Ebola is already in the United States

It's odd to see otherwise pretty rational folks getting nervous about the news that the American Ebola patients are being flown back to the United States for treatment. "What if Ebola gets out?" "What if it infects the doctors/pilots/nurses taking care of them?" "I don't want Ebola in the US!"

Friends, I have news for you: Ebola is *already* in the US.

Ebola is a virus with no vaccine or cure. As such, any scientist who wants to work with the live virus needs to have biosafety level 4 facilities (the highest, most secure labs in existence--abbreviated BSL4) available to them. We have a number of those here in the United States, and people are working with many of the Ebola types here. Have you heard of any Ebola outbreaks occurring here in the US? Nope. These scientists are highly trained and very careful, just like people treating these Ebola patients and working out all the logistics of their arrival and transport will be.

Second, you might not know that we've already experienced patients coming into the US with deadly hemorrhagic fever infections. We've had more than one case of imported Lassa fever, another African hemorrhagic fever virus with a fairly high fatality rate in humans (though not rising to the level of Ebola outbreaks). One occurred in Pennsylvania; another in New York just this past April; a previous one in New Jersey a decade ago. All told, there have been at least 7  cases of Lassa fever imported into the United States--and those are just the ones we know about, who were sick enough to be hospitalized, and whose symptoms and travel history alerted doctors to take samples and contact the CDC. It's not surprising this would show up occasionally in the US, as Lassa causes up to 300,000 infections per year in Africa.

How many secondary cases occurred from those importations? None. Like Ebola, Lassa is spread human to human via contact with blood and other body fluids. It's not readily transmissible or easily airborne, so the risk to others in US hospitals (or on public transportation or other similar places) is quite low.

OK, you may say, but Lassa is an arenavirus, and Ebola is a filovirus--so am I comparing apples to oranges? How about, then, an imported case of Ebola's cousin virus, Marburg? One of those was diagnosed in Colorado in 2008, in a woman who had traveled to Uganda and apparently was sickened by the virus there. Even though she wasn't diagnosed until a full year after the infection (and then only because *she* requested that she be tested for Marburg antibodies after seeing a report of another Marburg death in a tourist who'd visited the same places she had in Uganda), no secondary cases were seen in that importation either.

And of course, who could forget the identification of a new strain of Ebola virus *within* the United States. Though the Reston virus is not harmful to humans, it certainly was concerning when it was discovered in a group of imported monkeys. So this will be far from our first tango with Ebola in this country.

Ebola is a terrible disease. It kills many that it infects. It *can* spread fairly rapidly when precautions are not carefully adhered to: when cultural practices such as ritual washing of bodies are continued despite warnings, or when needles are reused because of a lack of medical supplies, or when gloves and other protective gear are not available, or when patients are sharing beds because they are brought to hospitals lacking even such basics as enough beds or clean bedding for patients. But if all you know of Ebola is from The Hot Zone or Outbreak, well, that's not really what Ebola looks like. I interviewed colleagues from Doctors without Borders a few years back on their experiences with an Ebola outbreak, and they noted:

"As for the disease, it is not as bloody and dramatic as in the movies or books. The patients mostly look sick and weak. If there is blood, it is not a lot, usually in the vomit or diarrhea, occasionally from the gums or nose. The transmission is rather ordinary, just contact with infected body fluids. It does not occur because of mere proximity or via an airborne route (as in Outbreak if I recall correctly). The outbreak control organizations in the movies have no problem implementing their solutions once these have been found. In reality, we know what needs to be done, the problem is getting it to happen. This is why community relations are such an issue, where they are not such a problem in the movies."

So, sure, be concerned. But be rational as well. Yes, we know all too well that our public health agencies can fuck up. I'm not saying there is zero chance of something going wrong. But it is low. As an infectious disease specialist (and one with an extreme interest in Ebola), I'm way more concerned about influenza or measles many other "ordinary" viruses than I am about Ebola. Ebola is exotic and its symptoms can be terrifying, but also much easier to contain by people who know their stuff.


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thanks for posting this.

By razib khan (not verified) on 02 Aug 2014 #permalink

Thanks for posting this.

I'm only left with one question - with lassa fever and the Marburg virus, were there any epidemics? Part of the reason why the current ebola outbreak is scary is that it seems to be an epidemic - cases are increasing exponentially, unlike previous ebola outbreaks that affected only a few hundred people at most.

It seems that the reason the current ebola outbreak is an epidemic is because of burial practices but also because of the spread from rural to urban areas. For example, with lassa fever, why wouldn't it become an epidemic too as people buried their loved ones & contracted it? Has ever become an epidemic before, and if so, how did it stop?

