Ebola

Rare, reliable data about Ebola from inside a treatment center in Sierra Leone

Everything we know about Ebola since the disease’s two dozen or so outbreaks since 1976 comes not from a rich, deep database of scientific evidence that’s been carefully collected and recorded. With few formal health care systems in the areas hardest hit by the disease, there were no medical records, no charts and no standardized ways to document patients’ symptoms, vital signs, treatment regimens and whether or not they survived. Instead, much of our knowledge comes from the haphazard scrawl of doctors’ notes and their recollections about treatment and survival rates.

But for the past 10 years at Kenema Government Hospital in Sierra Leone, the country’s Ministry of Health has been working with a group of international researchers to establish a meticulous medical records system—originally for patients with Lassa fever, another common infection in the region. So when the first Ebola patient walked through the door on May 25, the same procedures for documenting vital signs and treatment information stayed in place. Now, for the first time, doctors have a robust record of the first Ebola patients in the current outbreak treated at Kenema beginning in May—and the results of that record-keeping appear in the New England Journal of Medicine.

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The new records were a challenge to collect, since infection control rules meant that the paper charts could not be transferred back and forth between the ward where patients were treated and other areas of the hospital. “The nurses’ station was separated from the patient rooms by essentially a chicken wire window, so the nurses would talk to each other through the chicken wire—the nurse inside, in personal protective equipment, would tell the nurse outside what to write down,” says paper co-author Dr. John Schieffelin, an assistant professor of clinical pediatrics and internal medicine at Tulane University who has been serving stints at the hospital for the last four and a half years. Even that rudimentary system was state of the art for the region, where most health clinics do not keep medical records. “In most of Sierra Leone, the hospital chart is one of those little composition books that we used to write essays in during high school,” says Schieffelin. “There was no structure to it; the physician would just write daily notes and most hospitals don’t have a charting system.”

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The new documents confirm what previous health workers knew about Ebola from experience. Of 106 patients with Ebola, 44 had complete medical charts in paper form (the rest were destroyed because health officials feared they had been contaminated with the virus), and the findings supported some basic tenets of Ebola infection: that the incubation period for Ebola virus is about six to 12 days, that 74% of those infected died, that younger patients were more likely to survive infection than those over age 45, and that people with less virus in their blood when diagnosed were more likely to survive.

“It affirms our understanding of how to treat Ebola patients,” says Schieffelin. “We need to treat them aggressively with IV fluids and monitor their blood chemistries. The study also gives us a good solid baseline for understanding the disease, so we can build on it in a lot of different ways. It’s a foundation for doing further studies for optimizing treatment. It provides a great foundation for studies looking at novel treatment methods. Now that we understand how Ebola affects patients, can we improve symptoms and outcomes with novel therapies? We can start to ask and answer those questions.”

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Turning those answers into new treatment strategies, however, might be a daunting task—especially in the context of the current outbreak. On most days, the Kenema hospital would see about 90 Ebola-related patients, some of whom were suspected to have the disease but still needed to be tested, and others with confirmed infections who needed to be immediately assigned to a bed and given IV fluids. “There are a lot of confused Ebola patients,” says Schieffelin. “These people are wandering around the ward, often going from one bed to the next, and they are scared so often not very cooperative. To top that off, a lot of people didn’t speak English, so that made it even more challenging.”

He admits to often tossing patient confidentiality concerns aside by asking other patients who were feeling well to translate critical information to their peers, who either didn’t need to be in the hospital any longer because they tested negative, or needed to be immediately transferred to another ward if they were infected.

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At Kenema, the health care workers did not use the full-coverage hazmat suits that Medecins Sans Frontieres uses in its clinics. Instead, they wore Tyvek suits that covered their front and back, a mask, face shield, double gloves and a head covering. That left some skin in the front and back of the neck exposed. The reason was partly for practical reasons—Schieffelin was often the only health care worker on his part of the ward where patients were triaged, and frequently had to spend four to four and a half hours at a time suited up. The full coverage suits become uncomfortable and unbearable after about 45 minutes.

“But I was personally okay with our equipment,” he says. “Because my biggest concern was getting a needle stick. My mucous membranes—my eyes, nose and mouth—were pretty well covered.”

