Sequelae of Ebola virus disease: the emergency within the emergency

Review

Sequelae of Ebola virus disease: the emergency within the emergency Pauline Vetter, Laurent Kaiser, Manuel Schibler, Iza Ciglenecki, Daniel G Bausch

As the massive outbreak of Ebola virus disease (EVD) in west Africa wanes, it has become increasingly clear that thousands of survivors have many sequelae, some of which might be very severe, such as arthritis and visionthreatening uveitis. The mental health effects of EVD on survivors and other family and community members is similarly profound. Furthermore, it is increasingly being recognised that Ebola virus might persist for weeks or months in selected body compartments of survivors, most notably in the semen of men, bringing risk of renewed transmission where it has previously been eliminated. These challenges to EVD survivors constitute a new emergency in terms of addressing individual patient need and to control the disease spread. In this Review, we assess what is known regarding the sequelae of EVD, including possible delayed virus clearance. We discuss some of the key challenges regarding the provision of care to survivors and implementation of necessary future research.

Introduction The outbreak of Ebola virus disease (EVD) that began in 2013 in west Africa has resulted in over 28 500 reported cases. With reported case fatality proportions ranging from 40% to 70%, there are over 10 000 survivors who might need convalescent care.1 However, based on the small size of past outbreaks in remote and resource-poor locations that hinder systematic study, there is little knowledge of the frequency of various sequelae postEVD, their pathogenesis, and optimum treatment. Even when systematic longitudinal studies have been done, detailed microbiological and physical examination has rarely been possible, especially ocular, audiometric, and mental health exams, which typically need specialised skills or equipment. We review what is known regarding the sequelae of EVD, including possible delayed clearance of virus from select body compartments. We discuss some of the key challenges regarding the provision of care to survivors and implementation of necessary future research.

Overview of medical problems Sequelae have been noted after infection with all four species of Ebola virus (Zaire, Sudan, Bundibugyo, and Tai Forest) that are known to cause human disease, without obvious differences between the species. Many short-term and long-term health problems have been reported (table). However, the clinical findings have been largely uncontrolled, making it difficult to definitively attribute causality to EVD. Only two controlled studies on EVD survivors have been reported.7,9 Rowe and colleagues7 prospectively monitored 29 survivors (Zaire Ebola virus) and 152 household contacts after the 1995 outbreak in Kikwit, Democratic Republic of the Congo, for up to 21 months after recovery. Arthralgia, myalgia, abdominal pain, extreme fatigue, and anorexia were significantly more common in survivors than in people who had never been infected. Many symptoms were still present at the end of the 21 months of follow-up, with 70% reporting decreased work capacity. Clark and colleagues9 assessed 49 adult survivors (Bundibugyo Ebola virus)

matched with 157 controls 29 months after the 2007 outbreak in Bundibugyo, Uganda, noting a significantly increased frequency of fatigue, sleep disturbance, blurred vision, arthralgia, retro-orbital pain, hearing loss, difficulty swallowing, and muscle weakness in survivors.24 Sequelae often occur in the first few weeks after discharge and might last for years, although the intensity tends to decrease with time.7,9 Early but uncontrolled data suggest similar sequelae in survivors infected in west Africa.10–23

Rheumatological complications Arthralgia is one of the most frequently reported sequelae, noted in 50–75% of survivors.4,7,9,11,12,17–20,22,23 Rowe and colleagues reported the arthralgia to be generally symmetrical and polyarthritic, and worse in the morning and after working.7 The most affected joints were, in order, the knees, back, hips, fingers, wrists, neck, shoulders, ankles, and elbows. Findings on survivors suggest a periarticular tendinitis (enthesitis) frequently affecting the shoulders and hips consistent with a spondyloarthritis, especially when taken in the context of frequent inflammatory eye disease18 (J Fankhauser, ELWA Hospital, Monrovia, Liberia, personal communication). Physical examination does not typically reveal abnormalities, although swelling and tenderness are occasionally evident (figure 1). The few reports of radiographic imaging reveal no distinct joint abnormalities.17 There is only one report of arthrocentesis being done on an EVD survivor, in which synovial fluid taken from the knee of a patient with large joint noninflammatory polyarthritis 34 days after disease onset tested RT-PCR negative.17

Lancet Infect Dis 2016 Published Online March 22, 2016 http://dx.doi.org/10.1016/ S1473-3099(16)00077-3 Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland (P Vetter MD, L Kaiser MD, M Schibler MD); Laboratory of Virology and Swiss Reference Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland (P Vetter, L Kaiser, M Schibler); Médecins Sans Frontières/ Doctors Without Borders, Geneva, Switzerland (P Vetter, I Ciglenecki MD); University of Geneva Medical School, Geneva, Switzerland (L Kaiser); and Pandemic and Epidemic Diseases, World Health Organization, Geneva, Switzerland (D G Bausch MD) Correspondence to: Dr Daniel G Bausch Pandemic and Epidemic Diseases Department, World Health Organization, 27 Geneva, 1211 Switzerland [email protected]

Ocular complications Eye pain, conjunctivitis, photophobia, hyperlacrimation, uveitis, and loss of visual acuity seem to be common in survivors.21 Two studies touched upon ocular complications post-EVD in Kikwit. Bwaka and colleagues4 reported conjunctivitis, unilateral vision loss, and uveitis in three (16%) of 19 survivors followed up for 6 weeks after acute disease. Kibadi and colleagues6 explored ocular

www.thelancet.com/infection Published online March 22, 2016 http://dx.doi.org/10.1016/S1473-3099(16)00077-3

1

2

Retrospective survey

Retrospective survey

Case report

Case report

Case Report

Cross-sectional survey

Case report

Cross-sectional survey

Retrospective survey

Qureshi11

Epstein12

Christie13

Jampol14

Mate15

Hugo16

Howlett17

Mattia18

Nanyonga19

Observational

Wendo8

Cross-sectional survey

Case-control

Rowe7

Mohammed10

Observational

Kibadi6

Case-control

Retrospective survey

De Roo5

Clark9

Observational

Bwaka4

2000, Uganda

1995, Democratic Republic of the Congo

1995, Democratic Republic of the Congo

1995, Democratic Republic of the Congo

1995, Democratic Republic of the Congo

1994, Côte d’Ivoire

1976, laboratory accident in UK

Year and country of outbreak onset

Zaire

Zaire

Zaire

Zaire

Zaire

Zaire

Zaire

Zaire

Zaire

Zaire

2014, Sierra Leone

2014, Sierra Leone

2014, Sierra Leone

2014, Sierra Leone

2014, Liberia

2014, Liberia

2014, Liberia

2013, west Africa

2013, Guinea

2013, Guinea

Bundibugyo 2007, Uganda

Sudan

Zaire

Zaire

Zaire

Tai Forest

Zaire

Case report

Formenty3

Not specified: Zaire or Sudan

Case report

Ebola virus species

Emond2

Type of study

4 months

151 days

64 days

4 weeks

179 days

7 months

199 days

7 months

4 months

Not stated

29 months

1 year

21 months

3 months

1 year

2 months

3 months

3 months

Maximum duration of follow-up

81/0

277/0

1/0

24/0

1/0

2/0

1/0

8/0

105/0

4/113 unmatched contacts and relations

49/157

257/0

29/152

20/0

26/0

19/0

1/0

1/0

Number of survivors/ controls followed

(Table continues on next page)

