Thomas Eric Duncan: First Ebola death in

U.S.
By Greg Botelho and Jacque Wilson, CNN
October 8, 2014 -- Updated 1919 GMT (0319 HKT)
STORY HIGHLIGHTS

Thomas Eric Duncan passed away on October 8 at 7:51 a.m.

Duncan, 42, is the first person diagnosed with Ebola in the United States

Duncan had a fever, was vomiting when he went to a hospital; he was sent home

Liberian man was admitted to the same Dallas hospital, isolated days later

(CNN) -- Thomas Eric Duncan left Liberia for the United States, by official accounts, a healthy
man. Just over two weeks later, he passed away at a Dallas, Texas, hospital with Ebola.
Duncan was admitted into isolation at Texas Health Presbyterian Hospital on September 28 with
common symptoms of Ebola: fever, vomiting and diarrhea. He later tested positive for the virus
that has killed more than 3,400 people in West Africa.
He was started on the experimental drug brincidofovir on October 4 -- far too long after he
arrived at the hospital, his family has said. On Tuesday, the hospital reported that Duncan was on
a ventilator and his kidneys were failing.
Duncan died on Wednesday at 7:51 a.m.
"His suffering is over," his partner Louise Troh said in a statement. "My family is in deep
sadness and grief, but we leave him in the hands of God. Our deepest sympathies go out to his
father and family in Liberia and here in America. Eric was a wonderful man who showed
compassion toward all." Who was Duncan, besides the first person to be diagnosed with Ebola in
the United States? When did he start to feel sick, and why couldn't the U.S. health care system
save him?
"The past week has been an enormous test of our health system, but for one family it has been far
more personal," Dr. David Lakey, commissioner of the Texas Department of State Health
Services, said in a statement. "The doctors, nurses and staff at Presbyterian provided excellent
and compassionate care, but Ebola is a disease that attacks the body in many ways. We'll
continue every effort to contain the spread of the virus and protect people from this threat."

Who was Thomas Eric Duncan?

He was a 42-year-old Liberian citizen. Duncan's Facebook page indicates that he's from the
Liberian capital of Monrovia, where he attended E. Jonathan Goodridge High School.
Why did he come to the United States?
To visit family and friends. Duncan was visiting his son and his son's mother in Dallas, according
to Wilfred Smallwood, Duncan's half-brother, who noted this was Duncan's first trip to America.
When did Duncan leave Liberia?
He departed the West African nation on September 19, CDC Director Dr. Thomas Frieden says.
How did he get Ebola?
Health authorities haven't said.
Witnesses say Duncan had been helping Ebola patients in Liberia. Liberian community leader
Tugbeh Chieh Tugbeh said Duncan was caring for an Ebola-infected patient at a residence in
Paynesville City, just outside Monrovia.
The New York Times reported that Duncan had direct contact with a pregnant woman stricken
with Ebola on September 15, days before he left for the United States. Citing the woman's
parents and Duncan's neighbors in Monrovia, Liberia, the newspaper said Duncan had helped
carry the ailing woman home after a hospital turned her away because there wasn't enough space
in its Ebola treatment ward.
Was he screened for Ebola before getting on the plane?
Yes, according to Binyah Kesselly, board chairman of the Liberia Airport Authority.
"The first screening was at the gate, before you get to the parking lot. The second time is before
you enter the terminal building and the third is before you board the flight. At every point your
temperature is scanned."
His temperature at those checkpoints was a consistent 97.3 degrees Fahrenheit, Centers for
Disease Control and Prevention chief Thomas Frieden told reporters Thursday.
Yet on a health screening questionnaire, Duncan answered "no" to questions about whether he
had cared for a patient with the deadly virus and whether he had touched the body of someone
who died in an area affected by the disease, Kesselly said.
Complete coverage on Ebola

When did his Ebola symptoms appear?