I guess what concerns me with the differential infection vector with this ebola outbreak and whether that has any bearing on whether ebola would behave differently than lassa and Marburg in the U.S. We do not have West African burial practices, but we do have dense populations.

If highly trained doctors know how to deal with this, how did a doctor contract it? Was he partaking in a burial washing, reusing needles or did he run out of medical supplies?

No matter what, my prayers are with the doctor and all that have been stricken.

By Mike Wallace (not verified) on 02 Aug 2014 #permalink

Hi Mike,

He can't wear a fully protective body suit all day in the African heat, they were likely very limited in terms of medical supplies, and they probably had to enlist the help of many citizens who were not very well educated on the disease and sanitation. It's a very rough environment right now in Africa for practicing medicine without getting sick yourself.

If highly trained doctors know how to deal with this, how did a doctor contract it?
doctors aren't miracle workers the surrounding environment they work in has big effect . and u don't really know if they got the infection from isolated patients or from the ones who refused to report their disease and stayed outside spreading the virus
and you don't know what it is like to work in a corrupted damaged third world hospitals where u r not sure u have the best personal protective equipment to protect ur self and a good infection control system where everyone follow the rules to protect themselves and others in stupid countries who see infection control as waste of time and resources
so please thank God u live in a good country and stop the useless panic

By dr mariam (not verified) on 03 Aug 2014 #permalink

My big problem is that research has proven that this can become air born in the swine type and we hear all the time that the internal organs of the pig match human fairly close so there is no real way any of you can say it won't become air born that is why you use the statements it won't spread widely in the U.S. So I understand why we would bring them home to be close to better med. attention and family but why endanger the mass for just a few?

Thanks for the post. I was wanting for a real scientist that work on the field to say something about this subject

Tony, yes, there have been epidemics of both Marburg and Lassa. As noted, Lassa causes hundreds of thousands of infections each year.

Jon, pig and human organs are of similar size, that's all. There are many, many viruses that infect pigs that don't infect us and vice versa.

(1) The point of not wanting a live virus here is that no one knows when and where ebola might mutate into a more transmissible virus. And should the ebola escape into the wild, we also do not know what animals here in the US might conceivably become asymptomatic carriers like those fruit bats in Africa.

(2) When you say that ebola is here in the US, where exactly in the US? Some testing station on an island offshore, so as to reduce the risk of transmission in case of escape into the wild? Don't think they are otherwise testing ebola at Emory.

(2) Lassa is indeed apples and oranges, since roughly 4 in 5 infected with Lassa are mild or asymptomatic (or so says the Minnesota, N.J., etc., Depts of Health and you can add the Public Health Agency of Canada as well), meaning that not only is Lassa not anywhere near as lethal as Ebola, but we might have a hard time determining secondary transmission unless we round up everyone in the vicinity for antibody tests (since some will have no symptoms and perhaps all of those mild cases will be misdiagnosed for reasons that you can easily imagine).

(4) I would also have to disagree with your statement re Lassa not being transmitted by air. Is the same as with the Hantavirus, and so is also transmitted by air via the fresh and dried droppings of urine and feces of the rodents in question. Careful when you sweep the place. At least if you're in an area with a history of Lassa or Hantavirus.

(5) Perhaps someone might come up with the obvious, and so, if we are going to bring such people home, as with the testing facilities, perhaps the med care facilities should also be offshore, on an island, to reduce risk of escape into the wild and transmission into the larger population.

(6) Standing order no. 5 of the short form version of the standing orders for Rogers Rangers: Don't never take a chance you don't have to. The med and med research crews might learn something from some others whose lessons learned are almost entirely negative, i.e., someone died for no good reason so let's learn why that happened and make sure that it never happens again. Or we could say instead, as some have:



Note from the Nature piece:

A US National Research Council report released in September detailed 395 biosafety breaches during work with select agents in the United States between 2003 and 2009 — including seven laboratory-acquired infections — that risked accidental release of dangerous pathogens from high-containment labs.

So more than the one fvck up. 365 instead. We well and truly only need the 1 great fvck up.

Now well and truly lastly, the applicable film is not either or both of Hot Zone and Outbreak, but instead Jurassic Park:

John Hammond: When we have control again...
Dr. Ellie Sattler: You never had control, that's the illusion! I was overwhelmed by the power of this place. But I made a mistake, too, I didn't have enough respect for that power and it's out now.

