Bundibugyo Ebola patients in the DRC rely on intensive supportive care while vaccines stay in trials

The 48% is a crude ratio: 3,799 deaths against 7,890 recorded cases, or 48.1% ^[20]. It sits close to the top of the 30% to 50% range seen in the two earlier known Bundibugyo outbreaks in the DRC and Uganda ^[2][21]. Both figures are running totals for 23 September ^[3]. Some of those 7,890 people were probably still in treatment on that date, so the ratio is the outbreak's toll so far. Judging how well a treatment centre is doing would need deaths counted among its own admitted patients.

Richard Kojan, an intensive-care physician with The Alliance for International Medical Action (ALIMA) in Paris, has been working in the DRC response ^[15]. He has practised as an anaesthetist since 2002, after specialist training at the University of Kinshasa, and joined ALIMA in 2010 ^[16]. His explanation for high early mortality is timing. Health systems in countries like the DRC are poorly prepared for epidemics, he said, and "we tend to discover outbreaks late: that is why death rates are often very high at the beginning of an outbreak" ^[8]. Fatigue is one of the first symptoms, and so many people in the region work exhausting hours that it raises no alarm ^[10]. "While we're running diagnostic laboratory tests, the virus continues spreading," he said ^[9].

Patients often reach care very ill. Kojan describes arrivals with electrolyte imbalances from fluid loss, unstable blood pressure, poor blood flow to vital organs, shock or respiratory distress ^[19]. Many ultimately die of multi-organ failure ^[7]. The clinical picture is close to that of the more lethal Zaire species: fatigue, headaches, fever, bleeding, severe diarrhoea and vomiting ^[6]. Kojan also noted that many viruses in the filovirus family, the group that includes the Ebola viruses, have no vaccine at all ^[18].

Nature's introduction to the interview says Kojan is also helping relatives visit loved ones safely ^[17]. The available interview text does not describe how those visits are run or measure whether they, or supportive care, change survival. The case that frontline care matters as much as countermeasures therefore rests on one clinician's account and on the plain fact that the trial products are not yet licensed. I think the emphasis is right for the months before trial results, provided clinics have the people and equipment to deliver that care. Kojan said low resource levels leave health workers short of infection-control measures such as patient isolation, and some may lack the medical equipment they need ^[14].