"Four or five days" after his trip, according to the CDC's Frieden.
This doesn't mean that Duncan actually got infected with Ebola in the United States. The
incubation period for the virus is 2 to 21 days, meaning that a person could be infected with the
disease for up to three weeks before showing any signs of it.
When he did seek medical help?
Duncan first walked into Texas Health Presbyterian Hospital Dallas after 10 p.m. on September
25.
Smallwood reports Duncan had a fever and was vomiting during this first visit to the Dallas
hospital. The hospital, in a statement, said he had a "low grade fever and abdominal pain."
He underwent basic blood tests but wasn't screened for Ebola, said Dr. Edward Goodman from
the Dallas hospital. Duncan left the medical facility after being given antibiotics and a pain
reliever, his friend said.
"His condition did not warrant admission," the hospital said. "He also was not exhibiting
symptoms specific to Ebola."
Were flags raised that Duncan might have Ebola?
After being asked by a nurse, Duncan did say that he'd traveled from Africa, said Dr. Mark
Lester, executive vice president of Texas Health Presbyterian's parent company.
But that detail -- which might have raised an alarm that Duncan might have Ebola, since Liberia
is one of the countries hardest hit by the virus -- was not "fully communicated" to the medical
team, according to Lester.
When was he admitted to Texas Health Presbyterian Hospital?
On September 28. By the time Duncan arrived via ambulance, "EMS had already identified
potential need for isolation," the hospital said.
What treatment did he receive?
Duncan was given supportive therapy -- meaning fluids and other therapies that would help
support his immune system while it was trying to fight off the virus. He was also started on the
experimental anti-viral drug brincidofovir on October 4.

Since the drugs being used to treat Ebola are still experimental, it is up to each individual
hospital to file the paperwork with the Food and Drug Administration for permission to get the
drug from the manufacturer and use it.
The hospital has declined to tell CNN when they filed for permission to the FDA to use
brincidofovir.
"The care team has been consulting with the CDC and Emory, on a daily basis since Mr. Duncan
was admitted to the hospital, discussing the possible course of treatment, including the use of
investigational drugs," hospital spokesman Wendell Watson said in a statement.
Family questions wait on experimental drug
Duncan was not given a blood transfusion with blood donated by an Ebola survivor, as Ebola
patients Dr. Rick Sacra and Ashoka Mukpo were given in Nebraska.
Why did he die?
The other Ebola patients brought to the United States for treatment are still alive. Three have
been released from the hospital and one is reportedly in stable condition at The Nebraska
Medical Center. So what's different about Duncan?
As Lakey said, Ebola attacks the body in many ways. Experts estimate the current outbreak in
West Africa has around a 71% fatality rate. Supportive therapy can help, but there are no proven
cures for the disease.
Duncan did not start receiving treatment until several days after he started experiencing
symptoms, which may have contributed to his rapid decline.
What will happen to his body?
An Ebola patient's body is still highly infectious. Any contact with the bodily fluids could result
in transmission of the virus. "Only personnel trained in handling infected human remains, and
wearing PPE (personal protective equipment), should touch, or move, any Ebola-infected
remains," CDC guidelines state. "Autopsies on patients who die of Ebola should be avoided."
Duncan's body will be enclosed in two bags and the bags will be disinfected for transportation,
Texas health officials say. Then the body will be cremated.

Ebola virus disease (EVD), previous known as Ebola hemorrhagic fever (Ebola HF), is a
serious, often fatal condition in humans and nonhuman primates such as monkeys, gorillas
and chimpanzees. Ebola is one of several viral hemorrhagic fevers (VHF), caused by
infection with a virus of the Filoviridae family, genus Ebolavirus.1-3
Ebola has a case fatality rate of up to 90% and is currently one of the world's most infectious
diseases. The infection is transmitted by direct contact with the blood, body fluids and tissues of
infected animals or people. Severely ill patients require intensive supportive care.4
Contents of this article:
1. What is Ebola?
2. What causes Ebola?
3. Signs and symptoms
4. Risk factors
5. Tests and diagnosis
6. How is Ebola treated?
7. How is Ebola prevented?
8. The spread of Ebola outbreaks (1976-2015)

This Medical News Today information page will give you the essential details about Ebola. You
will also see introductions at the end of some sections to any recent developments that have been
covered by MNT's news stories. Also look out for links to information about related conditions.
Fast facts on Ebola
Here are some key points about Ebola. More detail and supporting information is in the main
article.

Ebola virus disease (EVD) is a serious, often fatal condition in humans and
nonhuman primates.

Ebola has a fatality rate of up to 90%.

It is one of the world's most infectious diseases.

Genus Ebolavirus is one of three members of the Filoviridae family (filovirus).

It has been hypothesized by researchers that the virus is animal-borne.

In an outbreak or isolated case among humans, the manner in which the

virus is transmitted from the natural reservoir to a human is unclear.

Ebola tends to spread quickly through families and friends as they are
exposed to infectious secretions when caring for an ill individual.

The time interval from infection with Ebola to the onset of symptoms is 2 to
21 days.

EVD is often characterized by the abrupt onset of fever, intense weakness,

muscle pain, headache and sore throat.

There is currently no licensed vaccine available for Ebola.

Several vaccines are being tested, but at this time none are available for
clinical use.