That's the one part. Now for the nimrods who thought it a good idea to engineer a more lethal and more transmissible strain of our favorite killer flu strain, we have this from that same film:

Dr. Ian Malcolm: Gee, the lack of humility before nature that's being displayed here, uh... staggers me.

Donald Gennaro: Well thank you, Dr. Malcolm, but I think things are a little bit different then you and I had feared...

Dr. Ian Malcolm: Yeah, I know. They're a lot worse.

Donald Gennaro: Now, wait a second now, we haven't even seen the park...

John Hammond: No, no, Donald, Donald, Donald... let him talk. There's no reason... I want to hear every viewpoint, I really do.

Dr. Ian Malcolm: Don't you see the danger, John, inherent in what you're doing here? Genetic power is the most awesome force the planet's ever seen, but you wield it like a kid that's found his dad's gun.

Donald Gennaro: It's hardly appropriate to start hurling generalizations...

Dr. Ian Malcolm: If I may... Um, I'll tell you the problem with the scientific power that you're using here, it didn't require any discipline to attain it. You read what others had done and you took the next step. You didn't earn the knowledge for yourselves, so you don't take any responsibility for it. You stood on the shoulders of geniuses to accomplish something as fast as you could, and before you even knew what you had, you patented it, and packaged it, and slapped it on a plastic lunchbox, and now

[bangs on the table]

Dr. Ian Malcolm: you're selling it, you wanna sell it. Well...

John Hammond: I don't think you're giving us our due credit. Our scientists have done things which nobody's ever done before...

Dr. Ian Malcolm: Yeah, yeah, but your scientists were so preoccupied with whether or not they could that they didn't stop to think if they should.

Good article, but I just wanted to post this clarification. The virus in the fictional film "Outbreak" was not Ebola at all. Instead, it was a fictional new virus created for the film named "Motaba" that was only very loosely inspired by Ebola.

Paul, point by point:

1) Sure, but you can say that about anything. Fact is that Ebola has been remarkably stable over ~40 or so years that we've been observing it. Taken to extremes, HIV is a retrovirus and way more mutable--are you concerned about it evolving into an efficiently respiratory-transmitted pathogen. We could freak out over every possibility, or use what we know to design the best containment plans possible based on a rational design based on good science. I prefer the latter.

2) Various labs throughout the US. Honestly given the hype right now I don't feel comfortable even naming any, but I assure you there are more than "offshore labs" such as Plum Island or something. Any place that has a BSL4 lab could conceivably do Ebola research.

3) Ebola can also be asymptomatic or very mild, for example all known human infections with the Reston virus, or this study: http://www.ncbi.nlm.nih.gov/pubmed/10717539 Once you have a serious case of Lassa, symptoms are very similar to Ebola, and the ones diagnosed and hospitalized in the US were obviously the more serious ones, so that makes the comparison more even.

4) I didn't say Lassa couldn't be airborne so you are attacking a strawman there. But the fact that yes, it certainly can be and still there have been no documented secondary cases shows that the fear of person-to-person spread of these types of viruses is overblown.

5) As research with Ebola has been on the mainland for almost 40 years with no cases in the general population, I think that suggestion is extreme overkill.

6) And as noted, I'm way more concerned about flu being released from something like that than with Ebola, and I already conceded that there have been fuck-ups and that no one is perfect. But, the fact that those are openly available and documented (usually by the researchers themselves or others around them) means that unlike some of the tinfoil hat brigade currently marching through the internets, there is some transparency and acknowledgement of fault and efforts to mitigate anything in the future. I love Hot Zone and The Stand as much as anyone, but those aren't scientific documents.

DonMac, yep, I'm aware, but it's based on Ebola and was released at a time that Ebola was very much in the news. It may have changed the name and some of the epi of the "Motaba virus" but c'mon, it's an Ebola movie.

My concern with this is that the scientists seem to be trying to calm the public, but they are saying things like "I would have no concerns about sitting next to an ebola infected person on an airplane" which is just nuts. When people start saying stuff like that, it's kind of like when someone comes into your workplace and says 'don't worry about layoffs, they will not happen'. It's about 80% likely that layoffs will happen, at that point.

I would feel so much more confidence in the scientists if they were more serious about it. They are so flippant that they make me more nervous than I was before.

And all your talk about ebola already being here...you are talking about samples in labs. Yes there is a ton of dangerous stuff in the freezer, but that's not the same as a human patient. My concern with transfering people here with the disease is that you would infect others along the way.