After about four hours, he and whoever else was working on the wards with the infected patients would get sprayed with a bleach solution from the shoulders down, in order to avoid splashing any potentially contaminated material onto their face and neck. Then they would take each piece of equipment off and wash their hands in bleach after each step. After a break of an hour or so, they would suit up again.

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When Schieffelin returned from his work in Sierra Leone in August, he was told by the World Health Organization, U.S. Centers for Disease Control and the Louisiana state health department (he lives in the state) to monitor his temperature twice a day for 21 days, which he did. He was also told not to use mass transportation. He worked at home for a couple days, only because he was exhausted after his trip, and when he returned to work he didn’t see patients for a few weeks—mostly out of a scheduling coincidence, not intentionally.

Given public concerns about Ebola potentially coming to the U.S. and spreading here, however, he says, “Perhaps we should say that in terms of physicians and nurses, maybe direct patient care for a couple of weeks would not be in anyone’s best interest.”

But while he recognizes that hospital organizations and the general pubic have legitimate concerns about being protected against an agent as deadly as Ebola, Schieffelin is against mandatory self-isolation or quarantine, measures the states of New York and New Jersey recently decided to require for all health care workers returning from the three countries affected by Ebola. “I think self-isolation is completely unnecessary if you are not symptomatic. In my mind, that enhances hysteria. I have young children. If their dad were in self isolation away from everybody for three weeks, that would adversely affect them and would be telling the community and the schools the wrong message: that I need to be a pariah and an outcast for three weeks,” he says. “In my mind, that’s not the right message. If I have no symptoms, I am not a threat to anybody—I’m not a threat to my children, nor are my children a threat to other children at their school.” Such mandatory quarantines could also deter health workers from contributing to the effort to control the epidemic, and that will only prolong it, he says.

Schieffelin says that if he had recorded a fever at any point during this 21 day monitoring period, he would have immediately reported to the Louisiana health department and gone into isolation. He knows how deadly Ebola can be from personal and professional experience: seven of Schieffelin’s co-authors on the paper have died of Ebola infection since the data were collected over the summer.

A father's claim that his two boys were beaten and called "Ebola" raises concern among Africans

The father says the bullying began soon after his two sons arrived at their New York City school from Senegal almost one month ago. They were called “Ebola” by other students, taunted about possibly being contagious and excluded from playing ball. Ousmane Drame says the baiting finally erupted into a physical fight on Oct. 24 when 11-year-old Amadou and his 13-year-old brother, Pape, were pummeled by classmates on the playground of Intermediate School 318 in the Bronx.

“It’s not just them,” Drame said at a press conference. “All the African children suffer this.”

The brothers’ experience is an extreme example of the backlash felt by some Africans in the United States since the Ebola virus arrived from West Africa. Many others tell of facing subtler, but no less hurtful, forms of discrimination at work, in school and as they commute as fear of the little-known but often deadly disease has spread among the public.

In Staten Island, the largest Liberian community outside of Africa, one woman says she was forced to take temporary, unpaid leave from her job because of her nationality. Liberians in Minnesota have been told to leave work after sneezing or coughing. In New Jersey, two elementary school students from Rwanda were kept out of school after other parents pressured school officials. At Navarro College, a public community college in Texas, officials mailed letters rejecting international applicants from African countries, even ones from countries without confirmed Ebola cases. (The school has since apologized for sending out “incorrect information.”)

“This is a larger problem,” says Charles Cooper, president of the African Advisory Council in New York, an advocacy group. “People are on the train and they sneeze and hear, ‘I hope you don’t have Ebola. I hope you don’t give me Ebola.’ Xenophobia is growing around this, but many people are afraid to come out publicly.”

The spread of previously unknown, contagious diseases in the U.S. has often led to these sorts of overreactions. For Ebola, those fears appear driven by the circumstances of the virus—its high mortality rate, its gruesome symptoms, its origins on a continent often misunderstood by Americans—even though the odds of contracting it in the U.S. remain exceedingly low. A recent poll from the Harvard School of Public Health found that more than half of adults worry there will be a large Ebola outbreak inside in the U.S. over the next year, while over a third are worried that they or a family member will be infected.

