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Ebola Virus Disease: An Update On Current Prevention and Management Strategies

MSF Field Research

Authors Trad, MA; Naughton, W; Yeung, A; Mazlin, L; O'sullivan, M; Gilroy, N; Fisher, DA; Stuart, RL

Citation Ebola Virus Disease: An Update On Current Prevention and Management Strategies. 2016, 86:5-13 J. Clin. Virol.

DOI 10.1016/j.jcv.2016.11.005

Publisher Elsevier

Journal Journal of Clinical Virology: The Official Publication of the Pan American Society for Clinical Virology

Rights Archived with thanks to Journal of Clinical Virology : The Official Publication of the Pan American Society for Clinical Virology

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Link to item http://hdl.handle.net/10144/618818

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Journal of Clinical Virology 86 (2017) 5–13

Contents lists available at ScienceDirect

Journal of Clinical Virology

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j c v

bola virus disease: An update on current prevention and anagement strategies

.A. Trad a,b,c,∗, W. Naughton g, A. Yeung g, L. Mazlin d, M. O’sullivan i,j, N. Gilroy i, .A. Fisher e,f, R.L. Stuart g,h

Department of Infectious Diseases, Wollongong Hospital, Wollongong, NSW, Australia Graduate School of Medicine, University of Wollongong, Wollongong, Australia Medecins Sans Frontieres, Paris, France Medecins Sans Frontieres, Brussels, Belgium Division of Infectious Diseases, University Medicine Cluster, National University Hospital, Singapore Yong Loo Lin School of Medicine, National University of Singapore, Singapore Department of Infectious Diseases, Monash Health, Clayton, Victoria, Australia Department of Medicine, Monash University, Victoria, Australia Centre for Infectious Diseases and Microbiology, Pathology West, Westmead Hospital, NSW, Australia Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, NSW, Australia

r t i c l e i n f o

rticle history: eceived 11 June 2016 eceived in revised form 6 October 2016 ccepted 8 November 2016

a b s t r a c t

Ebola virus disease (EVD) is characterised by systemic viral replication, immuno-suppression, abnormal inflammatory responses, large volume fluid and electrolyte losses, and high mortality in under-resourced settings. There are various therapeutic strategies targeting EVD including vaccines utilizing different antigen delivery methods, antibody-based therapies and antiviral drugs. These therapies remain experi-

eywords: bola anagement

accines herapeutics

mental, but received attention following their use particularly in cases treated outside West Africa during the 2014–15 outbreak, in which 20 (80%) out of 25 patients survived. Emerging data from current trials look promising and are undergoing further study, however optimised supportive care remains the key to reducing mortality from EVD.

utbreak bolavirus

ontents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.1. Practicalities of clinical trials for Ebola virus disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2. Vaccines against Ebola virus disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.1. Recombinant vesicular stomatitis virus vector vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.2. Adenovirus vector vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.3. Vaccine use post exposure to ebola virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.4. Other antigen and vaccine delivery methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3. Antibody based therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1. Convalescent blood products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.2. Monoclonal antibody combinations (ZMapp, MB-003, and ZMab) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3.3. Other antibody based therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Drugs and small molecules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Favipiravir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Phosphorodiamidate morpholino oligomers and small interfering

∗ Corresponding author at: Department of Infectious Diseases, Lawson House, Level 1, W E-mail address: [email protected] (M.A. Trad).

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 RNAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ollongong Hospital, Wollongong NSW 2500, Australia.

6 M.A. Trad et al. / Journal of Clinical Virology 86 (2017) 5–13

4.3. Brincidofovir CMX001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4.4. BCX443 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

5. Supportive care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 5.1. Authors’ remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 5.2. Mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

6. Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 7. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 8. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

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Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. Introduction

Zaire ebolavirus (EBOV), Sudan ebolavirus (SUDV), Bundibugyo bolavirus (BDBV), Taï Forest ebolavirus (TAFV), and the only Asian pecies Reston ebolavirus (RESTV) [1]. The first three of these have reviously caused large outbreaks in the Democratic Republic of ongo, Sudan, Gabon, Republic of Congo, and Uganda [2]. The most ecent and largest outbreak involving over 28,000 cases in West frica was caused by a variant strain of EBOV with an estimated verall case fatality rate of around 40% [3].

EVD is primarily a diarrheal illness that requires copious mounts of fluid and electrolyte replacement [4]. Failure to address uch requirements contributes to mortality and thus an intensive evel of support is required to optimize outcomes. This is challeng- ng in resource limited settings.

There were no approved therapeutics to treat Ebola virus disease EVD) during the 2014–15 outbreak, that devastated three West frican countries [5]. A small number of cases were treated with utative therapeutics in the U.S and Europe before formalised clin-

cal trials were established late in the outbreak [6]. Potentially, an ffective therapeutic available in large quantities could not only reat individual cases but halt outbreaks.

.1. Practicalities of clinical trials for Ebola virus disease

Although a number of experimental vaccines and antivirals gainst Ebola virus had been developed prior to the large EVD out- reak in West Africa in 2014-15, phase II/III field studies did not et underway until late in the epidemic [6]. Consequently, some tudies will now have insufficient recruitment to establish efficacy 40]. This highlights the unique difficulties encountered in conduct- ng clinical trials in the midst of a health emergency, particularly n resource poor settings. Nevertheless, for a disease such as EVD,

hich has such a high mortality and no proven directed therapy, it s imperative that an integral part of the international response be o facilitate clinical trials of therapeutic agents.

International agencies setting up treatment centres must be illing to recruit patients into clinical trials, and have structures in

lace to manage the ethical and medico-legal requirements to facil- tate their conduct [6]. Ethical considerations around the design of linical trials in such settings can be complex, and it has been argued hat randomized, placebo controlled designs are not ideal as they

ay lead to withholding of potentially beneficial treatment (albeit xperimental) from those with a condition that otherwise has a ery poor outcome [6]. Using historical controls can circumvent this ssue, but calls into question the robustness of the study outcomes. daptive trial designs where ongoing planned interim monitoring

f the outcome data can be used to alter the trial design after com- encement to maximize the potential benefit to study participants hile maintaining statistical reliability, have also been advocated

or such studies [55]. Other challenges to conducting clinical tri- ls in such settings are the need for study personnel to enter the

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“red zone” of Ebola treatment centres (ETCs) to consent patients, thereby risking exposure to Ebola themselves, obtaining consent from very unwell patients for complex studies when next of kin are unable to be present at the bedside, and co-ordinating and expedit- ing the ethical review process between multiple governmental and non-governmental healthcare organisations and research institu- tions. [55] Consent procedures can be further complicated by the cultural and linguistic barriers.

This paper will review proposed therapeutics (including vac- cines, antibody based therapies, and small molecules) – many of which have only been tested in vivo on rodents or non-human primates (NHPs) [2].