What is Ebola?
The first cases of Ebola were reported simultaneously in 1976 in Yambuku and the surrounding
area, near the Ebola River in Zaire, which is now the Democratic Republic of the Congo and in
Nzara, Sudan. Since then, eruptions or asymptomatic cases of Ebola viruses in humans and
animals have surfaced intermittently in the following locations due to outbreaks or laboratory
contamination and accidents:5
The first cases of Ebola were reported in 1976 in Yambuku and the surrounding
area, near the Ebola River in Zaire, which is now the Democratic Republic of the
Congo.

Zaire (Democratic Republic of the Congo - DRC)

Sudan (South Sudan)

England

US

Philippines

Italy

Gabon

Ivory Coast

South Africa

Russia

Uganda

Guinea

Liberia

Sierra Leone.

Genus Ebolavirus is one of three members of the Filoviridae family (filovirus), along with genus
Marburgvirus and genus Cuevavirus. Genus Ebolavirus comprises five distinct subspecies:1,2

Bundibugyo Ebolavirus (BDBV)

Zaire Ebolavirus (EBOV)

Reston Ebolavirus (RESTV)

Sudan Ebolavirus (SUDV)

Ta Forest Ebolavirus (TAFV).

BDBV, EBOV, and SUDV have been connected with considerable EVD outbreaks in Africa,
however RESTV and TAFV have not.
The RESTV subspecies found in Philippines and the People's Republic of China, can infect
humans, but no illness or death in humans from this species has been reported to date.2 Among
workers in contact with monkeys or pigs infected with RESTV, several infections have been
documented in people who were clinically asymptomatic. Hence, RESTV appears less able to
cause disease in humans than other Ebola species.

What causes Ebola?

Ebola is caused by the five viruses detailed above classified in the genus Ebolavirus, family
Filoviridae. The natural reservoir of Ebolavirus has not yet been proven, for that reason, how the
virus first appears in a human at the onset of an outbreak is unknown.6
It has been hypothesized by researchers that the virus is zoonotic (animal-borne), with the first
patient developing the infection through contact with an infected animal.
Ebola is caused by the five viruses above classified in the genus Ebolavirus, family
Filoviridae.

The theorized potential natural reservoirs of the Ebola virus are Fruit bats of the Pteropodidae
family.2 In Africa, infection has been documented through the handling of the following infected
animals found ill or dead or in the rainforest:

Chimpanzees

Gorillas

Fruit bats

Monkeys

Forest antelope

Porcupines.

In an outbreak or isolated case among humans, the manner in which the virus is transmitted from
the natural reservoir to a human is unclear. Person-to-person transmission is a method by which
further infections occur after a human is infected.
Transmission of Ebola between humans can occur in several ways, including through:

Direct contact through broken skin and mucus membranes with the blood,
secretions, organs or other bodily fluids of infected people

Indirect contact with environments contaminated with such fluids

Exposure to objects (such as needles) that have been contaminated with

infected secretions

Burial ceremonies in which mourners have direct contact with the body of the
deceased person can also play a role in the transmission of Ebola

Men who have recovered from the disease can still transmit the virus through
their semen for up to 7 weeks after recovery from illness

Health care workers have frequently been infected while treating patients
with suspected or confirmed EVD.

Ebola tends to spread quickly through families and friends as they are exposed to infectious
secretions when caring for an ill individual. The virus can also spread quickly within health care
settings for the same reason, highlighting the importance of wearing appropriate protective
equipment, such as masks, gowns and gloves.7 Sterilization and disposal of needles and syringes
thoroughly in hospitals is an important factor to prevent virus transmission continuing and
amplifying an outbreak.
There is no evidence that Ebola can be spread via insect bites.8
Recent developments on Ebola causes from MNT news
Scientists discover how deadly Ebola virus 'punches' its way into human cells

Researchers at the University of Virginia School of Medicine have discovered that the deadly
Ebola virus uses a "molecular fist" to punch its way out of vesicles - the secure pockets that cells
keep captured viruses and other unwanted agents in until they can be disposed of.
Examining the causes of Ebola virus outbreaks
What determines the location and severity of Ebola virus outbreaks? According to Tulane
University School of Public Health and Tropical Medicine researcher Daniel Bausch, lead author
of "Outbreak of Ebola Virus Disease in Guinea: Where Ecology Meets Economy," a new article
in PLOS Neglected Tropical Diseases, the causes are a composite of biological and ecological
circumstances superimposed on populations made vulnerable by social and political strife.
DRC Ebola outbreak 'distinct and independent event,' say WHO
The World Health Organization have announced that the Ebola virus in the new outbreak in the
Democratic Republic of Congo is not derived from strains circulating in the current outbreak in
West Africa.
Ebola gene study traces origin of current outbreak
An international research team has rapidly sequenced 99 Ebola virus genomes collected in the
2014 outbreak. The team, including members from the Broad Institute and Harvard University in
the US and the Sierra Leone Ministry of Health and Sanitation, hopes the findings will help
multidisciplinary, international efforts to understand and contain the unprecedented epidemic that
is growing in West Africa.