Rejection by community (96%), joint pain (81%), headache (68%), muscle pain (54%), sleeplessness (43%), visual problems (42%), depression (36%), abdominal pain (35%), skin peeling (33%), chest pain (32%), excessive fatigue (30%), pruritus (27%), testicular pain (27%), anxiety (21%), yellowing of eyes (14%), palpitations (9%), erectile dysfunction (3%), amenorrhoea (2%), confusion (2%), deafness (1%), numbness (1%)

Arthralgia (76%), new ocular symptoms (60%), uveitis (18%), auditory symptoms (24%); higher Ebola viral load at admission associated with uveitis and new ocular symptoms or ocular diagnoses

Late-onset encephalitis and large joint polyarthritis; CSF RT-PCR for Ebola virus RNA ≥13 days after blood cleared; CT scan showed cerebral atrophy without hydrocephalus; no abnormalities on knee radiographs and arthrocentesis RT-PCR negative

Lost immediate family members to EVD (100%), feeling of arousal and re-experience of reactions to EVD (71%), witnessed family member deaths (67%), experienced stigma upon return to community (32%), clinically important post-traumatic reactions predictive of PTSD (21%)

Male-to-female sexual transmission confirmed roughly 6 months after acute EVD through epidemiologic data,13 genomic analysis, and RT-PCR detection of virus in semen at least 179 days after disease onset

Patient 1: ocular fatigue and episodic blurred vision but normal eye exam at 7 months; Patient 2: mild bilateral anterior and posterior uveitis at 2 weeks

Suspected sexual transmission; Ebola virus detected by RT-PCR in blood of woman with fatal EVD and semen of male sex partner 199 days after his recovery from acute EVD; sequence match (28% of genome) between viruses

Arthralgia (75%), myalgia (38%), fatigue (75%), alopecia (75%), insomnia (62%), visual blurriness (62%), depression or anxiety (50%), palpitation or tachycardia (50%), peripheral paraesthesia or dysaesthesia (38%), shortness of breath (38%), unilateral uveitis (25%), unilateral hearing loss (12%)

Anorexia (100%), lack of acceptance from friends (97%), arthralgia (87%), decreased exercise tolerance (77%), back pain (46%), difficulty concentrating (43%), mood changes (33%), abdominal pain (32%), chest pain (31%), myalgia (27%), short-term memory loss (27%), decreased libido (23%), headaches (22%), sexual dysfunction (20%), sleep disturbance (19%), constipation (14%), dizziness (11%), long-term memory loss (8%), sore throat (7%), palpitations (5%), change in taste (3%), diarrhoea (2%), loss of balance (1%), change in smell (1%), alopecia (1%), depression (1%); mean weight loss=2·9 kg; no vision or hearing loss reported

Inability to concentrate (100%), loss of sleep (75%), and many other stress indicators frequent in both groups; no statistical analysis done between comparator groups

Significantly more frequent in survivors: fatigue (57%), sleep disturbance (57%), blurred vision (39%), arthralgia (35%), retro-orbital pain (29%), hearing loss (27%), difficulty swallowing (27%), joint stiffness (22%), muscle weakness (12%); memory problems six-times more prevalent in survivors than in controls

Abdominal pains, vision and hearing loss, impotence, bleeding, psychological problems, general weakness (frequencies not specified); 500 “Ebola orphans” due to parental deaths from EVD

Significantly more frequent in survivors: diminished work capacity (70%), arthralgia (48%), myalgia (24%), abdominal pain (12%), extreme fatigue (8%), anorexia (7%); hearing loss not significant

Uveitis (15%, plus 1 outside the original cohort) 2 posterior, 1 anterior, 1 not specified

Increased belief in God (100%); no consequences on mental health (39%, although grief for lost family members); rejection by family, friends, or neighbours (35%)

Arthralgia (37%), conjunctivitis (11%), hearing loss or tinnitus (11%), uveitis (5%), unilateral vision loss (5%), suppurative parotitis (5%), unilateral orchitis (5%), pericarditis (5%), weight loss, asthenia, frequent intercurrent infections (malaria and urinary tract)

Alopecia lasting 3 months

Alopecia, prolonged anaemia, leucopenia

Summary of findings

Review

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Arthralgia

Neurological complications

Table: Summary of literature on sequelae of Ebola virus disease

CSF=cerebrospinal fluid. EVD=Ebola virus disease. PTSD=post-traumatic stress disorder.

1/0 12 days 2014, patient infected while providing care to imported case of EVD in the USA Zaire Case report Liddell23

Unilateral panuveitis, arthritis, myalgia, arthralgia, hearing loss, paroxysmal fevers, grand mal seizure at 11 months 1/0 2014, patient evacuated 3 months (publication) and to USA from Sierra 12 months Leone (personal communication) Zaire Case report Varkey22 (plus I Crozier, personal communication)

Influenza-like illness followed by unilateral panuveitis >5 weeks after disease onset 1/0 Zaire Case report Chancellor21

Zaire Case report

2014, patient evacuated 7 months to USA from Liberia

complications in 20 survivors and documented unilateral uveitis in three (15%), plus a fourth patient from outside the cohort, between 42 and 72 days after disease onset. Vision loss was among the complaints reported in 60 (23%) of 257 survivors a year after the 2000 outbreak of Sudan Ebola virus in Gulu,8 and blurred vision (19 [39%] of 49) and retro-orbital pain (14 [29%] of 49) were common in survivors of Bundibugyo Ebola virus infection.9 Ocular sequelae are a major problem in survivors of the west African outbreak, reported in about half of the survivors assessed in Kenema and Port Loko, Sierra Leone.18,19 Uveitis is common, with reports of progression to severe visual impairment and blindness if untreated. Anterior uveitis seems to be the most common, although all forms have been noted. No eye complaints were reported in a self-reported questionnaire-based survey of 102 survivors in Guinea.11 Ocular exams have revealed a range of abnormal findings, including episcleritis and scleritis, conjunctival and ciliary injection, keratic precipitates, ocular hypertension, hypotony with corneal oedema and choroidal swelling, posterior or iridolenticular synechia, iris heterochromia, hypopyon, optic disc oedema and neuropathy, vitreous opacities and detachment, and diminished acuity.6,14,18,20–22