While fears erupted around people diagnosed with Polio in the 1940s and SARS in the 2000s, public health experts point to the start of the AIDS epidemic in the early 1980s as the last time Americans attached a similar stigma to people even loosely associated with the virus. At the time, many Americans refused to be near those suspected of having HIV, unaware of how it was actually transmitted.

“A lot of what I’m seeing today was present at the very beginning of the AIDS epidemic,” says Robert Fullilove, a Columbia University professor of sociomedical sciences, who has been researching HIV since the mid-1980s. “It’s this tendency to separate between two different groups, when somebody’s ‘otherness’ is associated with a deadly disease. It’s like déjà vu all over again.”

That toxic brew of fear and misinformation led to discrimination against gays—the disease was unfairly yet colloquially known as the “gay plague” for its disproportionate toll among homosexual men—and people from Haiti, which was the first country in the Western Hemisphere with confirmed cases of HIV.

“Haiti itself became stigmatized,” says Dr. Joia Mukherjee, a Harvard Medical School associate professor. “The same thing is happening now with Liberians, and indeed all of Africa.”

In both cases, the driving forces are the same: a general lack of understanding about the disease, how it is transmitted and where it’s been concentrated.

“The average American doesn’t even recognize how big Africa is,” Fullilove says of the Ebola stereotypes.

The bullying allegedly faced by the Drame brothers is a case in point. The vast majority of Ebola cases are in Liberia and Sierra Leone. Senegal had only one confirmed case and is now considered free of the disease by the Centers for Disease Control.

Countering such misinformation has been central to the messaging strategy of the CDC and government officials. It’s no coincidence that President Obama hugged Nina Pham after the Dallas nurse was declared free of the virus. And the image offensive may be paying off. According to a new ABC News/Washington Post poll, the people least worried about catching the disease or a larger U.S. outbreak were the ones who knew the most about how Ebola is transmitted.

For some West African doctors and nurses living overseas, the sense of obligation to their native countries outweighs the risk of contracting the highly infectious disease

The Ebola crisis that has made many want to flee West Africa has persuaded Derek Bangura to go back. “Since I’ve left Sierra Leone, I’ve not made that much contribution to its development,” says Bangura, a 46-year-old general physician who lives and works in London. He has not lived in his native Sierra Leone for 30 years. Now he is preparing to go to his native country for eight weeks, beginning in late December, to help combat the infectious disease that has killed at least 4,922 people. “I just felt that this is the time to make a difference,” he says.

As the Ebola crisis in West Africa continues to devastate entire communities across Liberia, Guinea and Sierra Leone, many expatriate health workers from the region have faced a complicated choice between continuing their lives in the West or returning home to help combat the disease and, in the process, risk contracting Ebola.

Public health experts, world leaders and aid organizations agree that more doctors on the front line is one of the only things that will help beat the epidemic in West Africa. “We need literally thousands and thousands of trained health workers who will need more training around Ebola to step up and volunteer,” said World Bank President Jim Yong Kim in Washington D.C. last week. The public health systems in the affected countries — including the staffing levels at hospitals and clinics — were woefully lacking even before the Ebola epidemic struck.

For decades the affected countries — like many nations in the developing world — had lost many of their doctors and nurses to the U.S. and Europe. Many trained or aspiring doctors and nurses — who may face low wages, poor working conditions and overwhelming workloads at home — are swayed by the promise of better facilities and higher salaries abroad. The result is that many African nations have an alarming shortage of qualified health care workers.

According to the Central Intelligence Agency’s figures, the number of doctors working in Liberia and Guinea before the outbreak of Ebola is one for every 100,000 citizens. Sierra Leone fares slightly better with two doctors for every 100,000 citizens. The U.S. has around 242 doctors for every 100,000 citizens.

In the best of circumstances, these nations’ health care systems are strained. The Ebola epidemic has all but broken them down completely. Stephen Kennedy, a Liberian doctor who did most of his training in the U.S. and returned home last year, tells TIME that Liberia’s “entire health care system has collapsed and people are dying from preventable diseases like malaria.”

For many Sierra Leonean, Liberian and Guinean health care workers living abroad, the epidemic has pulled them back to the places of their birth.

