (MoH) and Medecins sans Frontieres in Guinea about a rapidly evolving outbreak of a mysterious disease characterized by fever, sever diarrhea, vomiting and an apparently high fatality rate.  Eight patients were hospitalized in Gueckedou of which three died. Additional deaths were also reported among family members of the patients. In Macenta, deaths were also observed among hospital staff members.

On March 13^th, 2014 the Guinea Ministry of Health (MoH) notified the World Health Organization (WHO) of the outbreak of a communicable disease in the forested areas of South Eastern Guinea with cases reported in Gueckedou, Macenta and Kissidougou districts.  A total of 86 suspected cases, including 59 deaths were reported (case fatality ratio of 68.5%).

The Guinea Ministry of Health sent a team to the outbreak region on March 14^th, 2014. Medecins sans Frontieres in Europe were also notified and a team was also sent which arrived in Guekedou on March 18^th, 2014. Epidemiological investigation was initiated.

By March 27^th 2014, the disease had spread to the capital of Conakry with 4 confirmed cases and 1 suspected case.

Virologic investigation identified the Ebola virus as the causative agent. This is the first Ebola virus disease outbreak (formerly called Ebola Haemorrhagic Fever) in Guinea, thousands of miles away from Uganda and the Democratic Republic of Congo where recent outbreaks have been observed.

From the investigation it was discovered that epidemiological links between cases suggest a single introduction of the virus into the human population. This introduction might have happened in December 2013 or earlier. However the animal source of the outbreak is yet to be identified. It is suspected that the virus might have been transmitted for months before the outbreak became apparent as a result of clusters of cases in the hospitals located in Gueckedou and Macenta (Sylvian Baize et al, 2014).

To determine the index case, Sylvian Baize et al, conducted an epidemiological look-back. This was achieved by reviewing hospital documentations and interviewing affected families as well as patients with the suspected disease and inhabitants of villages where cases occurred. According to there investigation, the first suspected case of the outbreak was a two-year-old child who died in Meliandou village in Gueckedou prefecture on December 6, 2013. His sister, mother and grandmother were later infected and they too also died. Patient S14, health care worker with the suspected disease, seems to have triggered the spread of the virus to Macenta, Nzerekore, and Kissidougou in February 2014.

The epidemiological investigations by Sylvian Baize et al determined the index case and transmission chain as detailed in figure 1.

Figure 1: Transmission chain of the outbreak of Ebola Virus Disease in Guinea

Shown are the transmission chains of the outbreak involving laboratory-confirmed cases. The solid arrows indicate the presumed means of transmission as revealed by epidemiological investigation. Dashed arrows indicate that the epidemiological links have not been well established. Red circles indicate laboratory-confirmed (C) while suspected cases (S) are indicated with the case number. (Sylvian Baize et al, 2014).

Figure 2: Map of Guinea showing initial locations (highlighted in red) of outbreak of Ebola Virus Disease. (Courtesy: Sylvian Baize et al, 2014)

Since then the Ebola virus disease outbreak has reached the capital city of Conakry following the trails as shown in the figure 2.

The outbreak area is highlighted in red and the main road between the outbreak area and Conakry, the Capital of Guinea is also shown. (Sylvian Baize et al, 2014).  This main road provides easy access for people, goods and services to move from one part of the country to another, including crossing the porous borders with neighboring countries with which they share a common language, cultural practices as well as trade.  It also provides an enabling contact link across the country and as a matter of fact, puts across-border countries at a high risk of the EVD outbreak. For instance, Sierra-Leone and Liberia presently have recorded major outbreaks! Ivory Coast, Mali, Senegal and Guinea Bissau should be on high alert too!!

Apart from the outbreak areas cases have also been observed and confirmed in the following districts in Guinea: Dabola, Djingaraye, Telimele Boffa, Boke, Dubreka and Kouroussa, making it the largest Ebola outbreak in terms of geographical areas.

The figure below is a map of the Republic of Guinea showing the geographical distribution of cases.

Figure 3: Geographical distribution of Ebola virus disease Cases in Guinea.  Map by me.

(*From information reported as of 22^nd June 2014)

The district of Guekedou has the largest number of cases (221 cases) while Boke, Dubreka, Djingaraye and Kouroussa (each with 1 case) have the lowest number of cases since the onset of the outbreak. The figure below shows the geographical distribution of Ebola virus disease related deaths.

Figure 4: Geographical distribution of Ebola virus disease related deaths in Guinea. Map by me

(*From information reported as of 22^nd June 2014)

A total of 485 cases (340 confirmed, 133 probable and 12 suspected) and 358 deaths from the outbreak have been reported in Guinea.