Mora-Rillo20

(Continued from previous page)

Type of study

Ebola virus species

Year and country of outbreak onset

2014, patient evacuated 6 weeks to Spain from Sierra Leone

Maximum duration of follow-up

1/0

Number of survivors/ controls followed

Summary of findings

At 2 weeks: mild arthromylagia and asthenia; foreign body sensation with floaters and blurred vision in left eye, diagnosed as vitreous body detachment; symptoms resolved at 6 weeks without treatment; subclinical hyperthyroidism indicated from laboratory results, resolving at 6 weeks

Review

Various neurological complications have been noted in survivors, but the association with previous acute EVD and pathogenesis of the noted sequelae are not well understood. Cerebral involvement might be due to shock and hypoperfusion of the CNS during acute disease, true viral encephalitis, or secondary post-viral complications such as acute disseminated encephalomyelitis. Encephalopathy and cerebrovascular accidents with residual neurological deficits have been described in EVD, with onset both during acute illness and after fewweek interval of apparent clinical improvement and virus clearance from the blood17,25 (M Lado, King’sConnaught Hospital Partnership, Freetown, Sierra Leone, personal communication). Too few lumbar punctures and CT scans have been done on these patients to characterise the syndrome, but high opening pressure with a few cells and high protein in the cerebrospinal fluid (CSF) and cerebral atrophy with ventriculomegaly have been noted. Transient paroxysmal fevers, suspected to be of CNS origin, have been noted in a few patients months after recovery. In one case, a lumbar puncture was done and the CSF was shown to be virus negative, although the opening pressure was increased (I Crozier, WHO, Geneva, Switzerland, personal communication). This same patient, who had evidence of previous haemorrhagic encephalitis on an MRI, later had a grand mal seizure, presumably from epileptogenic scar tissue. In an unusual case, a patient developed severe meningitis and seizures 9 months after acute disease, with evidence of Ebola virus in both the CSF and blood by RT-PCR

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Skin disorders Generalised dry skin and pruritus and desquamation, mostly affecting the extremities and including the palms and soles, have been variably reported in survivors (figure 2A).4,19 Any correlation with the rash sometimes seen in acute disease or persistence of viral RNA in the skin26–29 remains unclear. Alopecia has often been noted, with resolution starting after a few months (figure 2B).2,3,12

Pathogenesis

Figure 1: Swollen hands in a 41-year-old woman 7 months after acute Ebola virus disease The patient reported severe symmetrical pain in the hands, feet, and knees, and markedly decreased vision in one eye. She noted occasional mild joint pain without swelling or tenderness before having Ebola virus disease. The joint pain and diminished vision improved with oral corticosteroid treatment. Photograph by Cornelia Staehelin.

(M Jacobs, Royal Free Hospital, London, UK, personal communication). Sequencing of viruses obtained from the blood during the initial bout of EVD and the blood and CSF 9 months later showed greater than 99% homogeneity, suggesting persistence of virus since initial infection. Tinnitus and hearing loss have been reported in up to 27% of survivors.4,7–9,12,17,18,22 However, in a small controlled study that used audiometric testing, there was no significant difference between survivors and age and sex matched controls.7 Thus, the potential association between EVD and hearing loss remains to be clarified. Altered sense of smell and taste were reported in four (4%) of 105 survivors in Guinea, but the study was uncontrolled.11 Cramping or colicky abdominal pain is a common complaint in EVD survivors, and is often challenging to treat. Neuropathy, chronic pancreatitis, and lactose intolerance because of altered gut bacterial flora after acute EVD have all been proposed as possible causes, but data are still scarce. Although children who survive EVD generally seem cognitively healthy, it is unknown whether there are more subtle developmental delays and no systematic studies on the subject have been done. 4

The pathogenesis and the biological events leading to EVD sequelae are only partly understood, as is any relation between severity of acute disease and frequency or severity of sequelae. Depending upon the specific sign or symptom in question and the timing post-infection, sequelae could be the result of residual dysfunction from direct viral cytopathic effect during acute EVD, sustained immune activation, delayed hypersensitivity reaction, molecular mimicry, autoimmune disease, or immune complex deposition, individually or in combination. Persistence of virus in some immunologically protected body compartments has been shown. McElroy and colleagues30 identified persistence of activated CD4 and CD8 T cells up to 2 months after virus clearance from the blood in two people who survived severe EVD, but not in two milder cases. Rowe and colleagues7 noted significantly higher IgG antibody titres against Ebola virus in survivors with arthralgia than in those without, suggesting an association between the intensity of the immune response and this sequela. However, measurement of a few basic markers of inflammation, such as C-reactive protein, did not differ between survivors and controls in Bundibugyo.9 Higher Ebola viral loads at acute EVD presentation, which are well known to correlate with severity,31 were associated with increased risk of uveitis and other ocular symptoms.18 Clark and colleagues9 noted sequelae to be more common in survivors who had two surrogate markers of severe acute disease—seizures and melaena. Increased susceptibility to other infections after EVD, especially malaria and urinary tract infections, has been postulated but not confirmed.4 Perhaps related, leucopenia lasting for 3 months after acute disease has been reported.2 Although studies in Ebola virus-infected rhesus macaques typically do not show evidence of viral replication in the parenchymal tissues,32,33 viral antigen and pathological lesions have been noted in the brain, eye, pancreas, thyroid, and lung of macaques that had death delayed as a result of experimental therapies.34,35 Ebola virus antigen has been noted in the cornea, retina, and pia arachnoid in experimentally infected and treated monkeys, only some of whom had clinical and pathological evidence of ocular inflammation.35 Deposition of immune complexes in the synovial space triggering monocyte or T-cell activation and inflammation, as seen in other viral infections such chikungunya, dengue, and parvovirus, has been postulated as a cause of the persistent arthralgia after EVD but no evidence is available.36,37

