EbolainContext:NovelInsightsintotheTransmission,Prevention,andTreatmentofEbolaVirusDiseaseandTheirClinicalImplications.StevenWang,10390391Supervisor:Dr.A.C.vanderKuyl(AMC-UvA)AmsterdamUniversityCollegeUvA•VU

CapstoneOralPresentation

BACKGROUND&CONTEXT

§  2014EVDOutbreakinWestAfrica§  TheHistoryofEVD1976-2015§  KnowledgeGap&CapstoneObjecTves

WHOEbolaSitua.onReportAsof10May2015

26,759TotalEVDCases

11,080TotalEVDDeaths

9CountriesAffectedGuinea,Liberia,SierraLeoneMali,Nigeria,Senegal,Spain,

UnitedKingdom,andUnitedStates

42DaysNoNewCasesEndofanEVDOutbreak(WHO)

20October2014NigeriaEbolaFree

October2014

Present

7October2014SenegalEbolaFree

9May2015LiberiaEbolaFree

18January2015MaliEbolaFree

10March2015UnitedKingdomEbolaFree

December2014UnitedStatesEbolaFree

2December2014SpainEbolaFree

Whowasthe‘Pa.entZero’?§  PhylogeneTcanalysis:atoddlerfromavillageinGuineawho

contractedthevirusfromabat,followedbyhuman-to-humantransmission.NewEnglandJournalofMedicine

§  Anthropological,ecological,andgeneTcanalysis:a2-yearoldboyinMeliandou,Guineacontractedthevirusfromabat.EMBOMolecularMedicine

Guinea

CurrentSituation

WHO,2015.CDC,2015.

23March2014NewEVDOutbreakConfirmedbytheWorldHealthOrganizaTon

8August2014PublicHealthEpidemicof

InternaTonalConcern(PHEIC)

CDC,2015.hbp://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html

CapstoneObjectives

KnowledgeGap2014EVDoutbreakinWestAfricahassTmulatedasignificantamountofresearchonebolavirus(pathophysiology,transmission,andtreatment).

CapstoneObjec.vesToreviewandintegraterecentresearchandknowledgeonebolavirus;togivenovelinsightsintotheebolaviruspathophysiology,transmission,

prevenTon,andtreatment.

EVDPATHOPHYSIOLOGY

§  Ebolavirusgenome&viralproteins§  Ebolaviruspathogenesis&immunoevasion

EbolavirusBroadOverviewFiloviridaeCuevavirusEbolavirus

Marburgvirus

5SpeciesofEbolavirusZaireebolavirus(EBOV),Sudanebolavirus(SUDV),TaiForestebolavirus(TAFV),Bundibugyoebolavirus(BDBV),Restonebolavirus(RESTV)[*donotcausediseaseinhumans]

Single-strandedRNAvirusEbolavirusisafilamentous,single-strandedRNA(negaTvesense)infecTousviralparTcle.Theebolavirusgenome

encodessevenviralproteins.

50%-90%FatalityRateThefatalityrateofebolavirusdependsonthespeciesandstrainsofdifferentebolavirus.

EbolaHemorrhagicFever(EHF)EbolaviruscausesEHF,alethalmedicalcondiTon

withhighfatalityrate.

NoVaccinesandTreatmentsThereiscurrentlynoFDAapprovedvaccinesnor

treatmentsforEVD.SomepromisingcandidatesarenowundergoingclinicalevaluaTons(twovaccinesandonedrughavecompletedclinicalphaseItrials).

EVDTransmissionCurrently,mostevidencesuggeststhatdirect

contactwithinfecTousmaterialsisnecessaryfortransmission.Moredetailswillbediscussedlater.

Suppor.veCareGivingsupporTvecarecansignificantlyincreasethechanceofsurvival;thesecareinvolvesgivingIV

fluids,balanceelectrolytes,maintainingoxygenlevelandbloodpressure,andtreatotherinfecTons.

Zoono.cOrigin?ManyevidencesuggeststhatebolavirushasanzoonoTcorigin.Fruitbatsareproposedtobethe

naturalanimalreservoirforthevirus.

WHO,2015.CDC,2015.

