Ebola: Virology and Epidemiology

Raymond Charles Sanders Ph.D.*

(*Scientist, Expanded Programme in Epidemiology, World Health Organization, Western Pacific Regional Office,
Manila Philippines. Presented during the PSMID Organized Post-Graduate Course, 23rd International Congress in
Internal Medicine, PICC, Manila Philippines)

ABSTRACT
Since the 1976 Zaire and Sudan epidemic, extensive studies of the Ebola virus have been made This virus
was morphologically identical to Marburg Virus; the cause of deadly outbreaks of hemorrhagic fever in Germany and
Yugoslavia in 1967, but serologically distinct. Because of their unique filamentous form, these viruses have been
placed in a separate family, the Filoviridae with one genus, Filovirus. While viral replication is similar to that of other
negative-stranded RNA viruses containing a monopartite genome, the mode of entry of the Ebola virus into ceils
remains unknown. Laboratory studies on filoviruses present an extreme biohazard and should be conducted only under
high, containment conditions. Antibodies (IgG and IgM) to the Ebola virus, originally detected by
immunofluorescence, are now more routinely detected. ELISA, and viral RNA by by reverse transcriptase-polymerase
chain reaction.
Small self-limiting Ebola outbreaks recurred in Sudan in 1979, in the same area as the 1976 outbrea and more
reently in Kikwit last April 1995. All attempts to trace the virus source from all the index cases, however, have failed to
uncover a reservoir. Whatever the original source, person-to-person transmission is the :means by which outbreaks and
epidemics progress. In all episodes, isolation of patienys and the use of barrier nursing procedures, including the use of
protective clothing and repirators, have been sufficient to interrupt transmission. [Phil J Microbiol Infect Dis 1996;
25(1):S4-S7]
Key Words: Ebola virus, filoviridae, filovirus epidemics

Background
Deadly outbreaks of haemorrhagic fever in Germany and Yugoslavia in 1967 marked the
introduction of a new group of viruses to the world medica1 and scientific community. The
outbreaks occurred among laboratory workers processing kidney tissue from African green
monkeys (Cercopithecus aethiops) that had been trapped in Uganda, and in medical personnel
who attending the laboratory workers when they became ill. In all there were 91 cases recorded,
with 7 deaths. A virus, morphologically unique and antigenically unrelated to any know human
pathogen, was isolated from blood and tissues of patients. This virus was named Marburg virus
after the city in Germany where it was first characterized. Many of the monkeys from the
shipment from Uganda, identified as the source of the outbreak, died of haemorrhagic disease,
and all African green monkeys experimentally inoculated with the virus died. Attempts to find
evidence of natural infection in monkey populations in Uganda, however, drew a blank,
suggesting that these monkeys were not the reservoir host of the virus.
The first recognised outbreak of Marburg disease in Africa occurred in South Africa in
1975, the index case of which had been travelling in Zimbabwe shortly before becoming ill. An
investigation of the travel route was made, but no source of the virus was discovered. Sporadic
cases have also been reported from Kenya and Zimbabwe. Again, studies in the areas were the
cases occurred failed to uncover the source of the virus.
In 1976, epidemics of severe haemorrhagic fever occurred simultaneously in Zaire and
Sudan. There were more than 550 cases and 430 deaths. A virus, Ebola virus, named after a small
river in Zaire, was isolated from patients in both countries. This virus was morphologitally
identical to Marburg virus, but serological distinct. The estimated case-fatality rate was over 50%
in Sudan, and more than 80% in Zaire. However, secondary and tertiary cases had lower casefatality rates, suggesting some attenuation of virulence with human-to-human passage. Small self-