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Review

Mental health complications and social welfare Few reports have formally examined mental health disorders and the potentially far-reaching effects on social welfare in survivors, but they seem common and profound.38 Survivors have had a life-threatening acute illness in the foreign and fearful environment of an Ebola treatment unit, cared for by people they do not know and whose faces cannot be seen. The experience is particularly daunting for children, who are often alone. Many survivors have witnessed deaths of family members. Furthermore, they are often not able to attend the burial or, because of risk of virus transmission, see the corpse of their loved one. Deaths of parents and caregivers have resulted in many EVD orphans.39 Upon hospital discharge and return to their community, many survivors experience stigma and isolation, sometimes even from family members. The physical and psychosocial sequelae of EVD might impede resumption of work.8 In the face of such extreme hardship, sleep and memory disturbances, anxiety disorders, depression, post-traumatic stress disorder, and survivors’ guilt are common.9,12,40–42 Of 34 survivors surveyed in Kikwit, 12 (35%) reported feelings of rejection by society, including family, friends, and neighbours, with 11 (32%) seeing the disease as divine punishment.5 A suicide in Gulu was attributed to depression over widowhood and stigmatisation of EVD.42 Similar mental health sequelae have been recorded in west Africa.11,12,16,19,22,43,44 Survivors surveyed in Sierra Leone and Guinea often reported discriminatory behaviour against them, including lack of acceptance by family and friends and not being welcome in their household.11 An adapted trauma screening questionnaire was administered to 24 survivors in Sierra Leone up to a month after discharge from the emergency treatment unit, all of whom had lost immediate family members. The questionnaire revealed stigma upon return to the community in eight (33%) of 24 survivors, and clinically important post-traumatic reactions predictive of posttraumatic stress disorder in five (21%).16 Mohammed and colleagues10 assessed four survivors and 117 contacts and relatives in Lagos, Nigeria, noting a host of psychological issues in both groups, especially in survivors and especially in those who had lost a family member. In a cross-sectional community survey of more than 5000 community members in Nigeria to assess perceptions of EVD, over 60% reported being unwilling to hug or shake hands with an EVD survivor.44 In recognition of the challenges they face, many governments and clinics have announced policies of free medical care for survivors.45 Although well intended, these measures of positive discrimination can at times have adverse effects, leading to envy and friction with the general population who are in need of medical care. In addition to the survivors themselves, an Ebola virus outbreak often poses heavy mental health and related social and economic challenges to uninfected people,

A

B

Figure 2: Skin disorders in Ebola virus disease survivors (A) Diffuse alopecia and (B) skin desquamation. Photographs by Pauline Vetter.

including food insecurity, scarcity of access to medical services, school and business closures, fear of contracting Ebola virus, fear of toxic effects from the ubiquitous spraying of chlorine, distrust of health-care workers and the health-care system, and stigma, ostracisation, and community isolation from having a family member with EVD.46

Clinical management Interim guidelines for clinical care of EVD survivors have been published by WHO.47 Survivors should be referred for psychological and social support counselling before discharge and then be seen in regular follow-up, sometimes helped by regular phone check-ins to gauge stress.43 A general history and physical and rheumatological, ocular (comprising tests of visual acuity, slit lamp examination, measurement of intraocular pressure, and dilated fundoscopic examination), nutritional, and mental health screening exams should be done soon after discharge, with continued psychological and social support as needed.48 Reduced visual acuity and raised intraocular pressure are two key potential markers of more severe eye disease. Treatment during convalescence is generally supportive. Sulfasalazine might be effective in arthralgia refractory to non-steroidal anti-inflammatory drugs, although the contraindication of underlying G6PD deficiency should be considered (J Fankhauser, ELWA Hospital, Monrovia, Liberia, personal communication). Uveitis usually responds over days to weeks to topical mydriatics (eg, 1% atropine drops) and corticosteroids,6 although systemic corticosteroids are needed in severe cases.21,22 Complications of uveitis might include synechiae, corneal oedema, band keratopathy, cataract, retinal oedema, high intraocular pressure, optic disc oedema, and refractive error needing optical correction. The role of antiviral therapy to clear virus from body compartments where it might persist remains to be assessed. Psychological counselling or pharmacotherapy for mental health disorders is often warranted. Survivors have been enlisted as assistants and caregivers in Ebola treatment units and as health promoters during outbreaks in an attempt to decrease stigmatisation.40,43

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Survivors have at times been promoted as heroes in their communities, especially when they donate blood for convalescent plasma therapy,49–52 although the effectiveness of these measures on survivor morale and community perceptions has not been assessed. Psychosocial and social support should be considered for the survivor’s family and others in communities.51,53,54

Delayed clearance of virus in selected body compartments

Delayed clearance of virus in eye

Although Ebola virus is widely disseminated during acute disease, the virus is rapidly cleared from most body fluids as acute illness subsides.2,4,20,29,32,55–61 However, virus clearance might be delayed in a few immunologically protected body compartments and fluids, including the semen (the site of persistence is presumed to be the testes but involvement of the prostate cannot be excluded), chambers of the eye, CNS, and the fetus, placenta, amniotic sac/fluid, and mammary gland in women infected during pregnancy (figure 3).7,13,15,17,22,55,59,62 The articular cartilage is another compartment where immune privilege could exist, but this site has rarely been sampled to explore for persistent virus.17

Delayed clearance of virus in semen Ebola virus has been isolated from the semen of survivors up to 82 days after disease onset.59 However, in a study in west Africa, small amounts of Ebola virus RNA were noted in the semen of patients for as long as 9 months after resolution of acute disease, with anecdotal reports of RNA persistence of over 1 year.62 Although cell-culture data are not yet available to establish if there is live virus in these samples, documentation of a case of sexual transmission of Ebola virus in Liberia 6 months after recovery from illness, with a sequence match between the virus identified in the man’s semen and woman’s

Semen Cerebrospinal fluid Aqueous humour Body compartment

blood, suggests that infectious virus can persist in the semen much longer than previously recognised.13,15 Despite this persistence, cases of suspected sexual transmission of Ebola virus are infrequently reported, even when active surveillance is done.63 Tests of semen years after recovery from acute EVD have consistently been negative, suggesting that the virus is eventually cleared.59

Urine Sweat or skin Amniotic fluid or placenta Vaginal secretions or swab Stool or rectal swab

The frequency and duration of Ebola virus persistence in the eye is unknown. Ebola virus was cultured from the aqueous humour of a patient with uveitis 14 weeks after acute EVD and 9 weeks after clearance of the virus from blood, which remained negative during the episode of uveitis.22 Sequence data from the anterior humour isolate revealed five point mutations compared with the virus obtained months earlier from the blood during acute EVD, suggesting persistent viral replication in the eye during convalescence. Unilateral uveitis with isolation of the virus was noted in a patient 2–3 months after recovery from infection with Marburg virus, another member of the virus family Filoviridae.64,65 Uveitis recurred at 5 and 11 months after recovery, although no samples were taken for culture at these later points in time.