2. Vaccines against Ebola virus disease

Vaccines are a potential cornerstone for limiting or fully pre- venting an EVD outbreak. There are numerous vaccine trials including two leading candidates in phase 3 trials (Table 1) rVSV- EBOV vaccines (recombinant vesicular stomatitis virus vector) and ChAd3-ZEBOV (adenovirus vector) [7,8]. Other potential candidates have been described elsewhere [9].

2.1. Recombinant vesicular stomatitis virus vector vaccines

When vesicular stomatitis virus was used in antigen delivery in NHPs, 50% protection was observed which was still effective up to thirty minutes post acquiring infection [7]. Recently, the interim results of a cluster randomized phase III trial of rVSV-EBOV in Guinea have been published [10]. The difficult logistics of conduct- ing such a trial were mitigated effectively by a ring vaccination strategy, where adult contacts and contacts of contacts of patients with EVD were included. Clusters of participants were randomized 1:1 into immediate versus delayed (21 days) vaccination. Out of 2014 participants from 48 clusters in the immediate group, there were no EVD cases after 10 days post vaccination, compared to 16 cases occurring in the delayed group of 2380 participants allocated to 42 clusters. Only one case had a febrile illness associated with the vaccine, which resolved without sequelae. Although the study did not provide measures of antibody titres, it concluded that it might take up to 6 days for the vaccine to provide protection.

Prior phase 1 trials of rVSV-EBOV vaccine, including patients from various sites in the U.S, Africa and Europe, found a high num- ber of adverse events in 90% of the study population [11,12]. The majority of events were reported as mild or moderate, appeared and subsided early (≤24 h), and were alleviated with simple anal- gesics. Rapid onset and transient haematological changes were

observed in all participants including transient leukocytopenia and lymphocytopenia. By 4 weeks, all vaccine doses produced EBOV- glycoprotein specific antibodies, although it could not be concluded whether higher vaccine doses would be required for optimal pro- tection.

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Table 1 Experimental: treatment approaches evaluated for efficacy against Ebola virus disease in mammals.

Approach Target/mechanism of action Demonstrated Efficacy Comments Ref.

Rodent NHP Human

Vaccines Plasmid DNA based vaccine VRC-EBODNA023-00-VP

DNA immunisation with boosting adenoviral vector

– Y Phase I (Uganda) Process takes 6 months to provide protection in NHP

[37]

Accelerated vaccine of plasmid DNA based vaccine: ChAd-EBOV, Ad5-EBOV, cAd3-EBOV (GSK) and Ad26 and MVA-EBOV (J&J)

Adenoviral vector delivers DNA encoding Ebola GP MVA used as a second dose booster

Y – Y Y Phase I (UK, U.S, China, Mali, Uganda, Switzerland) Phase II/III* : Liberia Phase I* : UK, II/III* US

Process takes 28 days to provide pre-exposure protection in NHP. Potential for outbreaks. Booster induces longer term protective immunity * NCT02509494 * NCT02240875, NCT02598388

[16,46,47]

rGP nanoparticle (Novavax) Recombinant Ebola GP admistered with a saponin based adjuvant (Matrix-M)

– – Phase I: Australia Requires 2 injections [48]

rVSV-EBOV (Merck), rVSV�G-EBOV

VSV delivers Antigen – Y Phase I (Kenya, U.S, Switzerland) STRIVE: Phase II/III Randomized trial in HCWs (Sierra Leone), PREVAIL: Phase II (Liberia). Ca Suffit: Phase III (Guinea)

Up to thirty minutes post infection (protection against Ebola −50%, Marburg 100%) 33% protection after 48 h, in NHP Geneva phase I trial halted for safety concerns. Less side effects with the newer strains. Potentially could provide protection after 6 days of vaccinations in humans. No booster required. Duration of protective antibodies unknown

[7,11–13,10,21]

Antibody based therapies IgG/IgM from convalescent patients

Virus neutralisation – – Case series, INTERCEPT Phase I and Phase II/III (Guinea, Sierra Leone, Liberia)

Widely used during 2014-15 outbreak. No significant mortality benefit in 99 transfused patients. Two consecutive transfusions of 200–250 ml plasma from separate concalescent donors

[26,28]

Purified IgG As above – Y Y 48 h protection post infection (100%) in NPH

[49]

Cocktail of 3 x mouse monoclonal antibodies-ZMab

Targets GP to neutralize the virus (m1H3, m2G4, m4G7)

– Y Cases 100% effective at 24 h 50% @ 48 h [31]

Cocktail combined with adenovirus vectored interferon-alpha

As above – Y – 72 h post infection 75–100% [32]

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Table 1 (Continued)

Approach Target/mechanism of action Demonstrated Efficacy Comments Ref.

Rodent NHP Human

Cocktail of 3 x humanised monoclonal antibodies (MB-003) ZMapp and MIL-77 (China)

(c13C6, h13F9, c6D8) A combination of chimeric mAB c13C6 from MB-003 and 2 chimeric mABs (c2G4 and c4G7) from ZMab. MIL-77 is produced by CHO cells rather than tobacco plants

– – Y Y Cases, Phase I/II trial (multi-centre) Liberia, Sierra Leone, U.S Phase I*

Protection 100% at 1 h, 67% at 24/48 h. 43% survival at 120 h post infection and development of viraemia and fever in NHP. 50 mg/Kg/day for 3 days * NCT02389192

[30,50,4,51,68]

Drugs or small molecules TKM-Ebola Tekmira Small interfering RNA cocktail

against VP24, VP35, and L protein. Encapsulated in stable nucleic acid lipid particles (SNALP)

– Y Phase I-suspended (partial lift by FDA). Phase II: Sierra Leone Cases

IV preparation 100% protection 30 mins post exposure in NHP. Phase II trial halted in Sierra Leone. 7 daily infusions: Day1: 0.3 mg/Kg, Day2: 0.4 mg/Kg, then Days3-7: 0.5 mg/Kg

[37]

PMOs (AVI-6002) Blocks mRNA transcription – Y Phase I PEP 62.5% protection within 30 mins in NHP

[38]

Favipiravir Pyrazine carboxamide derivative. Selective inhibition of viral RNA dependent RNA polymerase.

Y – Cases Phase III (U.S) Licensed in Japan for flu. JIKI Phase II trial in Guinea

Rapid viral clearance, used up to day 6 post infection- mice. Received by most European cases. Preliminary results from JIKI trial indicate effectiveness in cases with low viral load. Day0: 6000 mg then Days1-9: 2400 mg. Activity being studied in semen NCT02739477

[34–36]

Brincidofovir (CMX001) Nucleotide analogue. Broad spectrum antiviral.

– – Cases Phase II (halted in January 2015)

Developed for CMV, BK viruses. Trial in Liberia halted due to reduction in new cases. Loading dose: 200 mg then 100 mg twice weekly for total of 5 doses

[40,41]

BCX4430 Adenosine analogue (PO/IM). Incorporation into viral RNA causing chain termination

– Y – 100% protection of NHP at 48 h post infection (Marburg virus), also thought to have anti-EVD activity.

