Ebola nearly killed Nancy Writebol in July—and it also made her famous, which helped broadcast to the world that it needed to respond more aggressively to what had grown from a small outbreak into an out-of-control epidemic.

Writebol, a clinical nurse associate, became ill with the disease while working for the missionary group SIM in Monrovia. She and her husband David spoke with Science on 24 September about a topic that has yet to receive much attention: How do health care workers who are trained to protect themselves nevertheless become infected with the Ebola virus? The Writebols also discuss how the outbreak grew into an epidemic, as well as the treatment she received both in Liberia and then at Emory University Hospital in Atlanta. Questions and answers have been edited for clarity and brevity.

Q: Any idea how you became infected?

N.W.: I don’t know how I became infected and how I contracted it. There are some thoughts about how I might have gotten it. Nobody is really sure, least of all me. I never felt like I was unsafe and I never felt like I walked into a situation where I was being exposed. I was on the low-risk side of things. I never was in the crisis or the Ebola center. I was always on the outside. I made sure doctors and nurses were dressed properly before they went in, and I decontaminated them before they went out. We kept a close check on each other about whether people felt safe.

We had an employee who was doing the same job that I was doing. He got sick and I didn’t know he was sick. He didn’t tell anybody. He actually thought he had typhoid. The day that I started having symptoms, at least a fever, was the last day I saw him. He did have Ebola. He did not survive.

I never remember touching him, although it’s possible he could have picked up a sprayer to decontaminate someone, and I could have picked up the sprayer. Or we touched the same thing. I never touched him.

Q: You were educated about Ebola transmission?

N.W.: Oh my goodness, yes.

Q: Did you have sufficient personal protective equipment (PPE)?

N.W.: Yes, we did. It was my responsibility to make sure they were dressed properly in PPEs before they ever went into the isolation. I didn’t want any of our doctors or nurses getting infected. I mean, I saw people dying of Ebola. We had PPEs and followed every single protocol that [Doctors Without Borders (MSF)] had in their manual—and we had been trained by MSF.

Q: Were you wearing PPE in your job, disinfecting doctors and nurses?

N.W.: No, I was wearing gloves and a disposable apron. There were times I had a mask on. I was behind a line where I did the disinfecting. They were on one side of a line and I was on the other side. I never crossed those lines. We just don’t even have a clue what happened.

I’ve often wondered if I was back there now, having been through the experience, what would I do differently. The only thing is I took temperatures of family members who would come to see patients. I never had to turn anybody away because they had a temperature, but it’s possible I might have come in contact with somebody on the outside who had Ebola and maybe shook a hand? Although we weren’t really shaking hands with anybody. Most people had a fear of even us. They felt like to be involved with Ebola, you had it.

Q: On what date did you start feeling symptoms?

N.W.: Tuesday, 22 July. That afternoon I started running a fever. I felt like I had malaria. I contacted an SIM doctor. We did a malaria test and it was positive. I had malaria medication at home, and I went home and I stayed home. I was weak. I had the headache. Had the fever. Those were my symptoms. I took malaria medications but was just not shaking the fever at all. On Saturday, our doctor came over and she said, “We’re just going to do the Ebola test to relieve everyone.” I was just thinking still malaria. They did another malaria test and it showed negative, because I had taken the medication. Then they did the Ebola test that Saturday morning, and Saturday night the result came back that I was positive.

Q: Do you think you had malaria coincident with Ebola?

N.W.: I did. I tested positive for it.

Q: What happened next?

N.W.: They left me at home for the next 10 days.

Q: Was David there?

N.W.: Yes. It’s just the grace of God that David did not come down with Ebola. For the whole 4 days that they thought it was just malaria, David did the cooking at our home. I just didn’t feel good. We were still sharing our bedroom. Our doctor was exposed and she had dinner with us the night she told us I had Ebola. I’d had malaria once that year. I knew what it felt like and it was so similar.

D.W.: They isolated me after that. For a few days, I went in to see Nancy in a PPE. Our home became an isolation unit. Then they said, “We can’t let you do that anymore because you can’t get back to the United States by commercial aviation.” They kept me out.

N.W.: Thankfully there was a window near where my bed was and David could stand outside and talk to me.

Q: David, did you check your temperature every few hours?

D.W.: Yep. I got close to 99.2° [37.3°C], but I realized after I took my temperature that I’d just had a cup of coffee.

Q: What happened with Kent Brantly?

N.W.: I got sick the 22nd and Kent on the 23rd. Kent was actually much sicker to begin with, and then I took a turn for the worse. Kent went out on Saturday the 2nd. I left August 4.

