Wednesday, March 02, 2016

WHO: Revised Crtical Care For Ebola Survivors


It has become increasingly apparent that many - perhaps even most - of the Ebola survivors in West Africa continue to suffer from a variety of chronic post-Ebola ailments, and that the virus may persist in some organs and bodily fluids (i.e. semen, breast milk, etc.) for months (see ECDC On Ebola Persistence & Rapid Risk Assessment).

A recent EID Journal research article  Post-Ebola Syndrome, Sierra Leone followed 44 survivors from a single ETU (Emergency Treatment Unit) and found:

Thousands of persons have survived Ebola virus disease. Almost all survivors describe symptoms that persist or develop after hospital discharge. A cross-sectional survey of the symptoms of all survivors from the Ebola treatment unit (ETU) at 34th Regimental Military Hospital, Freetown, Sierra Leone (MH34), was conducted after discharge at their initial follow-up appointment within 3 weeks after their second negative PCR result. From its opening on December 1, 2014, through March 31, 2015, the MH34 ETU treated 84 persons (8–70 years of age) with PCR-confirmed Ebola virus disease, of whom 44 survived.
Survivors reported musculoskeletal pain (70%), headache (48%), and ocular problems (14%). Those who reported headache had had lower admission cycle threshold Ebola PCR than did those who did not (p less than 0.03). This complete survivor cohort from 1 ETU enables analysis of the proportion of symptoms of post-Ebola syndrome. The Ebola epidemic is waning, but the effects of the disease will remain.

The World Health Organization has released a revised interim guidance document addressing these issues.  Of note are new recommendations for nursing mothers to have their breast milk tested.

Due to the possible risk of virus persistence in breast milk, EVD survivors who are lactating are encouraged to have their breast milk tested for Ebola virus by RT-PCR. Women who do not know the status of their breast milk or who were tested and for whom no Ebola virus RNA was detected should continue breastfeeding. If Ebola virus RNA is detected, breastfeeding should be suspended and the breast milk retested every 48 hours until two consecutive “undetected” results are obtained

Regarding possible relapse, as we've seen with Scottish nurse Paula Cafferkey, the document advises:

Relapse due to persistent virus and evaluation of new onset fever EVD survivors readily clear Ebola virus from the blood as the acute symptoms resolve but the virus may persist for months, and in some cases perhaps up to a year or more, in body sites that are harder for the immune system to reach (‘immunologically privileged sites’). These sites include the inside of the eye, the central nervous system (brain and spinal cord), testes and the mammary gland. In women who have been infected while pregnant, the virus may persist in the fetus, amniotic fluid, and placenta (27-30). 

Although arthralgia is very common in EVD survivors, it is unknown whether Ebola  virus persists in the joints. There is presently no evidence that women who become pregnant after they have recovered from EVD run the risk of persistent Ebola virus infection in the developing pregnancy (fetus, amniotic fluid, or placenta). For women who become pregnant after they have have recover from EVD tests of possible Ebola virus RNA persistence in breast milk are ongoing (see below).

Although considered rare, relapse due to EVD has been reported. In one case, a survivor developed meningitis nine months after recovery from acute EVD. Ebola virus was detected by RT-PCR in the CSF and at a lower lever in the blood, which was thought to represent “leakage” from the active replication in the central nervous system.

Follow the link below to download the full document.

Clinical care for survivors of Ebola virus disease

Interim guidance


Publication details

Number of pages: 31 Publication date: February 2016 Languages: English WHO reference number: WHO Ref: WHO/EVD/OHE/PED/16.1.rev1



Today, there are over 10 000 survivors of Ebola virus disease. A number of medical problems have been reported in survivors, including mental health issues. Ebola virus may persist in some body fluids, including semen. Ebola survivors need comprehensive support for the medical and psychosocial challenges they face and also to minimize the risk of continued Ebola virus transmission.
WHO has developed this document to guide health services on how to provide quality care to survivors of Ebola virus disease. Table of contents include:
  • Introduction
  • Planning follow-up of the Ebola survivor
  • Common sequelae of Ebola virus disease and recommended evaluation and clinical management
  • Considerations for special populations
  • Monitoring for persistent Ebola virus infection in survivors: guidelines for testing and counselling
  • Infection prevention and control considerations in survivors
  • Risk communication considerations.