[32,39]

PO: oral route, IM: Intramuscular route, NHP: Non-human primates, GP: Glycoprotein, VP: Viral protein, VSV: Vesicular stomatitis virus, CHO: Chinese Hamster Ovarian cells mAB: monoclonal antibodies PMOs: Phosphorodiamidate morpholino oligomers, PEP: Post-exposure prophylaxis, FDA: Food and drug agency, MVA: Modified Vaccinia Ankara, GSK:GlaxoSmithKline, J&J: Johnson & Johnson, *Ongoing trials as per http://clinicaltrials.gov (at the time of writing) Note: Military vaccines (Russia, U.S.A and China) were not included in the table given unavailability of publications in scientific journals.

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Two further attenuated forms of rVSV: rVSVN4CT1GP1 and VSVN1CT1GP3 were studied by Mire et al. [13], following concerns f developing arthritis in some participants in prior trials [11]. None f the vaccinated experimental animals (n = 8) showed any signs of evere illness when exposed to lethal challenge of EBOV.

The advantages of the rVSV vaccine platforms include a shorter ime to achieve protecting antibodies by inducing humoral immu- ity which is key to survival in experimental subjects [8,14]. This enders them favorable in outbreak settings. The relatively low pre- xisting immunity to VSV in various populations is an added value 15]. Duration of protective immunity, however, remains unknown.

.2. Adenovirus vector vaccines

To date there are no published phase III trials describing ade- ovirus vector vaccines. In a phase 1 double-blinded, placebo ontrolled trial of an adenovirus type-5 vector-based Ebola vaccine onducted in China [16], 120 adults received a vaccine matching he glycoprotein of the 2014 EBOV. The study demonstrated signifi- ant increase in Glycoprotein-specific antibody titres at both day 14 nd day 28 (p < 0·0001) and the treatment was well tolerated. The eneralisability of this study however is limited given the variable revalence of baseline adenovirus type-5 neutralizing antibody in ifferent African populations [16].

There are concerns regarding adenovirus- linked vaccination iven previous failures in HIV trials, which were stopped early [17]. he vaccine may reduce suppressive regulatory cells [18]. As such, iven high rates of HIV prevalence in Africa, if vaccination was o continue with an adenovirus vector vaccine, it has been sug- ested that HIV education and prophylaxis should be included in he vaccination regimen [19].

In comparison to rVSV-EBOV, ChAd3-EBOV vaccines strongly nduce cellular immunogenicity, which could provide longer dura- ion of vaccine efficacy [20]. ChAd3-EBOV can potentially be oosted by a modified vaccinia Ankara (MVA) strain to produce igher and longer lasting antibody titres. [21] This advantage

avours their use in pre-outbreak settings or in health care workers.

.3. Vaccine use post exposure to ebola virus

Following needle stick injury, rVSV-ZEBOV vaccine has been sed in a 44 year old US physician caring for patients in an Ebola reatment unit in Sierra Leone [22]. Forty-three hours after expo- ure the vaccine was administered and the patient evacuated to the S. Similar to a previous case where vaccination was administered fter laboratory exposure [23], The patient had a clinical syndrome onsistent with vaccination response. He developed antibodies to bola virus glycoprotein (a vaccine component), but not to Ebola irus VP40, which would be indicative of natural infection.

.4. Other antigen and vaccine delivery methods

Cytomegalovirus (CMV) based vaccination has also been studied n rodents [24]. A single dose of CMV expressing a CD8T cell epitope rom nucleoprotein of Ebola Virus (designated MCMV/ZEBOV- PCTL) induced durable CD8 + T cell immunity for at least 33 weeks. o EBOV disease was observed in vaccinated mice when chal-

enged. These mice did however show loss of weight, suggesting rotection may be only partial.

The intranasal route has also been suggested as a potentially

ffective vaccine delivery method [25]. This method has the poten- ial to increase acceptance, especially in populations distrustful of

estern medicine. Intranasal vaccines target the mucosal sites at hich Ebola is contracted, minimise the need for specialised health

are workers in resource deplete settings and reduce cost. They

l Virology 86 (2017) 5–13 9

also decrease storage requirements, minimise medical waste and reduce the need for populations to travel to be vaccinated.

3. Antibody based therapies

Human survivors of EBOV tend to mount early, vigorous, and long standing neutralizing antibodies (NAbs) that can bind to EBOV structural envelop glycoprotein (GP) [52]. Identification of such NAbs and their mechanism of activity has been essential in the development of immunotherapies and vaccines against EBOV. The breadth of protection of such NAbs is variable and still undergoing study [53].

3.1. Convalescent blood products

Convalescent blood products have been used during Ebola out- breaks under the pretext that they contain NAbs against EBOV [26]. In one of the earliest landmark studies, from the Kikwit outbreak in 1995, whole blood transfusions were donated by five convales- cent patients, to eight patients with EVD. Five of the six patients tested demonstrated negative tests for EBOV antigens by day 4 after receiving their transfusions. The mortality rate for this patient group was 12.5% (1 in 8), which was smaller than the 80% overall mortality for the outbreak. Whether these results can be general- ized is unknown, as the study was limited by its small number of patients and lack of controls. Additionally, the intervention was undertaken during the late phase of the epidemic when health resources were greatly improved. There have also been sugges- tions that at the end of an EBOV epidemic, the virus may become less infectious and less virulent [27]. A more recent, larger, and better designed study that included 99 patients from Guinea did not show a statistically significant survival benefit in receiving up to 500 ml of convalescent plasma [28]. Paediatric patients younger than 5 years of age appeared to benefit from the transfusions, how- ever a conclusion could not be made due to the low numbers. The study was conducted towards the end of the outbreak, when mor- tality rates were less than 20%. Due to logistics, the convalescent plasma NAbs levels were not tested, but this reflected real life set- tings. It has been suggested that convalescent blood products after 9 months from recovery might contain higher levels of NAbs and hence be more protective [29]. At least 8 patients treated outside Africa have reportedly received convalescent serum, 7 of whom survived. [3,41–5]

3.2. Monoclonal antibody combinations (ZMapp, MB-003, and ZMab)

A single antibody may not be able to neutralize every single viral particle, and hence a cocktail of antibodies may be required. Neutralising antibodies from convalescent blood can be produced in vitro in the form of cocktails of monoclonal antibodies (mAbs) against EBOV glycoprotein (GP). For example, ZMapp is a cock- tail of 3 chimeric mAbs (c13C6, c2G4 and c4G7), ZMab a cocktail of mouse mAbs (m1H3, m2G4, m4G7), and MB003 a cocktail of human-mouse chimeric mAbs (c13C6, h13F6, c6D8) (Table 1). Four out of six patients treated outside Africa have reportedly received ZMapp and survived. [3,41–5] Details of those therapies, including timing and doses of serum or antibody cocktails remain unpub- lished. Compared to vaccines that require longer time to induce protection, antibody-based-therapies can potentially offer protec- tion immediately after EBOV exposure for up to 120 h in animal

models [30] (Table 1). Their major drawbacks however are a lack of availability and a significantly declining efficacy when given later in the course of experimental infection.