limiting outbreaks recurred in Sudan in 1979, in the same area as the 1976 outbreak. There was
no evidence that primates were involved in any of the outbreaks in Sudan or Zaire.
In April 1995, in the city of Kikwit in south-western Zaire, a laboratory worker was
admitted to Kikwit General Hospital with abdominal distension which had developed after a
protracted fever. Within 6 days the patient was dead, and the 1995 Kikwit Ebola outbreak had
begun. By the beginning of July, 315 cases had been recorded, of which 244 (77%) died. The
International Scientific and Technical Commission, set up to contain and control the Kikwit
Ebola outbreak, provided very rapid mobilization of technical expertise and resources, and
became a now celebrated model of effective international collaboration. During the outbreak and
in subsequent studies, field, teams captured and collected more than 3000 birds and mammals,
and several thousands of possible insect vectors. As yet, however, no reservoir host for the virus
has been detected.
Initial studies on these viruses suggested that they may belong in the family
Rhabdoviridae, the family that contains the rabies virus. Later studies have disclosed their unique
nature, and the viruses have been placed in a separate family, the Filoviridae, with one genus,
Filovirus. Membership of this genus includes Marburg virus, and at least 2 subtypes of Ebola
virus. There is no antigenic cross-reactivity between Marburg and Ebola viruses, but the subtypes
of Ebola have both common and unique antigenic characteristics.
Virology
In their natural state, Ebola viruses appear either as long filamentous forms, hence the
name Filovirus, or as shorter "U"-shaped, "6"-shaped or circular forms. The filamentous forms
vary in length (up to 14,000 nm), but the length associated with peak infectivity appears to be
around 970 nm. The filaments have a uniform diameter of 80 nm. They are composed of a helical
nucleocapsid (50 nm in diameter, with an axial space 20 nm in diameter and a helical periodicity
of about 5 nm), an envelope composed of material derived from host-cell plasma membrane, and
a surface layer with 10-nm-long glycoprotein projections studded out of it. Ebola virions contain
one molecule of non-infectious, linear, negative-sense, single -stranded RNA and seven
polypeptides.
Viral replication is similar to that of other negative-stranded RNA viruses containing a
monopartite genome, such as rhabdovimses and paramyxoviruses, Proteins are produced via a
monocistronic, polyadenylated mRNA molecule. As in the rhabdoviruses and inparamyxoviruses,
the gene closest to the 3' end encodes of the major nucleoprotein.
The mode of entry of the virus into cells remains unknown. Infection occurs in the
presence of antibody, and no neutralizing antibodies have yet been demonstrated. Uncoating is
presumed to occur in a manner similar to that of other negative-strand RNA viruses. Messenger
RNA can be detected in infected cells, but virion RNA is not detectable. This means that genomic
RNA is packaged very rapidly after transcription, and that nucleocapsids are rapidly released
from the cell.
Tissue culture-adapted strains of Ebola produce a striking cytopathic effect in culture,
intracytoplasmic vesiculation and mitochondrial swelling are followed by breakdown of
organelles and terminal cytoplasmic rarification or condensation. These cytoplasmic changes
occur at the same time as accumulation of massive amounts of viral nucleocapsid protein in
intracytoplaspamic inclusion bodies. Assembled nucleocapsids bud through the plasma
membrane, acquiring an envelope of membrane-derived material on the way.
Ebola virus infectivity is quite stable at room temperature (20C) but is destroyed in 30
minutes at 60C. Infectivity is also destroyed by ultraviolet and gamma irradiation, lipid solvents,
b-propiolactone, and commercial hypochlorite and phenolic disinfectants.
Laboratory studies on filoviruses present an extreme biohazard and should be conducted
only under high-containment conditions. Specimens for virus isolation and serology must be