Abdullah Kiatamba heads the Minnesota African Task Force Against Ebola, which is organizing a contingent of Liberian-born doctors and nurses who want to volunteer in Liberia, Sierra Leone and Guinea. He says that more than 150 nurses and doctors have volunteered and hope to leave by the end of November. “If we are setting the example that we are afraid to go, why would someone want to risk their life for us when we are not willing?” says Kiatamba.

Bandura shares that sense of obligation but he also knows that not everyone feels the same way. “The people who once lived there have a kind of expertise,” he says. “I was trying to get more doctors of Sierra Leonean origin who would be handy because of their local knowledge and language — they would be ideal.” But for many of his fellow Sierra Leonean colleagues, the pull hasn’t been strong enough. “It’s all to do with the risk. They’re not willing to take that risk.”

Kiatamba in Minnesota also says that worries have weighed on the minds of many volunteers. Even those who don’t fear contracting Ebola are concerned about how volunteering might affect their jobs, their families, their immigration status and their relationships in the U.S. “These are some of the concerns right now,” he says.

These fears have been increased by new guidelines set out by the Centers for Disease Control and Prevention, which could lead to returning health workers being asked to undergo voluntary at-home isolation.

The chances of contracting Ebola in Liberia, Sierra Leone and Guinea are higher than elsewhere, especially for health care workers treating infected patients. Basic equipment — such as gloves and adequate hand-washing stations — are often missing or sparse. A recent report from the Centers for Disease Control and Prevention analyzed four counties in Liberia and found, “There was insufficient personal protective equipment to care for patients with Ebola.” According to the World Health Organization, as of Oct. 8, 416 health workers in West Africa had been infected and 233 of those workers had died from Ebola.

The risk is so high that many physicians who were already practising in West Africa have fled. The CDC report also found that several doctors working in the Liberia counties studied had “left Liberia because of the epidemic.” Also: “In two of four hospitals assessed, nursing staff members were not coming to work or had abandoned facilities; in another hospital, health care providers had not been paid for three months but were still providing basic care. Frequently, nursing students, nursing aides, and community health care volunteers were providing basic medical care and responding to obstetric and surgical emergencies.”

In August, Liberian president Ellen Johnson Sirleaf went so far as to fire state officials who were abroad and refused to return to Liberia to fight Ebola. Yet her son, a physician who lives in Georgia, was at the same time also leaving Liberia after initially helping to combat the disease, out of fear of infection. “The symbolism of me going there and potentially getting Ebola when I have a nine- and a seven-year-old at home isn’t worth it just to appease people,” James Adama Sirleaf told the Wall Street Journal about his decision to return to the U.S.

Fear of the disease is more than understandable yet there are still those who are willing to return to the countries they left in search of a new life abroad. “My connection [to Sierra Leone] is there,” says Bangura, who begins specialized training for his mission in early December. “We all know it is risky but someone has to do it.”

Arthur Caplan, PhD, is the Director of the Division of Medical Ethics at NYU Langone Medical Center.

Not only is quarantine not needed for responsible people and health workers who self-monitor, if enforced it will do far more harm than good

Nervous government officials who seem more interested in appearing tough rather than letting science actually defeat Ebola in the United States are misusing quarantine.

Prominent governmental officials such as Defense Secretary Chuck Hagel and potential presidential candidate Governor Chris Christie of New Jersey have succumbed to pandering in the face of Ebola. In fact, the Governor has now doubled down on his unscientific and ill-thought through policy of quarantining those exposed to someone with Ebola. He practically begged to be sued for summarily quarantining a heroic nurse, Kaci Hickox, upon her return from West Africa, even after she tested negative for Ebola. “Whatever. Get in line…I’ve been sued lots of times before. Get in line. I’m happy to take it [the decision to quarantine] on.”

The line is already forming. Hickox, a nurse who wil not be bullied, is at the head of it. The Governor will lose. And he should. State-mandated quarantines make little sense as a weapon against Ebola in the United States.