Qiu et al. investigated the administration of ZMAb [31]. All four NHPs (100%) receiving the cocktail at 24 h post EBOV challenge sur-

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ived whilst two (50%) survived in the 48-h group. Of note one f the non-survivors carried an escape mutant with mutations in BOV-GP (amino acids 275 and 508). EBOV-GP IgM and IgG were resent up till day 28. ZMAb half-life is still unknown and as such iming of treatment and dosing still require further investigation. wo patients with EVD in the latest outbreak in Sierra Leone, who ere treated in Europe, received ZMAb and survived [45,56].

In a previous study utilizing NHPs, co-administration of Ab and adenovirus-vectored interferon-a (Ad-IFN) demonstrated

ffectiveness if provided following the third day of infection [32]. even of eight NHPs survived challenge with signs of mild disease. n a further design to test for an extension of the potential treatment

indow, NHPs were treated with Ad-IFN 24 h after challenge and MAb at 96 h after challenge. Two of four NHPs survived infection. 32]

The delayed administration of MB-003, manufactured in the obacco plant Nicotiana benthamiana, was investigated for efficacy n NHPs [30]. Treatment was initiated at 120 h after infection with BOV, with further administration of MB-003 at 170 and 250 h post xposure. Only 3 of 7 NHPs survived, and all controls died.

.3. Other antibody based therapies

The phosphatidylserine-targeting antibody (PGN401, bavitux- mab), an antibody previously demonstrated to have broad- pectrum antiviral activity, was shown in an in vitro trial to bind nd recognise Ebola virus and Ebola virus infected cells [33]. This ay also be a future treatment modality.

The above studies may be limited in their generalisability to uman subjects. The cohort numbers were low, which would also

imit the power to detect rare adverse outcomes of treatment dministration.

. Drugs and small molecules

.1. Favipiravir

The pyrazinecarboxamide derivative T-705 (favipiravir) is icensed in Japan for the treatment of influenza not responding to onventional therapies [34]. It has antiviral activity against other egative stranded RNA viruses, and has been used in the European entres that treated EVD in the last outbreak (Table 1). It induced apid Ebola viral clearance in a rodent model when administered s late as day 6 following inoculation with Ebola virus, in addition o a 100% survival rate compared to controls (100% fatality rate). esults from the JIKI trial in Guinea led by the French Institute of ealth and Medical Research (INSERM) suggest a non-significant

ower mortality in those with low viral loads as indicated by an BOV RT-PCR cycle to threshold (CT) of >20 (20% vs 30% in historic ontrols) but not in those with high viral loads (CT < 20), with a 91% ortality rate in those treated with favipiravir vs 85% in historic

ontrols [35]. The anti-EVD regimen used in adults was 6000 mg on ay 0, followed by 2400 mg/d from day 1 to day 9, whereas doses

n children were adjusted to body weight [36].

.2. Phosphorodiamidate morpholino oligomers and small nterfering RNAs

Molecules such as phosphorodiamidate morpholino oligomers PMOs), and small interfering RNAs (siRNAs) have shown efficacy n reducing mortality when administered to NHPs up to 1 h after

xposure [37,38]. AVI 6002 is a combination of positively charged hosphorodiamidate morpholino oligomers (PMOs) designed to arget mRNA sequences of VP24 and VP35 in EBOV. It is currently ndergoing phase I clinical trials for EBOV post exposure treatment.

n a study in 2010, AVI-6002 was given intravenously to NHP’s

l Virology 86 (2017) 5–13

initiated 30–60 min post EBOV exposure at varying doses for up to 14 days [38]. The results of the study demonstrated that 60% of NHPs given doses of 28 mg/kg and 40 mg/kg survived with 100 times greater suppression of mean viral load at the peak of plasma viraemia compared to controls. Phase I safety trials have shown AVI 6002 to be well tolerated in healthy adult subjects. TKM-Ebola (for- merly Tekmira), is a combination of small interfering RNAs (siRNAs) formulated in stable nucleic acid lipid particles was developed by Tekmira Pharmaceutical Corp. The combination of siRNAs targeting the EBOV L polymerase, VP 24 & 35, was given to 7 NHPs at 30 min post exposure to EBOV and either 3 or 6 further doses at various intervals after [37]. Six of the 7 NHPs were protected from EBOV infection with good tolerance of the drug. During its phase I clinical trial, the U.S Food and Drug Administration placed a hold on the drug due to safety concerns in regards to high cytokine levels [57]. This was partially lifted during the outbreak, and subsequently used in two patients who were treated in the U.S [58]. Furthermore, it is also being designed to target the Guinea variant of EBOV and was planned to enter human clinical evaluation in Guinea in emergency situations [57].

4.3. Brincidofovir CMX001

CMX001 (Brincidofovir) is a prodrug of cidofovir and is an effec- tive anti-DNA antiviral medication by inhibiting viral replication secondary to selectively inhibiting viral DNA polymerases [39]. It is currently undergoing Phase III clinical trials for use against adenovirus and cytomegalovirus. In vitro tests have demonstrated efficacy against EBOV although the mechanism of action is unclear [39]. As a result, Brincidofovir has been used in emergency situa- tions in patients infected with EBOV and was undergoing Phase II clinical trials, which were unfortunately halted due to lack of new cases. Brincidofovir was experimentally used to treat one of the first patients to be transferred to the U.S [41].

4.4. BCX443

The adenosine analogue, BCX443, when given 48 h after infec- tion via intramuscular injection demonstrated 100% protection from Marburg virus in a nonhuman primate model (Table 1), and could potentially be used for EVD [40]. BCX4430 inhibits viral RNA polymerase activity indirectly through non-obligate RNA chain ter- mination. It has shown efficacy in pre-exposure treatment of EBOV in vitro and in small animal models. In a rodent model, it demon- strated protection against lethal EBOV challenge receiving BD oral and IM administration for nine days [40]. BCX4430 is planned for further animal studies.