Signs and symptoms

The time interval from infection with Ebola to the onset of symptoms is 2 to 21 days, although 8
to 10 days is most common. Signs and symptoms may include:9
EVD is often characterized by the abrupt onset of fever, intense weakness, muscle
pain, headache and sore throat.

Fever

Headache

Joint and muscle aches

Weakness

Diarrhea

Vomiting

Stomach pain

Lack of appetite.

Some patients may experience:

A rash

Red eyes

Hiccups

Cough

Sore throat

Chest pain

Difficulty breathing

Difficulty swallowing

Bleeding inside and outside of the body.

EVD is often characterized by the abrupt onset of fever, intense weakness, muscle pain,
headache and sore throat. These signs are usually followed by vomiting, diarrhea, rash, impaired
kidney and liver function, and in some severe cases, both internal and external bleeding.
Laboratory outcomes include low white blood cell and platelet counts and elevated liver
enzymes.
As long as the patient's blood and secretions contain the virus, they are infectious. Ebola virus
was isolated from semen 61 days after onset of illness in a man who was infected in a
laboratory.2

Risk factors
Risk of contracting Ebola is low. There is a higher risk of becoming infected when:10

Traveling to Africa - where most confirmed cases of Ebola have been reported

Conducting animal research with monkeys imported from Africa or the

Philippines

Providing medical or personal care - protective gear such as surgical masks

and gloves should be worn

Preparing people for burial.

Tests and diagnosis

Before Ebola can be diagnosed, other diseases should be ruled out such as:2

Malaria

Typhoid fever

Shigellosis

Cholera

Leptospirosis

Plague

Rickettsiosis

Relapsing fever

Meningitis

Hepatitis

Other viral hemorrhagic fevers.

If Ebola is suspected, the patient should be isolated, and public health professionals
notified. Ebola virus infections can be diagnosed definitively in a laboratory through
several types of tests.11
Within a few days after symptoms begin, the virus can be diagnosed with:

Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing

IgM ELISA

Polymerase chain reaction (PCR)

Virus isolation.

In the more advanced stages of the disease or after recovery, the diagnostic test available is:

IgM and IgG antibodies.

Retrospectively Ebola can be diagnosed in deceased patients by:

Immunohistochemistry testing

PCR

Virus isolation.

According to the World Health Organization, samples from patients with Ebola are an
extreme biohazard risk. Testing should be conducted under maximum biological
containment conditions.
Recent developments on Ebola diagnosis from MNT news
Ebola outbreak in West Africa shows no sign of slowing down
The spread of deadly Ebola in West Africa appears to be increasing and getting out of control, as
a leading medical charity warns of over-stretched resources, and concerns are raised that it may
spread to other continents.
Sierra Leone researchers call for health surveillance improvements to tackle Ebola crisis
The Lancet publish a statement from researchers working in Sierra Leone calling for
improvements to health care resources, disease surveillance and diagnostic technologies to tackle
the ongoing Ebola crisis in West Africa.

How is Ebola treated?

Treatment for Ebola is limited to intensive supportive care and often includes:12

Balancing the patient's fluids and electrolytes

Maintaining their oxygen status and blood pressure

Treating a patient for any complicating infections.

Experimental treatments have been tested and proven effective in animal models but as yet have
not been used in humans.
Recent developments on Ebola treatment from MNT news
Natural antiviral protein stops HIV, deadly viruses entering cells
Researchers in the US have identified a natural antiviral protein that stops HIV and certain other
deadly viruses like Ebola, Rift Valley Fever and Nipah, from entering host cells.
'Miraculous' Ebola cure inspired by 19th century medicine

The so-called miraculous treatment of the two American missionaries struck down by the Ebola
virus has been in the headlines for the past week, but where did this drug come from? In a
scientific commentary, Dr. Scott Podolsky writes that the inspiration for the drug is rooted in the
pioneering research of the late 19th century.
Ebola virus protein offers potential drug target
As our knowledge of the molecular structure of Ebola virus increases, so does our chance of
preventing and treating the outbreaks of deadly hemorrhagic fever that it causes. Now, a new
crystallography study from the US shows how a key Ebola protein - important for virus
replication - could be a target for new drugs.
Ebola vaccine set for human trials after inducing long-term immunity in monkeys
In response to the Ebola outbreak across West Africa, scientists around the world are racing to
develop a vaccine against the disease. Now, a study by researchers from the National Institutes of
Health reveals the creation of a vaccine that has generated long-term immunity against the Ebola
virus in monkeys. The vaccine is now entering phase one clinical trials in humans.