As of 4^th August 2014, 13 new cases and 12 deaths were reported in Guinea. 

Figure 5:Weekly trend of new cases (confirmed, probable and suspected cases) and deaths in Guinea from March to July 2014.

(*Using data reported by W.H.O as of 4^th August 2014)

The figure above shows the progression of the Ebola Virus Disease in Guinea over time. The number of new cases reported declined after the peak in April but then a surge in new infections was observed in the month of June. This was followed by weeks of relatively low viral activity with another surge occurring in the last week of the month of July.

This surge indicates that undetected chains of transmission still exist in the community.

Figure 6: Cumulative number cases and deaths of the Ebola Virus Disease in Guinea from March to July 2014.

(*Using data reported by W.H.O as of 4^th August 2014)

Control of this strain of the Zaire Ebola virus subtype is proving difficult resulting in this peak and trough of new cases. The main factor has been the geographical spread of cases (as shown in figure 3) and movement of people not only within the country Guinea but also with its neighbors where cases have also been reported (figure 7) -in Liberia 468 cases and 255 deaths, Sierra Leone 646 cases and 273 deaths. Travel-linked cases have also been reported in Nigeria (5 cases and 2 deaths) and Morocco as well as Saudi Arabia. The Ebola virus disease outbreak is currently in its fifth month with a cumulative total of 1603 cases and 887 deaths (case fatality ratio of 55.3%) reported in four countries. Thus making this outbreak the largest in the history of the disease.  These movements make contact tracing (those who might be infected) very difficult. As epidemiologist Michel Van Herp from Medecins Sans Frontieres told The Lancet, “even the dead are moving”.  As a result person-to-person transmission is made possible.

Figure 7:  Map showing main roads connecting Guinea, Sierra Leone and Liberia. W.H.O Image

Unlike Central Africa where the disease is more common and health workers better equipped to handle Ebola, the West Africa region’s health workers have never dealt with this virus before and are therefore in dire need of training in infection-control measures to protect themselves and provide adequate care for their patients.  To date more than 60 health care workers have died.  Dr. Kahn, a virologist, who has played a key role fighting the disease in Sierra Leone, died from the Ebola virus disease infection on Tuesday 29^th July 2014 (which is so sad). He is credited with having treated more than 100 Ebola virus disease patients.

Families do not co-operate with medical teams. Community members have been known to throw stones at health workers as well as hide their sick relatives for fear of stigmatization.  MSF was forced to suspend activities in one of its treatment center after it came under attack by protesters in April. Relatives forcefully discharge Ebola virus disease patients from treatment center as they doubt the existence of the disease as well as view the isolation units as a “death sentence”.  Also reported was the corpse of a suspected Ebola patient, which was abandoned in Louisiana, in Montserrade Liberia on Friday 18^th July 2014. When health workers arrived to get the body, the son of the deceased started throwing stones and refused for the body to be removed. This is a major concern as direct contact with the corpse could lead to transmission of the virus. Infected corpse needs to be handled with care.

Figure 8: Staff of Doctors without Borders carrying the body of a person killed by the disease.  AFP/Getty Images

Apart from all these challenges, there are also Ebola-like diseases all over the place such as Lassa fever, Malaria, and Typhoid fever etc., which are endemic in West Africa, making early detection difficult.

Ebola is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals such as fruit bats, monkeys, antelope, gorillas, chimpanzees and porcupines. It then spreads in the human population with infection resulting from direct contact with (through broken skin or mucous membrane) blood, secretions (such as sweat, saliva, breast milk), organs or other bodily fluids of infected people, and indirect contact with environments contaminated with the victim’s fluids such as contaminated medical equipment. Men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness.

Figure 9: Life cycle of Ebola Virus. CDC.

Ebola virus disease is characterized by sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is often accompanied by vomiting, diarrhea, rash, impaired kidney and liver function and in some extreme cases internal and external bleeding.

The incubation period (i.e. the time from infection to the onset of symptoms) of the disease is 2- 21 days. It has a high fatality rate of 63-90% in identified cases.

At the moment there is no licensed vaccine or specific treatment available, only palliative care.

Despite all this, the medical charity MSF reports that three quarters of those suffering from the Ebola virus disease who entered their treatment center in Telimele a small town, in northern Guinea have recovered compared to only 20-40% of patients in Gueckedou. An unusually high proportion that is puzzling to scientist and aid workers.