5. Supportive care

In the absence of any available directed therapy, the mainstay of management in EVD has been supportive care. This includes rehydration, electrolyte replacement, supplemental oxygen, treat- ment of concomitant infections, blood products, antipyretics, anti-emetics and anti-diarrhoeal agents, nutritional support and psychologic care. The level of sophistication of these interven- tions varies from basic oral rehydration therapy without laboratory investigations in the most resource poor settings, through to inva- sive fluid, electrolyte and blood product management, mechanical ventilation, and haemodialysis with full laboratory and radiology support in intensive care units in developed countries [42]. Even

within countries most affected by EVD, the level of supportive care varied widely [59,60]. Whether increasing sophistication of sup- portive care is associated with improved outcomes is not proven, however, one could not dispute this intuitively. In an observational study, Cotte et al. compared the use of central venous catheters to

M.A. Trad et al. / Journal of Clinica

Box 1: Tips in resource limited settings

• Early administration of anti-emetics and anti-diarrhoeal agents

• Test and treat concurrent infections such as malaria • Healthcare worker training and education in principles and

practice of infection control, sharps management, and occu- pational safety in an ETC setting

• Dedicated staff health clinics given higher mortality rates among healthcare workers. [62]

• Early involvement of patients and their carers with ongoing education and psychologic care

• Establish a survivor network for potential training and recruitment

• Use of technology and minimisation of paper work: example,

p E a v

I t w l d E b o l h s i w r t e u u a

z p c l i

a o p u a C p H c f p a c

mobile phones and dedicated computers • Early coordination between all actors

eripheral venous catheters for IV access in patients treated at an bola Treatment Unit in Conakry in 2015. Central catheters were ssociated with longer line survival times and a higher ratio of olume of fluid infused to that which was prescribed [61].

.1. Authors’ remarks

Case management varied widely due to a variety of reasons. n one major centre in Liberia, during the peak of the outbreak, he case numbers overwhelmed the ETC capacity that a decision as made to “close the doors”, and a palliative approach was fol-

owed due to high rates of mortality (reaching 80%) [Box 1]. In a ifferent setting, the case load was lower. Patients with confirmed VD were admitted to air conditioned tents, each containing two eds. Observations included temperature, blood pressure, pulse, xygen saturations, respiratory rate, conscious state (AVPU) and

evel of hydration. Frequency of observation was between 12th ourly up to 4th hourly or more frequently, depending on the tage of disease. Fluid balance was recorded, and urinary catheter- sation and rectal tubes (Flexiseal Faecal Management System)

ere utilised as needed. Closed circuit cameras allowed continuous emote visual observation of patients from the staff station outside he ‘red zone’. Peripheral venous access was established when nec- ssary for intravenous hydration; central venous access was also tilised for patients with advanced disease. Ultrasonography was tilised to aid placement of central venous catheters, and also to ssess fluid volume status by observing inferior vena cava filling.

Point of care pathology testing was utilised within the red one, using iSTATTM devices (analytes tested included sodium, otassium, chloride, ionised calcium, glucose, urea, bicarbonate, reatinine, haematocrit, haemoglobin, anion gap, pH, PCO2, pO2, actate, base excess, prothrombin time, INR), glucometers, and mmunochromographic testing for malaria and beta-HCG.

An onsite laboratory performed PCR testing for Ebola virus, s well as rapid diagnostic tests for Dengue and HIV. In the lab- ratory, biochemistry testing was available using the PiccoloTM

latform. Analytes assayed on the PiccoloTM included albumin, rea, calcium, creatinine, glucose, potassium, sodium, amylase, lanine transaminase, aspartate transaminate, creatinine kinase, -reactive protein, bilirubin, lactate, chloride, magnesium, phos- hate and bicarbonate. Haemtology testing was performed on the emochronTM platform and included a full blood count with white

ell differential and coagulation testing. Blood cultures were per- ormed using the BacT/AlertTM system. The Biofire filmarrayTM

latform was also utilised for multiplex PCR testing of respiratory nd faecal pathogens, and to detect bacteria from positive blood ultures.

l Virology 86 (2017) 5–13 11

Pathology testing was performed at least daily in the initial phase of management, and as required in the convalescent phase. In advanced disease point of care testing in the red zone was utilised as clinically necessary for more frequent pathology monitoring.

5.2. Mental health

In our experience, psychosocial support and health promotion (PSHP) are integral to the care of patients with EVD. In West Africa, many ETCs were supported by dedicated PSHP teams, responsible for counselling relatives of those admitted with EVD, coordinating “fence line” visits, linking up family members admitted to different ETCs, coordinating safe and dignified burials and allowing fam- ily members the possibility of viewing the face of the deceased, across the fence line separating red zone from the ETC boundary. PSHP personnel were critical in facilitating access to social support programs for survivors (food packages, survivor clinics, survivor networks) and providing education and counselling, including safe sexual practices, in EVD survivors. They provided an essential point of contact for many survivors who experienced discrimination in the aftermath of their disease.

Mental health of healthcare workers (HCWs) must also not be neglected. Many returning volunteers experienced stigmatisa- tion. The names of those HCWs who contracted the illness were publicised [63]. Employers could play a role in mitigating the sen- sationalism driven by media by counselling families prior to an individual’s return.

6. Follow-up

With around 10,000 survivors of this disease now across West Africa, there is an increasing demand for the medical manage- ment of complications related to EVD in this survivor cohort. Most notably ocular complications, chronic pain – especially arthral- gias, cognitive, post traumatic stress syndrome and hearing deficits [64]. The emerging knowledge regarding immune privileged sites (e.g, eye, semen, cerebrospinal fluid) where the virus can remain sequestered, highlights the importance of ongoing follow-up and monitoring of these patients for late effects [65]. Such clinics are now being established in countries that have experienced high and intense transmission.

7. Discussion

There is evidence that current vaccines might have the potential to halt an outbreak, if a ring vaccination strategy is followed [10]. Both candidate vaccines seem to be well tolerated, however, we still do not have data on the duration of their protection or safety in subjects with underlying disease or medical conditions. There are also no data regarding their safety in paediatric or pregnant populations.

Supportive strategies and blood products have been commonly used, and there is accumulating evidence towards their benefit [61]. Intravenous (IV) fluid and electrolyte replacement are potentially challenging in certain contexts due to the lack of infrastructure for sharps management. Their use could be gradually introduced depending on the capacity of the etc. EVD patients can experience difficulties with absconding, denial and combativeness and it is not uncommon for patients to remove their lines, especially when not

observed.

Other clinical supportive measures can include the use of antipyretics and anxiolytics for symptom control when needed. Identifying and treating concurrent infections such as malaria was shown to reduce mortality [54].

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c a o m t

h f

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The orally administered therapeutics seem promising, espe- ially if given early when the viral load is still low. [35] Concomitant dministration of anti-emetics might be essential. Given the nature f increased volume losses in EVD, absorption of oral medications ight become an issue. To date there are no intravenous formula-

ions for those orally administered drugs.

. Conclusion

Clinics to follow-up on the survivors to establish the natural istory of EVD and its long term sequelae is an apparently straight

orward opportunity for us to learn. It is to the credit of WHO to establish a research and devel-

pment blueprint for action to prevent epidemics by accelerating vailability of vaccines, effective tests, and medicines at a large cale [66]. Indeed, there is a pipeline of interesting molecules that otentially could target EBOV [69]. We hope this will be a signifi- ant effort towards an evolving leadership in emergency research, nd in particular facilitating clinical trials in outbreaks. An exter- al investigation following the outbreak has created an opportunity

or WHO “to re-establish its pre-eminence as the guardian of global ublic health” [67].