EbolavirusGenome,ViralProteins,andCellEntryMechanism

L(RNApolymerase)Thelargestviralproteins

responsibleforposiTveRNAsynthesis.

VP40&VP24Majorandminormatrixproteinsthatformalayerundertheviral

membrane.

VP35&VP30ActasinterferonantagonistsandtranscripTonacTvators.

GP/sGPGlycoproteinstogetherwithhostderivedproteins(MHC)

formtheebolavirusmembrane.

NPNucleoproteinformsthe

nucleocapsidthatcontainsRNA.

EndocytosisMacropinocytosisorthealternaTve

clathrin-mediatedendocytosis(Aleksandrowuczetal.)

Morethan7ProteinsProducTonofmorethan7proteinsisachievedbyco-transcripTonalediTng&posttranslaTonal

processing.

G1&G2TrimerEbolavirussurfaceGPisatrimerconsisTngof2G1and1G2subunit.

EbolavirusPathogenesis&Immunoevasion*Limitedknowledgeduetoitsdangerousnatureandrareness.

HostImmunityPathogenesis Immunoevasion

ExposuretoebolavirusEbolavirusentershostcells

EbolavirusinCorneaEbolavirushasbeendetectedinthecorneaofanU.S.physicianwhorecoveredfromEVDmonthsago.

Eye&JointComplaintsSomepaTentswhorecoveredfromEVDsufferfromeyesightandjointrelatedproblems.Thephysiologicalmechanismremainsunclear.

Ini.alreplica.onsitesmonocytes,macrophages,

dendriTccells

UncontrolledProduc.onofCytokines&Chemokines:IL-1β,TNA-α,

MIP-1α,andROS

Implica.onsEbolavirusmightinfectmorecelltypesthanpreviouslythought.

Basedonthecelltypes

Migra.on&SpreadSpreadthroughlymphoidTssue,liver,andthespleentoendothelialcells,fibroblasts,hepatocytes,adrenalcorTcalcells,etc.àDamage

Akractmoreimmunecells&producemore

proinflammatorycytokinesandchemokines

Posi3veFeedback

Adap.veImmuneResponseAcTvatedbyanTgenpresenTngcellsandsignalingmoleculesàan3body

VP35&VP24Actsasinterferon

antagonists,andblockdendriTccellmaturaTon

process

sGPsecretedtoECMsGPcanneutralizeanTbodies

G1hybrid-glycansFormsaprotecTveshieldfromhumoralimmuneresponse

inhibi3on

InterferonProduc.on

Inhibi3onInterference

EVDTRANSMISSION

§  Ebolavirustransmissionroute(s)§  Theroleofculture,economy,society,andhealthcareinfrastructure§  NaTonalgovernments&internaTonalorganizaTons

EbolavirusTransmission

Non-directContactTransmissionSwineàHuman(RESTV)[Barebe,etal.],SwineàNHPs(EBOV)[Weingartletal.]

IMPORTANT!AsitdeterminesprevenTonstrategiesand

treatmentpossibiliTes.

‘Silent’EVDPa.entsSomepeoplearesymptom-freeamerinfecTon.

EVDTransmissioninGuineaPigsWongetal.usedaGuineapigsmodelto

demonstratethatEVDtransmissionwithoutdirectcontactispossibleamongGuineapigs.

FurtherevaluaTonsareneeded!IthasgreatimplicaTonson

publichealthpolicies.

71%IndividualswithposiTve

ebolavirusanTbodydidnotgetsick.(Richardetal.)

46%OfclosecontactsofEVDpaTents

(anTbody+),butremainedasymptomaTc.(Leroyetal.)

≈50%Asymptoma.cPa.entsEvidencefrom1996Gabonoutbreak,24

peoplemonitored(anTbody+),11(46%)wereasymptomaTc.

Monitoring&StudyAmonitoringsystemshouldbeestablishedtoevaluateEVD

pathophysiology.(e.g.monitorexposedpeopleandtheirhealth,

regularbloodsampling.)

Implica.onsNaturalinfecToncanalsoactsasaformofvaccinaTon(doesitprotectlife-long?);Ifitdoes,‘silentpaTents’cancarryout

riskymedicalhandling.