The observed difference in the survival rate might be due to mutation of the original virus, increased immunity in the population or false positive lab results (i.e. diagnosing a suspected Ebola case as having the disease when in fact he/she does not).

This ongoing Ebola outbreak should serve as a wake up call to all West African governments to:

• Improve and provide access to the much needed health care facilities (such as facilities for isolation and supportive therapy, this need to be built, equipped and adequately staffed) and diagnostic technologies. Only a few laboratories in the region have the capacity to safely test a biosafety level 4 pathogen.  Early in epidemic blood samples were sent to France, Germany and Senegal. In Sierra Leone there is only one laboratory capable of testing for Ebola.
• Support for clinical care providers should be expanded. Presently Liberia has just 0.014 doctors per 1,000 people while Bo, a city in Sierra Leone, has less than 15 doctors for a population of more than 150,000 people. Training and constant access to reliable personal protective equipment should also be provided for health care workers for they are the first port of call for any one who is sick.
• Improve regional and global surveillance and data sharing. Such surveillance can help in early warnings, outbreak response and communication between health-care providers, wildlife and veterinary professionals, local and national health authorities, as well as regional and international agencies. Adopting new data-sharing technologies can do this. Digitalized maps can be created using available satellite images with distinction been made between residential and unoccupied buildings, so as to improve disease mapping, this can be done using open source geographical information system. 
• Accurate information about the disease needs to be rapidly and widely spread across the infected countries so to curtail superstitious beliefs and improve compliance with prevention and control measures that have proven to be effective. 
• Also the government should stop threatening to prosecute individuals who knowingly harbor an Ebola patient. These threats have raised anxiety, fuelled rumors that led to counter-productive behaviors as well as increased the animosity between the government and the people.

Individuals also have a role to play in other to curb this epidemic.  These can be done by:

•  Attend the treatment center at the first onset of symptoms. Evidence exist that early detection of the disease and implementation of supportive therapy increases ones chances of survival. 
• Close contact with Ebola patients should be avoided as much as possible. Gloves and appropriate protective equipment should be worn when taking care of ill patients as contact with ALL body fluid are contagious even vomits and diarrhoea.
• Do not travel if you suspect you might be infected, thereby reducing contact with susceptible people. Be your brother’s keeper. 
•  Dignified burial helps in gaining the public’s trust and eases grieving. However burial of infected relatives should be done promptly and with the upmost care using personal protective equipment so to minimize transmission, as the virus remains present in the body of the deceased.  Traditional burial practices ignite further spread of the virus.
• Practice good hygiene. Wash your hands with sodium hypochlorite water after visiting patients in the hospital, as well as after taking care of patients at home. Knowing this is difficult in a region that barely has clean water for drinking.  The owner of a restaurant in Sierra Leone, had a bottle of chlorinated water placed at the entrance, and everyone who entered was asked to wash their hands. 
•  Sick animals should be handled with gloves and other protective clothing and also when slaughtering animals. Animal products should be thoroughly cooked before consumption.

Ebola can be contained and chains of transmission broken.

Notice: If you suspect a case of Ebola in Nigeria call/text the Nigerian Ministry Of Health Helpline: 08023169485, 08033086660, 08033065303, 08055281442, and 08055329229.

References:

Sylvain Baize, Ph.D., Delphine Pannetier, Ph.D., Lisa Oestereich, M.Sc., Toni Rieger, Ph.D., Lamine Koivogui, Ph.D., N'Faly Magassouba, Ph.D., Barrè Soropogui, M.Sc., Mamadou Saliou Sow, M.D., Sakoba Keïta, M.D., Hilde De Clerck, M.D., Amanda Tiffany, M.P.H., Gemma Dominguez, B.Sc., Mathieu Loua, M.D., Alexis Traoré, M.D., Moussa Kolié, M.D., Emmanuel Roland Malano, M.D., Emmanuel Heleze, M.D., Anne Bocquin, M.Sc., Stephane Mély, M.Sc., Hervé Raoul, Ph.D., Valérie Caro, Ph.D., Dániel Cadar, D.V.M., Ph.D., Martin Gabriel, M.D., Meike Pahlmann, Ph.D., Dennis Tappe, M.D., Jonas Schmidt-Chanasit, M.D., Benido Impouma, M.D., Abdoul Karim Diallo, M.D., Pierre Formenty, D.V.M., M.P.H., Michel Van Herp, M.D., M.P.H., and Stephan Günther, M.D., Emergence of Zaire Ebola Virus Disease in Guinea — Preliminary Report. The New England Journal of Medicine, 2014