It remains unfortunate that an outbreak involving 28,000 people ver more than a year has passed and the opportunity to evaluate o many putative therapeutics has been missed. While some ther- peutics were used on human subjects for the first time, we still annot make conclusions on their safety or effectiveness. Clinicians nd outbreak responders look forward to the day that well designed nd practical clinical trials can be seamlessly rolled out in parallel ith clinical efforts.

onflict of interest statement

The authors declare no conflicts of interests

eferences

[1] A.A. Bukreyev, K. Chandran, O. Dolnik, J.M. Dye, H. Ebihara, E.M. Leroy, et al., Discussions and decisions of the 2012–2014 international committee on the taxonomy of viruses (ICTV) filoviridae study group, January 2012–June 2013, Arch. Virol. 159 (4) (2014) 821–830, http://dx.doi.org/10.1007/s00705-013- 1846-9.

[2] H. Feldmann, T.W. Geisbert, Ebola haemorrhagic fever, Lancet 377 (2011) 849–862.

[3] S. Baize, D. Pannetier, L. Oestereich, T. Reiger, L. Koivogui, N. Magassouba, et al., Emergence of zaire ebola virus disease in Guinea, N. Engl. J. Med. 371 (2014) 1418–1425.

[4] G.M. Lyon, A.K. Mehta, J.B. Varkey, K. Brantly, L. Plyler, A.K. McElroy, et al. Clinical Care of Two Patients with Ebola Virus Disease in the United States November 12, (epub ahead of print) 2014. doi: 10.1056/nejmoa1409838.

[5] http://www.cdc.gov/vhf/ebola/treatment/ Last accessed on 5/10/2016. [6] D. Mohammadi, First trials for Ebola treatments announced, Lancet 384

(9957) (2014) 1833, http://dx.doi.org/10.1016/S0140-6736(14)62043-2. [7] H. Feldmann, S.M. Jones, K.M. Daddario-DiCaprio, J.B. Geisbert, U. Ströher, A.

Grolla, M. Bray, et al., Effective post-exposure treatment of Ebola infection, PLoS Pathog. 3 (January (1)) (2007) e2.

[8] W.Y. Choi, K.J. Hong, J.E. Hong, W.J. Lee, Progress of vaccine and drug development for Ebola preparedness, Clin. Exp. Vaccine Res. 4 (2015) 11–16, http://dx.doi.org/10.7774/cevr.2015.4.1.11.

[9] A. Marzi, H. Feldmann, Ebola virus vaccines: and overview of current approaches, Expert Rev. Vaccines 13 (4) (2014) 521–531, http://dx.doi.org/10. 1586/14760584.2014.885841.

10] A.M. Henao-Restrepo, I.M. Longini, M. Egger, N. Dean, W.J. Edmunds, A. Camacho, et al., Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial, Lancet 386 (2015) 857–866.

11] S.T. Agnandji, A. Huttner, M.E. Zinser, P. Njuguna, C. Dahike, J.F. Fernandes,

et al., Phase 1 trials of rVSV Ebola vaccine in Africa and Europe, NEJM 374 (2016) 1647–1660, http://dx.doi.org/10.1056/NEJMoa1502924 (Epub 2015 April 1).

12] J.A. Regules, J.H. Beigel, K.M. Paolino, J. Voell, A.R. Castellano, P.et al. Munoz, A recombinant vesicular stomatitis virus Ebola vaccine—preliminary report, NEJM (April) (2015).

[

l Virology 86 (2017) 5–13

13] C. Mire, D. Matassov, J. Geisbert, T.E. Latham, K.N. Agans, R. Xu, et al., Single-dose attenuated Vesiculovax vaccines protect primates against Ebola Makona virus, Nature (2015), http://dx.doi.org/10.1038/nature14428.

14] G. Wong, J.S. Richardson, S. Pillet, A. Patel, X. Qiu, J. Alimonti, et al., Immune parameters correlate with protection against ebola virus infection in rodents and nonhuman primates, Sci. Transl. Med. 4 (158) (2012) 158ra146, http://dx. doi.org/10.1126/scitranslmed.3004582.

15] T.C. Mast, L. Klerstead, S.B. Gupta, A.A. Nikas, E.G. Kallas, V. Novitsky, et al., International epidemiology of human pre-existing adenovirus (Ad) type-5, type-6, type-26 and type-36 neutralising antibodies: correlates of high Ad5 titers and implications for potential HIV vaccine trials, Vaccine 28 (4) (2010) 950–957, http://dx.doi.org/10.1016/j.vaccine.2009.10.145.

16] F.C. Zhu, L.H. Hou, J.X. Li, S.P. Wu, P. Liu, G.R. Zhang, et al., Safety and immunogenicity of a novel recombinant adenovirus type-5 vector-based Ebola vaccine in healthy adults in China: preliminary report of a randomised, double-blind, placebo-controlled, phase 1 trial, Lancet 385 (2015) 2272–2279, http://dx.doi.org/10.1016/S0140-6736(15)60553-0 (Epub 2015 March 25).

17] R. Steinbrook, One step forward, two steps back—will there ever be an AIDS vaccine, N. Engl. J. Med. 357 (2007) 2653–2655.

18] A. Flamming, HIV vaccine failure due to induction of immune suppressors? Nat. Rev. Drug Discov. (2014) 574–575, http://dx.doi.org/10.1038/nrd4398.

19] E.J. Kremer, P. Van de Perre, Ebola vaccines based on adenovirus vectors and risk of HIV, BMJ 350 (2015) h1307.

20] S. Lu, S. Wang, J.M. Grimmes-Serrano, Current progress of DNA vaccine studies in humans, Expert Rev. Vaccines 7 (2008) 175–191.

21] K. Ewer, T. Rampling, N. Venkatraman, G. Bowyer, D. Wright, T. Lambe, et al., A monovalent chimpanzee adenovirus Ebola vaccine boosted with MVA, N. Engl. J. Med. 374 (17) (2016) 1635–1646, http://dx.doi.org/10.1056/ NEJMoa1411627.

22] L. Lai, R. Davey, A. Beck, Emergency postexposure vaccination with vesicular stomatitis virus-vectored ebola vaccine after needlestick, JAMA 313 (12) (2015) 1249–1255, http://dx.doi.org/10.1001/jama.2015.1995.

23] S. Günther, H. Feldmann, T.W. Geisbert, L.E. Hensley, P.E. Rollin, S.T. Nichol, et al., Management of accidental exposure to Ebola virus in the biosafety level 4 laboratory, Hamburg, Germany, J. Infect. Dis. 204 (Suppl. 3) (2011) S785–S790.

24] Y. Tsuda, C.J. Parkins, P. Caposio, F. Feldmann, S. Botto, S. Ball, et al., A cytomegalovirus-based vaccine provides long-lasting protection against lethal Ebola virus challenge after a single dose, Vaccine 33 (2015) 2261–2266, http://dx.doi.org/10.1016/j.vaccine.2015.03.029.