regards as potentially infectious and laboratory diagnosis of these infections can only be carried
out in specialized laboratories equipped to handie them. Antibodies to Ebola virus, both IgG and
IgM, were originally detected by immunofluorescence, but are now more routinely detected by
ELISA. Viral antigen can be detected by ELISA, and viral RNA by reverse transcriptionpolymerase chain reaction.
Epidemiology
The origin in nature and the natural history of Ebola virus remain a mystery. It appears
that the viruses are zoonotic, i.e. that they are transmitted to humans from discrete life cylces in
animals or insects. All attempts to trace the virus source from outbreak index cases, however,
have failed to uncover a reservoir. Whatever the original source, person-to-person transmission is
the means by which outbreaks and epidemics progress. This involves direct contact with infected
blood, secretions, organs or semen. Hospital-acquired infections have been frequent, and many
health care workers have been infected while attending patients. Transmission also occurs
through preparation of the dead for burial. In the 1976 Zairian Ebola epidemic, many cases could
be linked to the use of contaminated syringes and needles.
During epidemiological investigations of the 1995 Kikwit outbreak, several chains of
deaths, one involving 7 out of 12 persons living in the same household, were identified and traced
retrospectively back as far as late December 1994. Active surveillance has shown that the first
case clearly related to the outbreak had an onset of disease on 6 January 1995.
The first case at Kikwit General Hospital was admitted on 9 April. He had previously
been admitted to another hospital in Kikwit with a differential diagnosis of typhoid fever with
intestinal perforation. A laparotomy was performed on the patient at Kikwit General Hospital on
10 April. Three days later, on 14 April, the patient died. Medical personnel who had taken care of
this patient, either in the operating theatre or in the hospital wards, became ill with fever starting
14 April. About three-quarters of the first 70 patients in the epidemic appear to have been health
workers, and the case fatality-rate was very high in the group.
In this outbreak, at least four generations of cases can be distinguished. The first
generation was made up of the spouses, other relatives and close friends of those infected at the
hospital, infected either during patient care or preparation of bodies for burial. Persons in the
second and third generations of cases were other relatives and friends of the first generation who
were infected in a similar manner. Fourth generation cases were those who tended the second and
third generation cases. By the middle of May, persons with suspected infection were being
isolated in their homes and transmission was minimized. After this time most of the transmission
was contained within the household, and the fourth generation of cases were mostly infected
through household contact.
In all episodes, isolation of patients and the use of barrier nursing procedures, including
the use of protective clothing and respirators, have been sufficient to interrupt transmission.
Although aerosol transmission has not been implicated in outbreaks to date, it cannot be totally
discounted. Until we know more about these viruses it remains possible that aerosol transmission
plays, or could play, some part in their natural history.
Although no non-human primates have been implicated in known outbreaks of Ebola
haemorrhagic fever in humans, they are susceptible to infection. Ebola -related filoviruses were
isolated from cynomolgus monkeys (Macaca fascicula ris) imported into the United States of
America from the Philippines in 1989. Although seroconversion occurred in 4 animal handlers,
there was no evidence of clinical illness. The monkeys, however, were severely ill and many
died. There have been recent reports of an Ebola outbreak among wild chimpanzees in a forest
area of the Ivory Coast. A zoologist investigating the outbreak, and who carried out post-mortem
investigations on dead chimpanzees, became infected but recovered. This is the first clear
documentation of a monfilovirus infection in wild primates. There is, however, no indication of

where the infection originated. The obvious susceptibility of the chimpanzees makes them
unlikely candidates for natural reservoirs of the virus.
Approaches for minimizing the spread of Ebola virus in outbreak situations in Africa
have been published and are now widely circulated. Clear instructions on how to establish active
surveillance, contact tracing and medical surveillance are also available. As the recent outbreak in
Zaire has demonstrated, it is possible to mount a rapid international response to reported
outbreaks, and to effectively contain and control them. Ecological control, however, aimed at
preventing the sporadic human cases that start outbreaks and epidemics, is impossible without an
understanding of the natural history of the viruses. Hopefully the massive international scientific
effort that has been mounted in the wake of the Kikwit outbreak will provide .that understanding.
Key references
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2. Murphy FA, Kiley MP, Fisher-HochS. Filoviridae. Marburg and Ebola Viruses. In: Fields BN, Knipe DM, et.al., ed. Virology,
second edition. NewYork;RavenPress, 1990.
3. Peters CJ, et al. Filoviruses. In: Morse SS, ed. Emerging Diseases. New York; Oxford University Press, 1993.
4. World Health Organization. Ebola haemorrhagic fever. Weekly Epidemiol Rec 1995; 70:147-148.
5. World Health Organization. Ebola haemorrhagic fever. Weekly Epidemiol Rec 1995; 70:14-151.
6. WorldHealthOrganization. Ebola haemorrhagic fever. Weekly Epidemiol Rec 1995; 70:261-242.
7. World Health Organization. Viral haemorrhagic fever. Management of suspected cases. Weekly Epidemiol Rec1995; 70:24252.