Christie tried to imprison Hickox without any explanation or even a hint of legal due process in a tent with no running water or TV at a Newark, New Jersey, hospital after she came back from a harrowing volunteer visit to fight Ebola in West Africa. She was tossed into the tent despite the fact that she exhibited no symptoms and was not infectious. She protested her confinement, scared New Jersey officials into letting her go and headed back in a limo to her husband and hometown in Maine.

Governor Paul R. LePage now says that Maine requires health care workers such as Hickox, who return to the state from West Africa, remain under a 21-day forced home quarantine. Hickox says no way.

“Going forward, she does not intend to abide by the quarantine imposed by Maine officials because she is not a risk to others,” her attorney, Steven Hyman, told reporters. “She is asymptomatic and under all the protocols cannot be deemed a medical risk of being contagious to anyone.” Hickox will, however, do what is right and appropriate. She plans to abide by all the self-monitoring requirements suggested by the Centers for Disease Control.

Self-monitoring is the accepted, scientifically validated way to handle non-symptomatic people exposed to those with Ebola. Craig Spencer, the doctor who is now the only Ebola patient in America in a hospital, self-monitored while moving around New York City. When he got symptoms, he went to the hospital. Number of people he infected while self-monitoring? Zero.

Not only is quarantine not needed for responsible people like Hickox and Spencer, if enforced it will do far more harm than good.

Amber Vinson was the second nurse from Texas Health Presbyterian Hospital Dallas to get the virus while caring for Thomas Eric Duncan, a Liberian man who began showing Ebola symptoms after arriving in Texas and died under her care when he was finally admitted to that hospital. When she was discharged from the isolation unit at Emory University Medical Center in Atlanta, there were at least 30 doctors and nurses gathered around her as she joyfully thanked them for saving her life. I saw a room of heroes.

But if you are the Governor of New Jersey or New York or Maine, you must have seen something very different—30 people who ought to be immediately quarantined as a result of exposure to a person with Ebola. The same holds true for everyone who had any interaction with Hickox in her short stay in the isolation tent in Newark. This will include everyone in the courtroom in Maine if she shows up there, as is her right to fight mandatory quarantine.

Quarantine is a very intrusive tool in fighting disease. Our legal system permits it, but only when there are no other less restrictive ways to control an outbreak. There are less restrictive ways to contain Ebola, for example, self-monitoring and voluntary isolation at home. Those things work. The only people in America who got Ebola are health care workers who cared for Ebola patients. And to date, all but one who have been treated in America have survived. Ebola is not the lethal disease in the U.S. that it is in Sierra Leone, Guinea and Liberia, making quarantine even harder to justify.

The way to manage Ebola is with strict monitoring for symptoms. The way to manage fear and ignorance is with quarantine. The way to defeat Ebola in West Africa is to treat volunteers as responsible, moral heroes. The way to allow the epidemic to spread is to lock-up those who offer the only chance for treatment and eradication.

Arthur Caplan, PhD, is the Director of the Division of Medical Ethics at NYU Langone Medical Center.

Recent experiences with SARS and bird flu make Asian nations especially skittish when faced with the possibility of an Ebola outbreak

As Ebola continues to play global hopscotch, Asian countries are seeking to make good on the advanced notice that the deadly virus could turn up anywhere, anytime.

At issue in Asia — and everywhere — is not just that medical scaffolding varies across and within nations, with some lacking robust medical facilities, but that even sophisticated cities boasting top-notch hospitals are foundering. The infections of two health care workers in Dallas, as well as a nurse in Madrid, have illustrated that even highly developed nations are not immune.

“Perceived preparedness and actual preparedness are not the same thing,” says Stephen Morse, professor of epidemiology at the Columbia University Medical Center.

“We thought the U.S. would be well prepared, but certainly our first case [in Dallas] was not a good model for replication, and I don’t think Spain did too well either,” explains Morse. “But that’s what happens when you haven’t seen this before. You don’t know what to do.”

Still, Asia has some advantages as it readies itself for Ebola. Flight patterns suggest that the influx of travelers from Ebola-stricken West African countries to the Asian continent is far less than it is to Africa, Europe or North America.

Asian nations also have an edge in that they have been through epidemics before: SARS tore through the West Pacific in 2003, killing almost 800 people worldwide, mostly in Hong Kong and mainland China. Avian flu also pummeled this area around the same time, and outbreaks of virulent influenza strains perennially menace the region.