TherolesofvariousfactorsonEVDtransmission

CultureThetradiTonburialpracTce

(preparaTonprocess)andtheritualsduringthefuneral,andtradiTonalheadersplayimportantrolesinEVDtransmission.STgmaTzaTontowards

EVDpreventspeoplereceivingnecessarymedicalhelpandisolaTon.

EnvironmentDeforestaTonresultedinan

increasingbats-to-humancontacts;Fruitbatsareconsideredasthe

ebolavirusreservoir.Ngetal.foundanassociaTonbetweenhumidity,temperatureandEVDoutbreaks.

EconomyUnderdevelopmentresultsinthe

popularityofcheapbushmeat(asasourceofprotein)&poorhealthcareinfrastructure.TheEVDoutbreakfurtherdamagestheeconomiesof

theaffectedcountriesàviciouscycle

HealthCareInfrastructureGuinea,SierraLeone,andLiberia

havepoorhealthcareinfrastructure.Thesystemwasalreadyoverloaded

bymalariaandothertropicaldiseases.Nigeriaisasuccessful

exampleofcontainingtheepidemicwithadequatemedicalinfrastructure.EVD

Transmission Society&GovernmentsAmermanyyearsof(civil)war,the

mostaffectedcountrieshavecompletelylostthesenseoftrustandcommunity.PeoplenolongerbelieveinthenaTonalgovernments.Many

peopledonotbelieveinEVD.

Interna.onalOrganiza.onsTheWHOtogetherwithMSFmobilizeresourcesandmediatecollaboraTons

tocombatthecurrentoutbreak.NumerousnaTonalgovernmentshavealsoprovidedfinancialand

medicalaids(limitedly).

EVDPREVENTION:VACCINES

§  Differentapproaches:strengths&weaknesses§  Promisingcandidates:NIAID/GSKChAd3-EBO&VSVΔZEBOV§  FuturedirecTonsandfocuses

DifferentApproaches&PromisingCandidates Endof2015

STRIVESierraLeoneTrialtoIntroduceaVaccineAgainstEbola

EbolavirusGlycoproteinCommonebolavirusvaccinetarget

FutureDirections&Focuses

Mul.valentVaccineFourofthefiveebolavirusescausediseaseinhumans.Itisdifficulttopredictthenextoutbreakspecies.Avaccinethatprotectspeoplefrommorethanoneebolavirus

speciesshouldbedeveloped.

BoostVaccina.onManycurrentvaccinesunderdevelopmentareadenovirus-vectorbasedvaccinesthatexpressebolavirusGP.Thehostpre-exisTngimmunityagainstadenovirusisacommonproblem.UsingaboostvaccinaTonsuchasMVAfor

Ad26mightsolvetheproblem.

MosaicAn.gensTherapiddevelopmentinprotein-based

vaccinesdemonstratedinHIV(Zazaetal.)andHCV(Changetal.)showpromisingresults;itinvolvesthearTficialproducTonofpathogen

epitopesthatdirectlyelicitstrongCD8+response.

þ EBOVþ SUDVþ BDBVþ TAFV

EVDTREATMENT

§  Varioustreatmenttypes:strengths&weaknesses§  Promisingcandidate:ZMapp(monoclonalanTbodies)§  InnovaTon:repurposingexisTngdrugs

TreatmentTypes&PromisingCandidatesConvalescentPlasma

Theeffectofthistherapyisnotproven.TheserumofarecoveredEVDpaTentsomeTmesprotecttherecipientsàlackofknowledge

MonoclonalAn.bodiesHavedemonstratedtherapeuTc

effectsinNHPs.ThemodificaTonandselecTonofthemonoclonal

anTbodiesenhancetheireffects.

SmallMoleculesInterfereviralreplicaTonby

inhibiTngcertainviralproteinsuchasL(RNApolymerase).Difficultto

delivertotheinfecTonsites.

NucleosideAnalogue&RNAInterference

RelaTvelynewandexpensive.IniTalresultsarepromising,butrequires

furtherevaluaTon.

