Longitudinal antibody and T cell responses in Ebola virus disease survivors and contacts: an observational cohort study.

BACKGROUND: The 2013-16 Ebola virus disease epidemic in west Africa caused international alarm due to its rapid and extensive spread resulting in a significant death toll and social unrest within the affected region. The large number of cases provided an opportunity to study the long-term kinetics of Zaire ebolavirus-specific immune response of survivors in addition to known contacts of those infected with the virus. METHODS: In this observational cohort study, we worked with leaders of Ebola virus disease survivor associations in two regions of Guinea, Guéckédou and Coyah, to recruit survivors of Ebola virus disease, contacts from households of individuals known to have had Ebola virus disease, and individuals who were not knowingly associated with infected individuals or had not had Ebola virus disease symptoms to serve as negative controls. We did Zaire ebolavirus glycoprotein-specific T cell analysis on peripheral blood mononuclear cells (PBMCs) on location in Guinea and transported plasma and PBMCs back to Europe for antibody quantification by ELISA, functional neutralising antibody analysis using live Zaire ebolavirus, and T cell phenotype studies. We report on the longitudinal cellular and humoral response among Ebola virus disease survivors and highlight potentially paucisymptomatic infection. FINDINGS: We recruited 117 survivors of Ebola virus disease, 66 contacts, and 23 negative controls. The mean neutralising antibody titre among the Ebola virus disease survivors 3-14 months after infection was 1/174 (95% CI 1/136-1/223). Individual results varied greatly from 1/10 to more than 1/1000 but were on average ten times greater than that induced after 1 month by single dose Ebola virus vaccines. Following reactivation with glycoprotein peptide, the mean T cell responses among 116 Ebola virus disease survivors as measured by ELISpot was 305 spot-forming units (95% CI 257-353). The dominant CD8+ polyfunctional T cell phenotype, as measured among 53 Ebola virus disease survivors, was interferon γ+, tumour necrosis factor+, interleukin-2-, and the mean response was 0·046% of total CD8+ T cells (95% CI 0·021-0·071). Additionally, both neutralising antibody and T cell responses were detected in six (9%) of 66 Ebola virus disease contacts. We also noted that four (3%) of 117 individuals with Ebola virus disease infections did not have circulating Ebola virus-specific antibodies 3 months after infection. INTERPRETATION: The continuous high titre of neutralising antibodies and increased T cell response might support the concept of long-term protective immunity in survivors. The existence of antibody and T cell responses in contacts of individuals with Ebola virus disease adds further evidence to the existence of sub-clinical Ebola virus infection. FUNDING: US Food & Drug Administration, Horizon 2020 EU EVIDENT, Wellcome, UK Department for International Development. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Nurses' experiences of their decision-making process when participating in clinical trials during the 2014-2016 West African Ebola crisis.

OBJECTIVE: Due to the absence of a licenced vaccine or drug for treatment of Ebola patients during the 2014-2016 West Africa outbreak, frontline nurses were at increased risk of exposure. Hence, they were prioritized to participate in clinical trials to receive experimental therapeutics. To our knowledge no study has explored the nurses' experiences of their decision-making process when volunteering in clinical trials using unproven agents, which is the purpose of this qualitative study. METHODS: This study, part of a larger Ebola study, thematically analyzed the interview data of nine nurses recruited from Sierra Leone, Guinea and Liberia; of which four joined a convalescent plasma trial and five a vaccine trial. RESULTS: In their decision-making process to partake in a clinical trial, nurses identified two distinct decision points: the initial commitment followed by the point of no return when they presented themselves to participate. Each of these decisions were influenced by risk versus benefits calculations, and contextual factors. CONCLUSION: Results showed the need for more health education and communication around the unproven agents in order for nurses to make informed decisions.

Dying in honour: experiences of end-of-life palliative care during the 2013-2016 Ebola outbreak in Guinea.