Delayed clearance of virus in CNS Only a few lumbar punctures have been done to assess for persistent virus in the CNS.17 One patient with EVD developed a protracted course, eventually becoming comatose despite the clearance of virus from the blood by day 28 after disease onset.17 Although her condition gradually improved, her family still described her as “slow”. A lumbar puncture done on day 41 after disease onset was positive on RT-PCR for Ebola virus, albeit with a high cycle threshold of 37·6, indicating a low viral load. Blood remained RT-PCR negative. The patient was eventually discharged, but with decreased mental status. Evidence of Ebola virus was noted by RT-PCR in both the CSF and blood in a patient who developed severe meningitis with seizures 9 months after resolution of acute disease (M Jacobs, personal communication).The viral load was reportedly lower in the blood than the CSF, leading to the conclusion that the viraemia was attributable to reseeding of the blood from the CNS. These two cases reveal the potential for Ebola virus to persist in the CNS, but the precise duration and frequency are unknown.

Tears or conjunctival swab Breastmilk

RT-PCR Culture

Saliva 0

50

100

150

200

250

Time from disease onset (days)

Figure 3: Virus persistence after disease onset in body compartments of survivors of Ebola virus disease detected by RT-PCR and cell culture Red bars represent the day of the first negative RT-PCR detection in the patient’s blood, when available.

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300

Delayed clearance of virus in pregnant women, fetuses, products of conception, and breastmilk Case fatality ratios for pregnant women with EVD and their offspring are very high, with fetal loss approaching 100% because of spontaneous abortion, stillbirth, and neonatal death in the first 3 weeks of life.66–71 However, a few women infected with Ebola virus during pregnancy, possibly with no or atypically mild disease, have recovered

www.thelancet.com/infection Published online March 22, 2016 http://dx.doi.org/10.1016/S1473-3099(16)00077-3

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and remained pregnant, only to spontaneously abort a macerated and non-viable fetus in subsequent weeks or months.70,72 Although the mothers’ blood remained free of virus at the time of delivery, swabs of the fetus, placenta, or amniotic fluid have tested positive for Ebola virus RNA by RT-PCR in some cases, with low cycle threshold values suggesting persistence of live virus, although cell culture results are not yet available.67,69,70,72 The cause of this occurrence remains to be established, but is presumed to be because of delayed virus clearance from the uterus, which is an immunologically protected site during pregnancy. Ebola virus RNA has been noted in breastmilk up to 26 days after disease onset.73 Lactation was then suppressed so no further samples were available to assess the full duration of infection. Nevertheless, anecdotal reports from west Africa reveal Ebola RNA in breastmilk months after recovery (P Formenty, WHO, Geneva, Switzerland, personal communication). There is no evidence of virus persistence in women who recover from EVD and then become pregnant, although data on pregnancy, birth rates, and outcomes in women who survived EVD are still scarce.

Delayed clearance of virus in other body compartments Ebola virus RNA has been identified in various other body fluids, including urine,29 skin swabs/sweat,29 vaginal secretions,55 rectal swab or stool,59 and saliva,20 for weeks and even months after disease onset and after virus has been cleared from the blood (figure 3). However, the significance of these findings is unknown; in most cases infectious virus was not isolated in samples obtained a few weeks after disease onset, if at all, and no cases of secondary transmission resulting from these patients has been suspected. Nevertheless, continued enhanced surveillance and study to understand the potential for delayed clearance of virus in these non-immunologically protected body compartments and the possible risk of transmission is warranted.

Recrudescence and risk of transmission from convalescent patients Rare reports exist of recrudescence after partial or complete recovery from acute EVD. Recrudescence is generally linked to virus persistence in one of the aforementioned immunologically protected body compartments, and is postulated to relate to seeding of these sites in cases with severe initial acute EVD and high viral loads. Similar mechanisms have been reported with other RNA viruses, such as measles.74 In some cases, underlying HIV infection is thought to enhance the risk of recrudescence, although this association has not been validated. During recrudescence, the virus is thought to generally be restricted to the immunologically protected compartment. However, rare reports exist of recrudescent viraemia, including in the meningitis case noted above,

in which virus was detected by PCR in the CSF and at a lower lever in the blood. Although recrudescence in EVD seems to be rare, it could be that such cases have been attributed to other causes, such as malaria, based on a lessened index of suspicion for EVD-related manifestations during convalescence. Full genome sequencing of Ebola viruses identified during acute infection and during recrudescence might help shed light on the mechanisms of these events, especially the possibility of escape mutants. Despite the possibility of persistence of Ebola virus in a few body compartments and recrudescence, other than rare reports of suspected sexual transmission, there is no conclusive evidence of virus transmission from convalescent patients. With the exception of one possible case of sexual transmission, Rowe and colleagues7 noted no transmission from EVD convalescent patients to household contacts in 21 months of followup in Kikwit. WHO recommend that survivors and their partners abstain from sex or observe safe sex through condom use for 12 months or until the semen has twice tested negative.75 In two patients with uveitis post-EVD (including the one laboratory-confirmed case described above), there was no evidence of virus in tear films and conjunctival swabs, suggesting that virus replication was confined to the interior compartments of the eye.17,22 This assumption is corroborated by a study by Rowe and colleagues,7 in which 85 tear specimens taken from the 29 survivors over 21 months post-EVD onset all tested negative by ELISA antigen and cell culture. Kibadi and colleagues6 did report a positive RT-PCR result on a conjunctival swab obtained from a patient with uveitis 22 days after acute disease onset, but no virus could be isolated in cell culture by Rodriguez and colleagues on the same patient.59 Until more is known regarding the precise duration of infectious virus in EVD survivors, elective surgery on any of the immunologically protected body sites should be done only after careful consideration of the riskbenefit to the patient and the surgical team and supporting health workers. In most cases, it is advisable to delay elective surgery until at least 1 year after resolution of acute EVD. In cases where it is deemed essential to proceed with surgery, the procedure should be done under full infection prevention and control precautions for EVD.76 To assess and manage risk postoperatively, swabs of the implicated body site or fluid should be taken and tested for Ebola virus by RTPCR. The same approach should be taken when attending to EVD survivors with penetrating trauma to an immunologically privileged body site and to childbirth in women who were Ebola virus infected while pregnant.77 Because of the possible persistence of virus in breastmilk, infants in whom infection is not already confirmed should be formula-fed, unless there is no other way to nourish the child.47,78

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Search strategy and selection criteria We searched the MEDLINE database for reports of post-EVD complications due to any Ebola virus species from Jan 1, 1976, when the virus was discovered, through Jan 31, 2016. Search terms used in various combinations were “Ebola”, “Ebola virus disease”, “survivors”, “complications”, “sequelae”, “mental health”, “stigmatization”, and “virus persistence”. We reviewed all articles rendered from these search terms and relevant references cited in those articles. There were no language restrictions.