25] K. Jonsson-Scmunk, M. Croyle, A long-lasting, single-dose nasal vaccine for Ebola: a practical armament for an outbreak with significant global impact, Expert Rev. Anti Infect. Ther. 13 (5) (2015) 527–530.

26] K. Mupapa, M. Massamba, K. Kibadi, K. Kuvula, A. Bwaka, M. Kipasa, et al., Treatment: of Ebola hemorrhagic fever with blood transfusions from convalescent patients. International Scientific and Technical Committee, J. Infect. Dis. 179 (Suppl. 1) (1999) S18–S23.

27] R.C. Baron, J.B. Mc Cormick, O.A. Tubeir, Ebola virus disease in Southern Sudan: hospital dissemination and intrafamilial spread, Bull. World Health Organ. 61 (1983) 997–1003.

28] J. Van Grienswen, T. Edwards, X. de Lamballerie, M.G. Semple, P. Gallian, S. Baize, et al., Evaluation of convalescent plasma for Ebola virus disease in Guinea, N. Engl. J. Med. 374 (2016) 33–42, http://dx.doi.org/10.1056/ NEJMoa1511812.

29] J. Luczkowiak, J.R. Arribas, S. Gomez, V. Jimenez-Yuste, F. de la Calle, A. Viejo, et al., Specific neutralizing response in plasma from convalescent petients of Ebola virus disease against the West Africa Makona variant of Ebola virus, Virus Res. 213 (2016) 224–229, http://dx.doi.org/10.1016/j.virusres.2015.12. 019.

30] J. Pettitt, L. Zeitlin, H. Kim do, C. Working, J.C. Johnson, O. Bohorov, et al., Therapeutic intervention of Ebola virus infection in rhesus macaques with the MB-003 monoclonal antibody cocktail, Sci. Transl. Med. 5 (2013) 199ra113, http://dx.doi.org/10.1126/scitranslmed.3006608.

31] X. Qiu, J. Audet, G. Wong, S. Pillet, A. Bello, T. Cabral, et al., Successful treatment: of ebola virus–infected cynomolgus macaques with monoclonal antibodies, Sci. Transl. Med. (2012) 1138ra81, http://dx.doi.org/10.1126/ scitranslmed.3003876.

32] X. Qiu, G. Wong, L. Fernando, J. Audet, A. Bello, J. Strong, et al., MAbs and ad-vectored IFN-a therapy rescue ebola-infected nonhuman primates when administered after the detection of viremia and symptoms, Sci. Transl. Med. 5 (2013) 207ra143, http://dx.doi.org/10.1126/scitranslmed.3006605.

33] S.D. Dowall, V.A. Graham, K. Corbin-Lickfett, C. Empig, K. Schlunegger, C.B. Bruce, et al., Effective binding of a phosphatidylserine-targeting antibody to ebola virus infected cells and purified virions, J. Immunol. Res. (2015) 9, http://dx.doi.org/10.1155/2015/347903 (Article ID 347903).

34] L. Oestereich, A. Lüdtke, S. Wurr, T. Rieger, C. Muñoz-Fontela, S. Günther, Successful treatment of advanced Ebola virus infection with T-705 (favipiravir) in a small animal model, Antiviral Res. 105 (2014) 17–21.

35] D. Sissoko, C. Laouenan, E. Folkesson, A.-B. M’Lebing, A.-H. Beavogui, S. Baize, et al., Experimental treatment: with favipiravir for ebola virus disease (the

JIKI trial): a historically controlled, single-arm proof-of-concept trial in Guinea, PLoS Med. 13 (3) (2016) e1001967, http://dx.doi.org/10.1371/journal. pmed.1001967.

36] N. Bouazza, J.-M. Treluyer, F. Foissac, F. Mentré, A.-M. Taburet, J. Guedj, et al., Favipiravir for children with Ebola, Lancet 385 (2015) 603–604, http://dx.doi. org/10.1016/s0140-6736(15)60232-x.

Clinica

[

G. de Heer, S. Kluge, et al. A case of severe Ebola virus infection complicated by gram-negative septicemia, NEJM (2014), 371 (25) 2394–2401. 10.1056/NEJMoa1411677.

[44] J. Parra, O. Salmeron, M. Velasco. The first case of ebola virus disease acquired outside africa NEJM (2014), 371, 2439–2440.

M.A. Trad et al. / Journal of

37] T.W. Geisbert, A.C. Lee, M. Robbins, J.B. Geisbert, A.N. Honko, V. Sood, et al., Postexposure protection of non-human primates against a lethal Ebola virus challenge with RNA interference: a proof-of-concept study, Lancet 375 (2010) 1896–1905.

38] T.K. Warren, K.L. Warfield, J. Wells, D.L. Swenson, K.S. Donner, S.A. Van Tongeren, et al., Advanced antisense therapies for postexposure protection against lethal filovirus infections, Nat. Med. 16 (September (9)) (2010) 991–994, http://dx.doi.org/10.1038/nm.2202.

39] D.F. Florescu, M.A. Keck, Development of CMX001 (Brincidofovir) for the treatment of serious diseases or conditions caused by dsDNA viruses, Expert Rev. Anti Infect. Ther. 12 (October (10)) (2014) 1171–1178, http://dx.doi.org/ 10.1586/14787210.2014.948847.

40] T.K. Warren, J. Wells, R.G. Panchal, K.S. Stuthman, N.L. Garza, S.A. Van Togeren, et al., Protection against filovirus diseases by a novel broad-spectrum nucleoside analogue BCX4430, Nature 508 (2014) 402–405.

41] D.F. Florescu, A.C. Kalil, A.L. Hewlett, A.J. Schuh, U. Stroher, T.M. Uyeki, et al., Administration of Brincidofovir and convalescent plasma in a patient with Ebola virus disease, Clin. Infect. Dis. 61 (6) (2015) 969–973, http://dx.doi.org/ 10.1093/cid/civ395.

42] T. Wolf, G. Kann, S. Becker, C. Stephan, H.R. Brodt, P. de Leuw, et al., Severe Ebola virus disease with vascular leakage and multiorgan failure: treatment of a patient in intensive care, Lancet (December) (2014) 62384–62389, http:// dx.doi.org/10.1016/s0140-6736(14)62384-9, pii: S0140-6736(14)62384.

45] M.A. Lópaz, C. Amela, M. Ordobas, M.F. Domínguez-Berjón, C. Álvarez, M. Martínez, et al., First secondary case of Ebola outside Africa: epidemiological characteristics and contact monitoring, Spain,S eptember to November 2014, Euro Surveill. 20 (1) (2015), pii=21003.

46] N.J. Sullivan, T.W. Geisbert, J.B. Geisbert, L. Xu, Z. Yang, M. Roederer, et al., Accelerated vaccination for Ebola virus haemorrhagic fever in non-human primates, Nature 424 (2003) 681–684.