With no cure and a high mortality rate, Ebola virus disease (EVD) outbreaks require preparedness for the provision of end-of-life palliative care. This qualitative study is part of a larger project on palliative care in humanitarian contexts. Its goal was to document and deepen understanding of experiences and expectations related to end-of-life palliative care for patients infected with Ebola virus disease (EVD) in West African Ebola treatment centres (ETCs) during the 2013-2016 epidemic. It consisted of 15 in-depth semi-structured interviews with individuals impacted by EVD in a Guinean ETC: either as patients in an ETC, healthcare providers, healthcare providers who were also EVD patients at one point, family relations who visited patients who died in an ETC, or providers of spiritual support to patients and family. Analysis was team based and applied an interpretive descriptive approach. Healthcare delivery in humanitarian emergencies must remain respectful of patient preferences but also local and contextual values and norms. Of key importance in the Guinean context is the culturally valued experience of "dying in honour". This involves accompaniment to facilitate a peaceful death, the possibility of passing on final messages to family members, prayer, and particular practices to enact respect for the bodies of the deceased. Participants emphasized several challenges to such death in Ebola treatment centres (ETCs), as well as practices they deemed helpful to alleviating dying patients' suffering. An overarching message in participants' accounts was that ideally more would have been done for the dying in ETCs. Building on participants' accounts, we outline a number of considerations for optimizing end-of-life palliative care during current and future public health emergencies, including for COVID-19.

COVID-19 in sub-Saharan Africa: impacts on vulnerable populations and sustaining home-grown solutions.

This commentary draws on sub-Saharan African health researchers' accounts of their countries' responses to control the spread of COVID-19, including social and health impacts, home-grown solutions, and gaps in knowledge. Limited human and material resources for infection control and lack of understanding or appreciation by the government of the realities of vulnerable populations have contributed to failed interventions to curb transmission, and further deepened inequalities. Some governments have adapted or limited lockdowns due to the negative impacts on livelihoods and taken specific measures to minimize the impact on the most vulnerable citizens. However, these measures may not reach the majority of the poor. Yet, African countries' responses to COVID-19 have also included a range of innovations, including diversification of local businesses to produce personal protective equipment, disinfectants, test kits, etc., which may expand domestic manufacturing capabilities and deepen self-reliance. African and high-income governments, donors, non-governmental organizations, and businesses should work to strengthen existing health system capacity and back African-led business. Social scientific understandings of public perceptions, their interactions with COVID-19 control measures, and studies on promising clinical interventions are needed. However, a decolonizing response to COVID-19 must include explicit and meaningful commitments to sharing the power-the authority and resources-to study and endorse solutions.

Sex practices and awareness of Ebola virus disease among male survivors and their partners in Guinea.

INTRODUCTION: Towards the end of the 2013-2016 West African outbreak, sexually-transmitted Ebola virus re-emerged from Ebola virus disease (EVD) survivors in all three hardest hit countries. We explore sex practices and awareness of the risk of Ebola virus transmission among EVD survivors and their partners. METHODS: In this cross-sectional study, we recruited a convenience sample of study participants aged >15 years who were male EVD survivors, their sexual partners and a comparison group. We administered a questionnaire to all respondents, estimated self-reported sexual practices and risk awareness and conducted in-depth interviews. RESULTS: We recruited 234 EVD survivors, 256 sexual partners of survivors and 65 individuals in the comparison group from five prefectures in Guinea. The prevalence of safe sexual behaviour (regular condom use or sexual abstinence >12 months) and regular condom use in EVD survivors was 38% (95% CI 31% to 44%) and 21% (95% CI 16% to 27%), respectively. Among partners, these prevalences were lower (11%, 95% CI 7% to 15% and 9%, 95% CI 5% to 12%, respectively). EVD survivors were more than five times as likely to engage in safe sexual behaviour compared with the comparison group (aOR 5.59, 95% CI 2.36 to 13.2). One-hundred and thirty one EVD survivors (57%) and 94 partners (37%) were aware of the risk of Ebola virus re-emergence associated with having unsafe sex. Partners who reported not being informed by their husband/boyfriend (EVD survivor) were more likely to be unaware of this risk (aOR 20.5, 95% CI 8.92 to 47.4). CONCLUSIONS: We disclose here a need to improve knowledge of the disease and close the gap between knowledge and practice found in EVD survivors and their partners. Current and future survivors' follow-up programmes should include partners and be more effective at communicating sex-related risks. Community-level fears and attitudes that enable stigmatisation should be addressed. Safe sex interventions targeting EVD survivors and their partners should be prioritised.