Future directions and key research questions Just as the international community was unprepared for the size of the EVD outbreak in west Africa, we are fighting now to address the unpredicted emergency within the emergency—the challenge of caring for thousands of survivors across a broad geographical landscape in the devastating wake of this humanitarian disaster. Although thousands of health workers have been trained to manage acute EVD over the past 2 years, plans for structured follow-up and treatment of post-EVD complications, including social and psychological support, are only now being implemented. Similar to the initial outbreak response, the task is complicated by restricted human resources in west Africa, further compounded by the fact that many of the governmental and nongovernmental agencies associated are still reeling from the heavy burden of acute outbreak control activities while simultaneously trying to re-establish the broader healthcare system. A further challenge is that survivors often need subspecialised services not readily available in the afflicted countries, such as ophthalmic care and mental health services. For example, Sierra Leone has two practising ophthalmologists and one practising psychiatrist, with similar numbers in Liberia and Guinea.40 Despite these limitations, service provision for survivors is gaining momentum in west Africa; with the participation of many stakeholders and the survivors themselves, clinical care protocols for the myriad EVD sequelae have been developed and shared.47 Mental health, eye care, and other paraprofessionals are being trained, and clinics—some fixed, some mobile—established. Progress is being made, but still we need to do better. Reaching survivors in remote rural regions is a particular challenge. Albeit unwelcome, the size of the outbreak in west Africa provides a unique opportunity and obligation to better understand the challenges that survivors face, the science behind them, and their solutions. Structured, longitudinal, and controlled studies are underway in west Africa. The questions to be answered are myriad, such as the frequency and severity of specific sequelae; the duration and associated risk of transmission from virus persistence in various body compartments; the clinical, virological, and immune profiles during acute 8

disease that might predict the risk of sequelae; the role of specific antiviral therapy in the management of sequelae; and the possible lingering effects on child development because of the profound biological and psychological trauma of EVD. These studies hold the potential to generate knowledge far beyond EVD, comparing and contrasting with key manifestations with other viral infections, such as the uveitis evident in herpes simplex, herpes zoster, and cytomegalovirus; the retinal complications of Rift Valley fever; the hearing loss in Lassa; and the arthralgia of chikungunya. Lastly, with both the provision of care and research, we must seize this opportunity to build long-term capacity for strong health-care systems and research and development in the affected countries. The goal must be not merely to treat EVD survivors, but to use the opportunity to build capacity, initially dedicated to this group in urgent need, but ultimately expanded to the general population and to possible future outbreaks, irrespective of cause. Far more than holding workshops and building hospitals and laboratories, this will need a major long-term investment in training to develop and support the health-care workers and principal investigators of the region’s future. There are many challenges to this endeavour, not the least of which is procuring the necessary resources as EVD hopefully soon recedes, but with the risk that donors then look at the crisis as over, turning their attention and their funding elsewhere. The international community has an opportunity now to make a major investment in the future of west Africa. We must not forget, and we must not turn back. Contributors PV conducted the literature research and wrote the first draft. All authors provided critical review and revisions. Declaration of interests We declare no competing interests. Acknowledgments We thank Médecins Sans Frontières/Doctors Without Borders, Partners in Health, GOAL, IMC, and the many other groups providing care for survivors in west Africa, Julie-Anne Dayer and Sharmistha Mishra for their work in survivor follow-up, Angela Huttner, Sabine Yerly, Rosemary Sudan, and Steven Yeh for their kind review of the manuscript, and all EVD survivors. DGB is a consultant at WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of WHO. © 2016. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. References 1 WHO. Ebola response roadmap situation report. Geneva: World Health Organization, 2015; http://apps.who.int/ ebola/current-situation/ebola-situation-report-30-december-2015 (accessed Dec 30, 2015). 2 Emond RT, Evans B, Bowen ET, Lloyd G. A case of Ebola virus infection. BMJ 1977; 2: 541–44. 3 Formenty P, Hatz C, Le Guenno B, Stoll A, Rogenmoser P, Widmer A. Human infection due to Ebola virus, subtype Côte d’Ivoire: clinical and biologic presentation. J Infect Dis 1999; 179 (suppl 1): S48–53. 4 Bwaka MA, Bonnet MJ, Calain P, et al. Ebola hemorrhagic fever in Kikwit, Democratic Republic of the Congo: clinical observations in 103 patients. J Infect Dis 1999; 179 (suppl 1): S1–7.