Lea, do you think the Ebola viruses stay in the freezers? No--they are used in experiments, both in petri dishes and in animal models. The patients were brought in on private planes and everyone was gowned up. The risk will never be completely zero but it is extremely, extremely low.

Tara, thanks for being responsive to all of us who are highly concerned about this virus threat. First question: How contagious is Ebola compared to the Norovirus? From what I have read, the Norovirus also is not airborne, but spread via viral particles. It infects thousands of people a year. So can you assure us that Ebola is far less contagious than Norovirus? Second question: the issue with Ebola is not just contagion, but what is necessary in order for a victim to survive: the equivalent of isolated, intensive care. Let's say Ebola is 1/100th as contagious as Noro...I am guessing there is not nearly enough centers/beds to handle 1/100th of the cases which would mean a higher death rate and higher contagion rates. Can you speak to this? Thanks so much for your advice.

By Steffani Aranas (not verified) on 06 Aug 2014 #permalink

Norovirus is highly transmissible--both because it only takes a few viral particles to cause an active infection, but also because it's very hardy in the environment and difficult to get rid of (hence remaining on cruise ships etc. despite massive decontamination efforts). Ebola is much more sensitive to environmental conditions and doesn't last as long in the environment, so fomite spread (doorknobs, countertops etc.) is less of an issue (though things like heavily contaminated bedsheets & even contaminated biohazard suits may play a role in spread).

And yes, absolutely there is way more involvement of hospitals etc. for a victim of Ebola than noro, but any outbreak here would be handled very quickly before such beds would be exhausted--and even if for some reason they were, hospitals all over the country are currently mobilizing for just such an event (I'll note, as merely a precautionary measure--it pays to be prepared for anything, and these types of preparations can come in handy if, say, it's a horrible influenza year). In Africa, the issue of dearth of beds is one reason this is spreading (sometimes beds are shared) and obviously hospitals/clinics are overwhelmed in some areas.

What do you mean by "mobilizing"? From what I have seen, U.S. action has been confined to distributing information on proper quarantine and treatment measures and putting airport quarantine stations on alert (that'll be loads of fun for the thousands of false alarms - it's hard to go to West Africa without picking up diarrhea or a fever). But it's not like they're getting thousands of isolation rooms cleared and stockpiling biohazard suits at every major hospital. Or is it? Frankly, that would make me feel like they did have reasons for fear that they weren't sharing with the public.

I mean testing and preparing for what happens if a test is positive. There was already a report from Columbus Ohio and a few out of NYC that publicized patients who are being tested (all negative to date).

Hi! I enjoy your blog and thank you for trying to get the truth about Ebola out there. I earned my PhD in arenavirus pathogenesis and worked with Ebola and Junin in a BSL4 lab. I've decided to start my own blog in response to the irresponsible media hype, and my first post is meant to provide the science behind why we won't have an Ebola epidemic in the U.S.. I hope to see you there and feel free to send people my way.


By Heather Lander (not verified) on 08 Aug 2014 #permalink

Nice! Thanks for sharing--I'll send out the link over Twitter.

Quick and easy question: Can someone briefly explain or give me a good link to understand why some viruses are spread by air and other not? Seems like a small virus in a droplet should do in any event? Obviously not, but why not? Also what is the lifespan of Ebola when not in a host, say on the bed sheet mentioned in an example. A much deeper question, which you can of course avoid answering if it is complicated, is what determines how long a virus can live say noro vs Ebola or flu? Overall seems like it could spread quite a bit or be very hard to shut down with a 21 day incubation period. Very interesting stuff- and I admit I am as interested in this topic as much as I am afraid of deadly diseases.

more information please, not mis-information or hysteria or hype. This is one of the best articles I've seen yet, because of the balance of information while not creating undue panic which could be a much bigger problem than Ebola itself. Panic leads to overeaction and irrational behaviour. I already have a friend talking about moving to the wilderness to escape this and I say really??? As if it got that bad it would not eventually reach you anywhere on the planet?? So I think we need more rational voices to emerge on this in the coming days and weeks to quiet the spread of too much "hype" which these days is all too easy with the internet and so much 24/7 media.

By Mandee Monee (not verified) on 17 Aug 2014 #permalink

is ebola able to be transmitted via flea bites, mosquitoes, or other means?

By joy macaulay (not verified) on 02 Oct 2014 #permalink

I feel a lot better. Thanks.

I don't believe that if it all were true then it would have been all over the news

Joy, Ebola is only able to be transmitted through direct contact with an individual who is showing the symptoms.

By Anon Unseen (not verified) on 07 Oct 2014 #permalink