How is Ebola prevented?

There is currently no licensed vaccine available for Ebola. Several vaccines are being
tested, but at this time none are available for clinical use.
As it is still unknown how individuals are infected with Ebola, the prevention of the infection
presents a challenge. However, there are primary prevention measures that can assist with the
challenge, such as:13

Wearing of protective clothing (such as masks, gloves, gowns and goggles)

for health care professionals

The use of infection-control measures (such as complete equipment

sterilization and routine use of disinfectant)

Isolation of Ebola patients from contact with unprotected persons.

Together with the World Health Organization, CDC has developed a set of guidelines to help
prevent and control the spread of Ebola - Infection Control for Viral Hemorrhagic Fevers In the
African Health Care Setting.14
Recent developments on Ebola prevention from MNT news
WHO: Ebola-affected countries should screen exiting travelers
The World Health Organization is urging countries affected by the current Ebola outbreak in
West Africa to check exiting travelers for signs consistent with infection by the virus.

Examining the causes of Ebola virus outbreaks

Last updated: 31 July 2014 at 11am PST

What determines the location and severity of Ebola virus outbreaks? According to Tulane
University School of Public Health and Tropical Medicine researcher Daniel Bausch, lead author
of "Outbreak of Ebola Virus Disease in Guinea: Where Ecology Meets Economy," a new article
in PLOS Neglected Tropical Diseases, the causes are a composite of biological and ecological
circumstances superimposed on populations made vulnerable by social and political strife.
The outbreak addressed in Bausch's article is currently occurring in West Africa, impacting the
neighbor countries of Guinea, Sierra Leone, and Liberia, with over 1,000 cases and a fatality rate
over 60 percent to date.
Bausch, who has spent much of the last few months in Guinea and Sierra Leone as part of the
outbreak response team, poses the questions why the outbreak is occurring there and why now?
There have never been any cases of Ebola virus disease observed in these countries before,
observes Bausch. There are five varieties of the Ebola virus, and until this time, each has been
found only in well-defined geographic areas in three Central African countries, Democratic
Republic of the Congo, Republic of the Congo, and Gabon, all of which are over two thousand
miles from West Africa.

Bausch contemplates two possible mechanisms behind the current West African outbreak. The
first is that the virus actually has been in West Africa all along. "The virus is likely maintained in
fruit bats, with which humans normally have little contact, thus providing limited opportunity for
infection," says Bausch.
The second possibility is that the virus was carried from Central Africa to West Africa. In this
case, Bausch believes that introduction by a human traveler is unlikely. "There is little regular
travel or trade between Central Africa and Guinea, and Guckdou, the remote epicenter and
presumed area of first introduction, is far off the beaten path..." says Bausch. An Ebola viruscarrying bat flying from the original territory of the virus in Central Africa to West Africa is more
likely, Bausch concludes.
Regardless of what biological and ecological factors may have resulted in introduction of Ebola
virus into the area, human social and political conditions of the impacted countries play a
significant role in facilitating an outbreak, Bausch says. "The sites of attack are far from random;
large hemorrhagic fever virus outbreaks almost invariably occur in areas in which the economy
and public health system have been decimated from years of civil conflict or failed
development." All three of the West African countries currently experiencing the spread of Ebola
have histories of civil conflict and political unrest.
Bausch notes three specific effects of these socio-political conditions. First, "poverty drives
people to hunt deeper into the forest for food, and to find wood for fuel, and to go deeper into
mines to find minerals, all of which can bring them into risk of exposure to Ebola," he says.
Secondly, the impoverished condition of such countries results in a lack crucial healthcare
resources such as protective gloves, masks and gowns, as well as clean needles and disinfectants,
allowing diseases to spread. Thirdly, the countries lack intergovernmental coordination needed to
monitor the movement of people, including infected persons, across their borders, frustrating
efforts to contain the spread of disease.
As to the question why the outbreaks are occurring now, Bausch believes that the advent of the
dry season may be a factor, as has been noted in other outbreaks. "At present, we can only
speculate that these drier ecologic conditions somehow influence the number or proportion of
Ebola virus - infected bats and/or the frequency of human contact with them," he says.
When an outbreak such as the current Ebola virus epidemic occurs "the focus is often on the
rapidity and efficacy of the short-term international response," says Bausch. Nevertheless,
"attention to these admittedly challenging underlying factors - economic, cultural, political - will
be required for long-term prevention and control."