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18

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De Roo A, Ado B, Rose B, Guimard Y, Fonck K, Colebunders R. Survey among survivors of the 1995 Ebola epidemic in Kikwit, Democratic Republic of Congo: their feelings and experiences. Trop Med Int Health 1998; 3: 883–85. Kibadi K, Mupapa K, Kuvula K, et al. Late ophthalmologic manifestations in survivors of the 1995 Ebola virus epidemic in Kikwit, Democratic Republic of the Congo. J Infect Dis 1999; 179 (suppl 1): S13–14. Rowe AK, Bertolli J, Khan AS, et al. Clinical, virologic, and immunologic follow-up of convalescent Ebola hemorrhagic fever patients and their household contacts, Kikwit, Democratic Republic of the Congo. Commission de Lutte contre les Epidémies à Kikwit. J Infect Dis 1999; 179 (suppl 1): S28–35. Wendo C. Caring for the survivors of Uganda’s Ebola epidemic one year on. Lancet 2001; 358: 1350. Clark DV, Kibuuka H, Millard M, et al. Long-term sequelae after Ebola virus disease in Bundibugyo, Uganda: a retrospective cohort study. Lancet Infect Dis 2015; 15: 905–12. Mohammed A, Sheikh TL, Gidado S, et al. An evaluation of psychological distress and social support of survivors and contacts of Ebola virus disease infection and their relatives in Lagos, Nigeria: a cross sectional study—2014. BMC Public Health 2015; 15: 824. Qureshi AI, Chughtai M, Loua TO, et al. Study of Ebola virus disease survivors in Guinea. Clin Infect Dis 2015; 61: 1035–42. Epstein L, Wong KK, Kallen AJ, Uyeki TM. Post-Ebola signs and symptoms in U.S. survivors. N Engl J Med 2015; 373: 2484–86. Christie A, Davies-Wayne GJ, Cordier-Lassalle T, et al. Possible sexual transmission of Ebola virus—Liberia, 2015. MMWR Morb Mortal Wkly Rep 2015; 64: 479–81. Jampol LM, Ferris FL 3rd, Bishop RJ. Ebola and the eye. JAMA Ophthalmol 2015; 133: 1105–06. Mate SE, Kugelman JR, Nyenswah TG, et al. Molecular evidence of sexual transmission of Ebola virus. N Engl J Med 2015; 373: 2448–54. Hugo M, Declerck H, Fitzpatrick G, et al. Post-traumatic stress reactions in Ebola virus disease survivors in Sierra Leone. Emerg Med 2015; 5: 1–4. Howlett P, Brown C, Helderman T, et al. Ebola virus disease complicated by late-onset encephalitis and polyarthritis, Sierra Leone [letter]. Emerg Infect Dis 2016; 22: 150–52. Mattia JGVM, Vandy MJ, Chang JC, et al. Early clinical sequelae of Ebola virus disease in Sierra Leone: a cross-sectional study. Lancet Infect Dis 2015; 16: 331–38. Nanyonga M, Saidu J, Ramsay A, Shindo N, Bausch DG. Sequelae of Ebola virus disease, Kenema District, Sierra Leone. Clin Infect Dis 2016; 62: 125–26. Mora-Rillo M, Arsuaga M, Ramírez-Olivencia G, et al. Acute respiratory distress syndrome after convalescent plasma use: treatment of a patient with Ebola virus disease contracted in Madrid, Spain. Lancet Respir Med 2015; 3: 554–62. Chancellor JR, Padmanabhan SP, Greenough TC, et al. Uveitis and systemic inflammatory markers in convalescent phase of Ebola virus disease. Emerg Infect Dis 2016; 22: 295–97. Varkey JB, Shantha JG, Crozier I, et al. Persistence of Ebola virus in ocular fluid during convalescence. N Engl J Med 2015; 372: 2423–27. Liddell AM, Davey RT Jr, Mehta AK, et al. Characteristics and clinical management of a cluster of 3 patients with Ebola virus disease, including the first domestically acquired cases in the United States. Ann Intern Med 2015; 163: 81–90. Bausch DG. Sequelae after Ebola virus disease: even when it’s over it’s not over. Lancet Infect Dis 2015; 15: 865–66. Dhillon P, McCarthy S, Gibbs M. Surviving stroke in an Ebola treatment centre. BMJ Case Rep 2015; PII:bcr2015211062. Dallatomasina S, Crestani R, Sylvester Squire J, et al. Ebola outbreak in rural west Africa: epidemiology, clinical features and outcomes. Trop Med Int Health 2015; 20: 448–54. Nkoghe D, Leroy EM, Toung-Mve M, Gonzalez JP. Cutaneous manifestations of filovirus infections. Int J Dermatol 2012; 51: 1037–43. Schieffelin JS, Shaffer JG, Goba A, et al. Clinical illness and outcomes in patients with Ebola in Sierra Leone. N Engl J Med 2014; 371: 2092–100. Kreuels B, Wichmann D, Emmerich P, et al. A case of severe Ebola virus infection complicated by gram-negative septicemia. N Engl J Med 2014; 371: 2394–401.

30

31

32

33

34

35

36

37

38

39 40 41 42 43

44

45

46

47

48

49

50

51

52 53

McElroy AK, Akondy RS, Davis CW, et al. Human Ebola virus infection results in substantial immune activation. Proc Natl Acad Sci USA 2015; 112: 4719–24. Towner JS, Rollin PE, Bausch DG, et al. Rapid diagnosis of Ebola hemorrhagic fever by reverse transcription-PCR in an outbreak setting and assessment of patient viral load as a predictor of outcome. J Virol 2004; 78: 4330–41. Geisbert TW, Jahrling PB, Larsen T, Davis KJ, Hensley LE. Filovirus pathogenesis in nonhuman primates. In: Klenk H-D, Feldmann H, eds. Ebola and Marburg viruses: molecular and cellular biology. Norfolk: Horizon Bioscience, 2004: 203–38. Martines RB, Ng DL, Greer PW, Rollin PE, Zaki SR. Tissue and cellular tropism, pathology and pathogenesis of Ebola and Marburg viruses. J Pathol 2015; 235: 153–74. Larsen T, Stevens EL, Davis KJ, et al. Pathologic findings associated with delayed death in nonhuman primates experimentally infected with Zaire Ebola virus. J Infect Dis 2007; 196 (suppl 2): S323–28. Alves DA, Honko AN, Kortepeter MG, et al. Necrotizing scleritis, conjunctivitis, and other pathologic findings in the left eye and brain of an Ebola virus-infected rhesus macaque (Macaca mulatta) with apparent recovery and a delayed time of death. J Infect Dis 2016; 213: 57–60. Gasque P, Couderc T, Lecuit M, Roques P, Ng LF. Chikungunya virus pathogenesis and immunity. Vector Borne Zoonotic Dis 2015; 15: 241–49. Hoarau JJ, Jaffar Bandjee MC, Krejbich Trotot P, et al. Persistent chronic inflammation and infection by chikungunya arthritogenic alphavirus in spite of a robust host immune response. J Immunol 2010; 184: 5914–27. Shultz JM, Baingana F, Neria Y. The 2014 Ebola outbreak and mental health: current status and recommended response. JAMA 2015; 313: 567–68. Evans DK, Popova A. West African Ebola crisis and orphans. Lancet 2015; 385: 945–46. Reardon S. Ebola’s mental-health wounds linger in Africa. Nature 2015; 519: 13–14. WHO. Ebola haemorrhagic fever in Zaire, 1976. Bull World Health Organ 1978; 56: 271–93. Hewlett BS, Amola RP. Cultural contexts of Ebola in northern Uganda. Emerg Infect Dis 2003; 9: 1242–48. Arwady MA, Garcia EL, Wollor B, et al. Reintegration of ebola survivors into their communities—Firestone District, Liberia, 2014. MMWR Morb Mortal Wkly Rep 2014; 63: 1207–09. Gidado S, Oladimeji AM, Roberts AA, et al. Public knowledge, perception and source of information on Ebola virus disease—Lagos, Nigeria; September, 2014. PLoS Curr 2015; 7: 7. AllAfrica, Sierra Leone: As Ebola clocks one year...president pledges to support survivors, May 26, 2015. http://allafrica.com/ stories/201505260286.html (accessed June 7, 2015). Matua GA, Wal DM. Living under the constant threat of Ebola: a phenomenological study of survivors and family caregivers during an Ebola outbreak. J Nurs Res 2015; 23: 217–24. WHO. Clinical care for survivors of Ebola virus disease. Interim guidance, 2016. http://apps.who.int/csr/resources/ publications/ebola/guidance-survivors/en/index.html (accessed Jan 24, 2016). Lee-Kwan SH, DeLuca N, Adams M, et al. Support services for survivors of ebola virus disease—Sierra Leone, 2014. MMWR Morb Mortal Wkly Rep 2014; 63: 1205–06. Bausch DG, Bangura J, Garry RF, et al. A tribute to Sheik Humarr Khan and all the healthcare workers in west Africa who have sacrificed in the fight against Ebola virus disease: Mae we hush. Antiviral Res 2014; 111: 33–35. Colebunders RL, Cannon RO. Large-scale convalescent blood and plasma transfusion therapy for Ebola virus disease. J Infect Dis 2015; 211: 1208–10. Rodríguez-Vega B, Amador B, Ortiz-Villalobos A, et al. The psychosocial response to the Ebola health emergency: experience in Madrid, Spain. Clin Infect Dis 2015; 60: 1866–67. Smith J, Boulton J, Walker E. Ebola survivor Will Pooley honoured at BJN Awards. Br J Nurs 2015; 24: 316. Greenberg N, Wessely S, Wykes T. Potential mental health consequences for workers in the Ebola regions of west Africa—a lesson for all challenging environments. J Ment Health 2015; 24: 1–3.