47] D.A. Stanley, A.N. Honko, C. Asiedu, J.C. Trefry, A.W. Lau-Kilby, J.C. Johnson, et al., Chimpanzee adenovirus vaccine generates acute and durable protective immunity against ebolavirus challenge, Nat. Med. 20 (October (10)) (2014) 1126–1129, http://dx.doi.org/10.1038/nm.3702.

48] N. Thomas, Novavax Study to evaluate the immunogenicity and safety of an Ebola virus glycoprotein vaccine in healthy subjects. In: ClinicalTrials.gov [internet] Bethesda (MD): National Library of Medicine (US). 2000- [cited 2016 Jun 8]. Available from: http://clinicaltrials.gov/show/NCT02370589. NLM Study identifier: NCT02370589.

49] J.M. Dye, A.S. Herbert, A.I. Kuehne, J.F. Barth, M.A. Muhammad, S.E. Zak, et al., Postexposure antibody prophylaxis protects nonhuman primates from filovirus disease, PNAS 109 (13) (2012) 5034–5039, http://dx.doi.org/10.1073/ pnas.1200409109.

50] G.G. Olinger Jr., J. Pettitt, D. Kim, C. Working, O. Bohorov, B. Bratcher, et al., Delayed treatment of Ebola virus infection with plant-derived monoclonal antibodies provides protection in rhesus macaques, Proc. Natl. Acad. Sci. U. S. A. 109 (October (44)) (2012) 18030–18035, http://dx.doi.org/10.1073/pnas. 1213709109.

51] Liberia-U.S. Clinical Research Partnership Opens Trial to Test Ebola Treatments http://www.niaid.nih.gov/news/newsreleases/2015/Pages/ ZMapp.aspx (accessed 27.02.15).

52] D.J. Shedlock, M.A. Bailey, P.M. Popernack, J.M. Cunningham, D.R. Burton, N.J. Sullivan, Antibody mediated neutralization of ebola virus can occur by 2 distinct mechanisms, Virology 401 (2) (2010) 228–235, http://dx.doi.org/10. 1016/j.virol.2010.02.029.

53] http://hfv.lanl.gov/content/sequence/HFV/ToolsOutline.html (accessed 04.03.16).

54] E. Gignoux, A.S. Azman, M. de Smet, P. Azuma, M. Massaquoi, D. Job, et al., Effects of Artesunate-Amodiaquine on mortality related to Ebola virus

disease, N. Engl. J. Med. 374 (1) (2016) 23–32, http://dx.doi.org/10.1056/ NEJMoa1504605.

55] B.S. Cooper, M.F. Boni, W. Pan-ngum, N.P.J. Day, P.W. Horby, P. Olliaro, et al., Evaluating clinical trial designs for investigational treatments of ebola virus disease, PLoS Med. 12 (4) (2015) e1001815, http://dx.doi.org/10.1371/journal. pmed.1001815.

l Virology 86 (2017) 5–13 13

56] N. Petrosillo, E. Nicastri, S. Lanini, M.R. Capobianchi, A. Di Caro, M. Antonini, et al., Ebola virus disease complicated with viral interstitial pneumonia: a case report, BMC Infect. Dis. 15 (2015) 432, http://dx.doi.org/10.1186/s12879- 015-1169.

57] A.C. Shurtleff, C.A. Whitehouse, M.D. Ward, L.H. Cazares, S. Bavari, Pre-symptomatic diagnosis and treatment of filovirus diseases, Front Microbiol. 6 (108) (2015), http://dx.doi.org/10.3389/fmicb.2015.00108 (Published onlineFebruary 20).

58] C.S. Kraft, A.L. Hewlett, S. Koepsell, A.M. Winkler, C.J. Kratichvil, L. Larson, et al., The use of TKM-100802 and convalescent plasma in 2 patients with Ebola virus disease in the United States, Clin. Infect. Dis. 61 (4) (2015) 496–502, http://dx.doi.org/10.1093/cid/civ334.

59] K. Wong, C. Perdue, J. Malia, J.L. Kenney, S. Peng, J.K. Gwathney, et al., Supportive care of the first 2 Ebola virus disease patients at the monrovia medical unit, Clin. Infect. Dis. 61 (7) (2015) e47–e51, http://dx.doi.org/10. 1093/cid/civ420 (first ublished online May 28, 2015).

60] M.K. O’shea, K.A. Clay, D.G. Craig, A.J. Moore, S. Lewis, M. Espina, et al., Case report a health care worker with Ebola virus disease and adverse prognostic factors treated in Sierra Leone, Am. J. Trop. Med. Hyg. (2016), http://dx.doi. org/10.4269/ajtmh.15-0461 (Published online February 22, 2016).

61] J. Cotte, P.Y. Cordier, J. Bordes, F. Janvier, P. Esnault, E. Kaiser, et al., Fluid resuscitation in Ebola Virus Disease: a comparison of peripheral and central venous accesses, Anaesth. Crit. Care Pain Med. 34 (December (6)) (2015) 317–320, http://dx.doi.org/10.1016/j.accpm.2015.06.010 (Epub 2015 Nov 2).

62] D.K. Evans, M. Goldstein, A. Popova, Health-care worker mortality and the legacy of the Ebola epidemic, Lancet Global Health 3 (8) (2015) e439–40, http://dx.doi.org/10.1016/S2214-109X(15)00065-0.

63] http://www.nbcdfw.com/news/health/Ebola-Patient-Dr-Kent-Brantly-to- Leave-Hospital-Thursday-272102161.html (Last accessed 06.07.16).

64] A. Tiffany, P. Vetter, J. Mattia, J.A. Dayer, M. Bartsch, M. Kasztura, et al., Ebola virus disease complications as experienced by survivors in Sierra Leone, Clin. Infect. Dis. 21 (2016), http://dx.doi.org/10.1093/cid/ciw158 (first published online March).

65] M.S. Sow, J.F. Etard, S. Baize, N. Magassouba, O. Faye, P. Msellati, et al., New evidence of long-lasting persistence of Ebola virus genetic material in semen of survivors, J. Infect. Dis. (May) (2016) (Pii:jiw078. [Epub ahead of print]).

66] www.who.int/csr/research-and-development/blueprint/en (Last accessed on 03.10.16).

67] www.who.int/csr/resources/publications/ebola/report-by-panel.pdf?ua=1 (Last accessed 03.10.16).

68] E. Davidson, C. Bryan, R.H. Fong, T. Barnes, J.M. Pfaff, J.B. Rucker, et al., Mechanism of binding to Ebola virus glycoprotein by the ZMapp, ZMAb, and MB-003 cocktail antibodies, J. Virol. 89 (21) (2015) 10982–10992, http://dx. doi.org/10.1128/JVI.01490-15.

69] A.G. Baranovskiy, N.D. Babayeva, Y. Suwa, J. Gu, Y.I. Pavlov, T.H. Tahirov, Structural basis for inhibition of DNA replication by aphidicolin, Nucleic Acids Res. 42 (December (22)) (2014) 14013–14021.