EbolavirusBioSafetyLevel4

RepurposingExis.ngDrugs

ChallengesThedangerousnatureoftheebolavirus(BSL4)willfurtherhamperthedevelopmentofan

effecTveebolavirustreatment.

Opportuni.esAsourunderstandingofebolavirusconTnuestoimprove,

itwillprovidemoreinsightsintotheebolaviruspathophysiologyandmorepotenTaldrugtargets.

SUMMARY&DISCUSSIONS

§  Summary§  Discussions

Summary

q  2014EVDoutbreakinWestAfricaisthelargestandmostcomplexEVDepidemic

q  TheepidemichasalsosTmulatedsignificantamountofresearchonEVD

q  OurunderstandingofEVDpathophysiologyhassignificantlyimproved

q  Culture,economy,environment,society,governments,healthcareinfrastructure,

andinternaTonalorganizaTonsallplayrolesinEVDtransmission

q  TherearecurrentlynumerousvaccinesandtreatmentsunderclinicalevaluaTon

q  ThedangerousnatureofebolaviruswillconTnuetohamperfutureresearch

q  Previousresearchandclinicaltrialsonotherviruses(HIVandHCV)mightalso

providesomecluesinfindinganeffecTvevaccineandtreatmentforEVD.

Discussions

EVDSilentPa.ents§  Whydothesepeoplenotgetsymptoms?§  Whatisthenextlogicalstep?§  WhataretheimplicaTonsforfutureoutbreaks?EVDTransmission§  WhatcanbedonetopreventfutureEVD?§  IsclimatereallyrelatedtoEVDoutbreaks?§  Ifso,whatprecauTonarymeasuresshouldbetaken?EVDisanAncientVirus§  WhataretheimplicaTonsofviralevoluTonresearch?§  WhydoesRESTVnotcausediseaseinhumans?§  Howhaveotheranimals(suchasfruitbats)developedimmunityagainsttheebolavirus?Innova.ons:EVDVaccine&Treatment§  WhatcanbeinspiredfromtheabundantpreviousvaccineresearchintheprocessofEVDvaccine

development?§  WhatnoveltechnologiescanbeusedtoapproachEVDvaccineandtreatmentdifferentlyandmore

effecTvely?

References

•  Agnandji,SelidjiT.,AngelaHubner,MadeleineE.Zinser,PatriciaNjuguna,ChrisTneDahlke,JoséF.Fernandes,SabineYerly,etal.2015.“Phase1TrialsofrVSVEbolaVaccineinAfricaandEurope—PreliminaryReport.”NewEnglandJournalofMedicine,150401140035006.doi:10.1056/NEJMoa1502924.

•  Aleksandrowicz,Paulina,AndreaMarzi,NadineBiedenkopf,NadineBeimforde,StephanBecker,ThomasHoenen,HeinzFeldmann,andHansJoachimSchnibler.2011.“EbolaVirusEntersHostCellsbyMacropinocytosisandClathrin-MediatedEndocytosis.”JournalofInfecMousDiseases204(SUPPL.3):957–67.doi:10.1093/infdis/jir326.

•  Baize,Sylvain,DelphinePanneTer,LisaOestereich,ToniRieger,LamineKoivogui,N’falyMagassouba,BarrèSoropogui,etal.2014.“EmergenceofZaireEbolaVirusDiseaseinGuinea-PreliminaryReport.”TheNewEnglandJournalofMedicine,1–8.doi:10.1056/NEJMoa1404505.

•  Barouch,DanH.,KathrynE.Stephenson,EricaN.Borducchi,KaitlinSmith,KellyStanley,AnnaG.McNally,JinyanLiu,etal.2013.“XProtecTveEfficacyofaGlobalHIV-1MosaicVaccineagainstHeterologousSHIVChallengesinRhesusMonkeys.”Cell155(3).ElsevierInc.:531–39.doi:10.1016/j.cell.2013.09.061.