“The most likely scenario, if we have an imported case of Ebola, is that there will be some risk of having secondary cases, but I don’t think we will have a big outbreak at this point in time,” says Hitoshi Oshitani, professor of virology at Tohoku University Graduate School of Medicine in Sendai, Japan.

In part, that’s because Ebola is much more straightforward to contain than the airborne SARS — spread through coughing and sneezing — if procedures are followed rigorously, says Oshitani, who from 1999 to 2005 was the regional adviser for communicable-disease surveillance and response at the WHO’s Western Pacific Regional Office during the SARS and avian-flu outbreaks. When SARS first appeared “we didn’t know what to do at first,” he says.

But having weathered these outbreaks now makes Asian nations stronger. “After SARS and Avian flu, Asian countries have invested quite a lot in infectious disease control,” says Oshitani. “Before 2003, many countries in Asia had very limited capacity, and today they have much more capacity.”

That said, much depends on where across Asia’s socioeconomic smorgasbord a hypothetical Ebola case makes landfall.

For example, Hong Kong, blistered by the memory of SARS, has made significant preparations, says Malik Peiris, director of the School of Public Health at the University of Hong Kong. “Infectious diseases, especially diseases coming from the outside, have been a constant threat to Hong Kong and have kept people on their toes,” he says.

Hong Kong, which had just “a handful” of isolation beds in 2003, now has about 1,400, plus a designated infectious disease hospital, says Peiris. At that hospital, he adds, the facilities are “more than adequate to deal with SARS and certainly more than adequate to deal with Ebola.”

Preparing for Ebola is also foremost on health officials’ agendas in mainland China, Peiris says, while noting that health care is uneven across the world’s most populous nation, with world-class hospitals in major cities but spotty health care in rural areas. Dense populations and an incubation period of up to 21 days make Ebola potentially extremely problematic.

Chinese officials told state media in August that security at the airport in China’s southern Guangdong province, which does roaring business with African traders, had been bolstered.

India also presents a problem. Peter Piot, director of the London School of Hygiene and Tropical Medicine who co-discovered Ebola, told the Guardian earlier this month that Ebola outbreaks in Europe or North America could quickly be brought under control. However, “I am more worried about the many people from India who work in trade or industry in West Africa,” he said.

Indian Health Minister Harsh Vardhan told Parliament in August that some 4,700 Indians are working in Guinea, Liberia and Sierra Leone. India is using thermal scanners at its airports similar to those used at Nigeria, which was declared Ebola-free earlier this month. The country has also designated hospitals for handling the virus, and has also held preparedness drills, though a paltry ratio of 0.07 hospital beds per person does not bode well for any significant outbreak.

“The big problem is in high-density populations with low health coverage,” says Peiris. “In Mumbai, you have areas of quite significant poverty, and if Ebola enters such a situation, you could have a problem on your hands. Major cities really need to be prepared.”

The Philippines, boasting an estimated 1,700 nationals working in West Africa, is also bolstering readiness. Lyndon Lee Suy, spokesman at the Philippines Department of Health, says that three hospitals are designated to handle any Ebola cases, plus a training workshop is being run at 19 government hospitals, about 50 private hospitals and numerous local government clinics. All hospitals in the Philippines, which battled SARS in 2003 and H1N1 in 2009, have isolation rooms, he says.

“No country can ever rate how prepared it is for something like this,” says Lee Suy. “But the health system here is not the same as the one in West Africa. We are in a better position.”

Even Asian countries that have no direct flights to West Africa, and have limited ties to the region, are wary of being caught off guard.

Krishna Kumar, president of the Malaysian Medical Association, says his country was jolted by the Nipah virus in 1999, which killed more than 100 people nationwide, and has learned “hard but important lessons.”

“We weren’t expecting it,” he says. “It woke us up.”

Krishna says public alarm is low in Malaysia, but health officials are yet mindful “anything could happen.” All airports have thermal checks, and 28 government hospitals have isolation rooms and are fully equipped with protective gear.

“We have the systems in place,” he says, “but to know how ready you are — well, it’s only when something happens, then you know if you were ready.”