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Review

54

55

56

57

58

59

60

61

62

63

64 65 66 67

10

Smith CL, Hughes SM, Karwowski MP, et al. Addressing needs of contacts of Ebola patients during an investigation of an Ebola cluster in the United States—Dallas, Texas, 2014. MMWR Morb Mortal Wkly Rep 2015; 64: 121–23. Bausch DG, Towner JS, Dowell SF, et al. Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. J Infect Dis 2007; 196 (suppl 2): S142–47. Formenty P, Leroy EM, Epelboin A, et al. Detection of Ebola virus in oral fluid specimens during outbreaks of Ebola virus hemorrhagic fever in the Republic of Congo. Clin Infect Dis 2006; 42: 1521–26. Lyon GM, Mehta AK, Varkey JB, et al. Clinical care of two patients with Ebola virus disease in the United States. N Engl J Med 2014; 371: 2402–09. Richards GA, Murphy S, Jobson R, et al. Unexpected Ebola virus in a tertiary setting: clinical and epidemiologic aspects. Crit Care Med 2000; 28: 240–44. Rodriguez LL, De Roo A, Guimard Y, et al. Persistence and genetic stability of Ebola virus during the outbreak in Kikwit, Democratic Republic of the Congo, 1995. J Infect Dis 1999; 179 (suppl 1): S170–76. Schibler M, Vetter P, Cherpillod P, et al. Clinical features and viral kinetics in a rapidly cured patient with Ebola virus disease: a case report. Lancet Infect Dis 2015; 15: 1034–40. Wolf T, Kann G, Becker S, et al. Severe Ebola virus disease with vascular leakage and multiorgan failure: treatment of a patient in intensive care. Lancet 2015; 385: 1428–35. Deen GF, Knust B, Broutet N, et al. Ebola RNA persistence in semen of Ebola virus disease survivors—preliminary report. N Engl J Med 2015; published online Oct 14. DOI:10.1056/ NEJMoa1511410 Eggo RM, Watson CH, Camacho A, Kucharski AJ, Funk S, Edmunds WJ. Duration of Ebola virus RNA persistence in semen of survivors: population-level estimates and projections. Euro Surveill 2015; 20: 1–6. Gear JS, Cassel GA, Gear AJ, et al. Outbreake of Marburg virus disease in Johannesburg. BMJ 1975; 4: 489–93. Kuming BS, Kokoris N. Uveal involvement in Marburg virus disease. Br J Ophthalmol 1977; 61: 265–66. Akerlund E, Prescott J, Tampellini L. Shedding of Ebola virus in an asymptomatic pregnant woman. N Engl J Med 2015; 372: 2467–69. Baggi FM, Taybi A, Kurth A, et al. Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014. Euro Surveill 2014; 19: 1–4.

68 69

70

71

72

73

74 75

76

77

78

Mupapa K, Mukundu W, Bwaka MA, et al. Ebola hemorrhagic fever and pregnancy. J Infect Dis 1999; 179 (suppl 1): S11–12. Oduyebo T, Pineda D, Lamin M, Leung A, Corbett C, Jamieson DJ. A pregnant patient with Ebola virus disease. Obstet Gynecol 2015; 126: 1273–75. Bower H, Grass JE, Veltus E, et al. Delivery of an Ebola virus-positive stillborn infant in a rural community health center, Sierra Leone, 2015. Am J Trop Med Hyg 2016; 94: 417–19. Nelson JM, Griese SE, Goodman AB, Peacock G. Live neonates born to mothers with Ebola virus disease: a review of the literature. J Perinatol 2015; published online Dec 10. DOI:10.1038/jp.2015.189. Caluwaerts S, Fautsch T, Lagrou D, et al. Dilemmas in managing pregnant women with Ebola: 2 case reports. Clin Infect Dis 2016; 62: 93–05. Nordenstedt H, Bah I, de la Vega M, et al. Ebola virus in breast milk in an Ebola virus–positive mother with twin babies, Guinea, 2015. Emerg Infect Dis 2016; published online Jan 21. DOI:10.3201/eid2204.151880. Griffin DE, Lin WH, Pan CH. Measles virus, immune control, and persistence. FEMS Microbiol Rev 2012; 36: 649–62. World Health Organization. 2015. Interim advice on the sexual transmission of the Ebola virus disease. http://www.who.int/ reproductivehealth/topics/rtis/ebola-virus-semen/en/ (accessed May 26, 2015). World Health Organization. 2015. Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola. http://apps.who.int/iris/bitstream/10665/130596/1/ WHO_HIS_SDS_2014.4_eng.pdf?ua=1 (accessed Jan 24, 2016). World Health Organization. 2015. Ebola virus disease in pregnancy: screening and management of Ebola cases, contacts and survivors. http://www.who.int/csr/resources/publications/ebola/pregnancyguidance/en/ (accessed Sept 18, 2015). World Health Organization. 2014. Nutritional care of children and adults with Ebola virus disease in treatment centres. http://www. who.int/elena/titles/full_recommendations/nutrition_ebola/en/ index4.html (accessed Nov 2, 2015).

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