Q: You and Kent Brantly both received ZMapp. Do you think it helped?

N.W.: It’s given at three different times. I had two of the doses in Liberia, and the third at Emory. I don’t know that I can say when I was given the ZMapp it made a dramatic difference in how I was feeling. I think I was very, very, very sick, critically sick. I’m not saying it didn’t help—I do think it had some benefit to it—but it wasn’t this huge, dramatic “I had this ZMapp and now I can sit up and take a shower.”

They give ZMapp via IV and they give it slowly and then turn it up a little. When they turned it up on me, my hands started itching terribly and then they turned it back down so I wouldn’t have a reaction to it. That’s the only thing I remember about the ZMapp.

Q: Were you very ill when you left Liberia?

N.W.: I didn’t know whether I would survive the flight.

D.W.: I wasn’t sure either. She had to be carried into the aircraft. She didn’t walk in or walk off.

N.W.: I was in PPE the whole trip back. And I was dehydrated. They were having a terrible time in Liberia finding a vein in which to run fluid. At one point they decided to try and do an IV into the bone. That was very painful. They don’t really know what happened, whether the needle bent when it went into the bone, but once they tried pushing fluid, it was excruciating and they decided to stop. When I got to Emory they just put a central line in.

Q: Would you go back again and work in an Ebola treatment unit?

N.W.: I’ve done some reading on that and talked to doctors at Emory about that. My doctors at Emory are not sure how long immunity would last. It’s not been studied. I’ve read that even if a survivor was willing and able to help with the care for Ebola patients, because there are so many strains of Ebola, it would still be very wise and necessary to operate in PPEs and not just assume you’re immune.

Q: What do you think of your own role in this epidemic and the fact that it wasn’t until you and Kent Brantly became ill that the world began to take notice that something was seriously amiss?

N.W.: Never in my life would I have dreamed this would happen. We’d been in Liberia for a year and had a doctor come into the country in March or April who laid out a graph of other Ebola timelines and how the disease had gone along in Congo and Uganda, and how it was just this steady little disease working its way along—and then it spikes and spikes again and grows into a mushroom. He overlaid where Liberia was on that graph. He made the observation that we had not seen the worst of it yet.

D.W.: People were calmed down and thought it was over. In early June, Monrovia started getting the multiple cases from Foya [a town in the north that borders both Sierra Leone and Guinea, the two other hard-hit countries].

N.W.: We hadn’t started to hit the mushroom at all. And then Samaritan’s Purse had an epidemiologist who came into the country who sat with us and said, “I went to Foya. You have not seen the end of this. It’s going to get bad.”

D.W.: All along, we were concerned there was not a larger response. It’s the publicity that was generated from Nancy’s story and Dr. Brantly that woke things up. That was astonishing.

Q: You knew it was wildly out of control?

N.W.: I would have never predicted the numbers WHO [the World Health Organization] and CDC [the Centers for Disease Control and Prevention] are predicting now. I looked at that and thought, “Oh my goodness”; we had no clue it was going to go to that extent. You’re talking a half-million in Liberia alone.

Q: What did you think of the media coverage of ZMapp?

D.W.: Initially it seemed a bit sensational: This is the magic bullet. That’s what they do, they gravitate toward that, but they’ve also backed off that and had a more balanced approach. It’s promising, but don’t put too much hope into it until more studies are done.

N.W.: I think they understand, too, that nobody really knows how much it helped. Because there were so many other things playing into it. There were blood transfusions. The other care given to us.

Q: Did you have a blood transfusion?

N.W.: I did. I had blood transfusions in Liberia and Emory. Neither was convalescent serum, though. There wasn’t a match.

Q: How’s your health now?

N.W.: I’m recovering. I’m regaining my strength. When I left Emory, I could hardly walk up steps at all. I have some neuropathy in my feet. While I was in Emory it was excruciating. They couldn’t even put sheets or blankets on my toes. That’s much better.

I wear out easily. And of course there’s just the emotional side of it. I was on that job from the 11 June case, that first patient we had, to 22 July, and I saw about 40 people and we saw one survivor during that period of time. To watch the rest of those people die was difficult. I was dealing with some of their families and trying to encourage them and pray with them. To watch families watch their loved ones die, that’s hard, too.

For a story about Ebola's infection risk for health care workers, click here.

*The Ebola Files: Given the current Ebola outbreak, unprecedented in terms of number of people killed and rapid geographic spread, Science and Science Translational Medicine have made a collection of research and news articles on the viral disease freely available to researchers and the general public.