His attempt to force a nurse to stay under a 21-day quarantine didn't work out as expected

Governor had been criticized for quarantine measures

Two-year-old girl from Guinea tested positive on Oct. 23, died the next day

A two-year-old Guinean girl who recently traveled to Mali and was later confirmed to have Ebola has died, officials said on Friday, one day after her positive diagnosis meant the virus had reached its sixth nation in West Africa.

The child died around 4 p.m. local time at a treatment center in the western town of Kayes, a health official told Reuters. On Thursday, Health Minister Ousmane Kone told state television that she had traveled from neighboring Guinea, where more than 900 people have died in an outbreak that has killed nearly 4,900 and infected more than 9,900 others. The girl was admitted to a hospital on Wednesday night, where she tested positive for Ebola.

Health officials told the World Health Organization (WHO), according to a report released Friday, that she was accompanied to Mali by her grandmother. The girl’s mother was reported to have died a few weeks earlier, but WHO could not yet confirm that the grandmother went to Kissidougou, in southern Guinea, for the funeral. The pair returned to Mali by public transportation and arrived in the capital, Bamako, where they stayed for two hours before moving on to Kayes.

The girl had begun bleeding from the nose before she left Guinea, the report found, “meaning that the child was symptomatic during their travels through Mali” and that “multiple opportunities for exposure occurred when the child was visibly symptomatic.” The initial investigation identified 43 close and unprotected contacts, including 10 health workers.

The Ministry of Health and Public Hygiene said in a statement it had “taken all necessary steps to prevent the spread of the virus” and the government called for calm, claiming it had identified and isolated those who had contact with the child and begun monitoring for symptoms. Tracing this particular case is “a work-in-progress,” Isabelle Nuttall, the WHO’s director of Global Capacities, Alert and Response, tells TIME. WHO had already sent a team of 10 to Mali at the beginning of the week to work on mobilization activities and preparedness operations, and is sending more as part of a rapid response team.

Mali still has its border open to travelers from Guinea, though border checkpoints and health points have been implemented on major roads and crossings. Greg Rose, health advisor to the British Red Cross, says the fact that the child is now “in a more remote location is a good thing” because Kayes is not situated on the main transport routes (unlike larger towns situated on the Niger River) and only has a population of around 127,000, a fraction of Bamako’s 1.8 million. Another positive, Rose says, is that “it doesn’t look like the situation from where this child has come is out of control,” which could reduce the risk of transmission. He adds that Kissidougou, where the child’s mother is believed to have died, has seen relatively few cases since the beginning of the epidemic and is now the site of a treatment center.

Rose believes that being able to isolate people who are asymptomatic will prove a major advantage for Mali. Since the government has reacted very quickly and identified this case early, he adds, it will be able to do much more to contain any spread of Ebola from this sole case. In comparison, “when you have a disseminated outbreak like in Guinea, Liberia or Sierra Leone, where resources are limited, they can only isolate symptomatic people.”

Nuttall believes it is still too premature to assess the effectiveness of Mali’s public health response. But “so far, it looks good,” Rose says. “If you look back to Guinea when the outbreak first began in January of this year, nothing was being done because everybody was taken by surprise,” he adds. “Experience of Ebola in other contexts had shown that Ebola outbreaks tend to burn out so Guinea was neglected, which is why this got out of hand.”

While experts believe Mali’s health system is stronger than some of its neighbors, it is still quite weak. “In this part of Africa, as a general rule, the health system needs to be strengthened,” Nuttall says. Maternal mortality ratio, which Rose says is a solid indicator of public health infrastructure because it depends so much on the provision of health services and skilled attendants, is at 550 deaths per 100,000 live births in Mali. That figure isn’t as high as other countries affected by Ebola — Liberia stands at 640, Guinea at 650 and Sierra Leone at 1,100 — but is still remarkably high when compared with the U.S. (28 per 100,000) and the U.K., at just eight.

As the situations in Nigeria and Senegal have shown — both were recently declared Ebola-free — it is possible to contain the virus and control the epidemic. But as more cases pop up in the three hardest-hit countries, and now with Mali’s first case quickly turning deadly, controlling anxiety and fear alongside any actual spread could be a feat.