•  Basler,ChristopherF.2015.“InnateImmuneEvasionbyFiloviruses.”Virology480:122–30.doi:10.1016/j.virol.2015.03.030.•  Bellan,SteveE,JulietRCPulliam,JonathanDushoff,andLaurenAncelMeyers.2015.“CorrespondenceEbolaControl :EffEctofAsymptomaTc

InfecTon.”TheLancet384(9953).ElsevierLtd:1499–1500.doi:10.1016/S0140-6736(14)61839-0.•  Chang,J.C.,B.Ruedinger,M.Cong,S.Lambert,E.Lopareva,M.Purdy,B.P.Holloway,etal.1999.“ArTficialNS4MosaicAnTgenofHepaTTsC

Virus.”JournalofMedicalVirology59(4):437–50.doi:10.1002/(SICI)1096-9071(199912)59:4<437::AID-JMV4>3.0.CO;2-5.•  “EbolaVaccineLandscape01-08-15.”n.d.,0–5.•  “EbolaVirusDiseaseinGuinea.”2015.AccessedMay5.hbp://www.afro.who.int/en/clusters-a-programmes/dpc/epidemic-a-pandemic-alert-

and-response/outbreak-news/4063-ebola-hemorrhagic-fever-in-guinea.html.•  “FactsaboutBushmeatandEbola.”2015.AccessedMay5.hbp://www.cdc.gov/vhf/ebola/pdf/bushmeat-and-ebola.pdf.•  Fasina,F,aShibu,DLazarus,OTomori,LSimonsen,CViboud,andGChowell.2014.“TransmissionDynamicsandControlofEbolaVirusDisease

OutbreakinNigeria,JulytoSeptember2014.”Eurosurveillance19(40):20920.doi:10.2807/1560-7917.ES2014.19.40.20920.•  Feldmann,H,VEVolchkov,VAVolchkova,andHDKlenk.1999.“TheGlycoproteinsofMarburgandEbolaVirusandTheirPotenTalRolesin

Pathogenesis.”ArchivesofVirology.Supplementum15(January):159–69.hbp://www.ncbi.nlm.nih.gov/pubmed/10470276.•  Feldmann,Heinz,andThomasW.Geisbert.2011.“EbolaHaemorrhagicFever.”TheLancet377(9768).ElsevierLtd:849–62.doi:10.1016/

S0140-6736(10)60667-8.•  Feldmann,Heinz,StevenJones,Hans-DieterKlenk,andHans-JoachimSchnibler.2003.“EbolaVirus:FromDiscoverytoVaccine.”Nature

Reviews.Immunology3(8):677–85.doi:10.1038/nri1154.•  Folayan,MorenikeO,BrandonBrown,andAminuYakubu.2014.“BlackMarketBloodTransfusionsforEbola:PotenTalforIncreasesinOther

InfecTons.”GlobalHealthAcMon7(January):26356.hbp://www.pubmedcentral.nih.gov/arTclerender.fcgi?arTd=4236640&tool=pmcentrez&rendertype=abstract.

•  Geisbert,ThomasW,MichaelBailey,LisaHensley,ClementAsiedu,JoanGeisbert,DaphneStanley,AnnaHonko,etal.2011.“RecombinantAdenovirusSerotype26(Ad26)andAd35VaccineVectorsBypassImmunitytoAd5andProtectNonhumanPrimatesagainstEbolavirusChallenge.”JournalofVirology85(9):4222–33.doi:10.1128/JVI.02407-10.

•  Geisbert,ThomasW.,AmyChLee,MarjorieRobbins,JoanB.Geisbert,AnnaN.Honko,VandanaSood,JoshuaC.Johnson,etal.2010.“PostexposureProtecTonofNon-HumanPrimatesagainstaLethalEbolaVirusChallengewithRNAInterference:AProof-of-ConceptStudy.”TheLancet375(9729).ElsevierLtd:1896–1905.doi:10.1016/S0140-6736(10)60357-1.

•  Gibb,TR,MBray,TWGeisbert,KESteele,WMKell,KJDavis,andNKJaax.2001.“PathogenesisofExperimentalEbolaZaireVirusInfecToninBALB/cMice.”JournalofComparaMvePathology125(4):233–42.doi:10.1053/jcpa.2001.0502.

•  Gupta,M,SMahanty,MBray,RAhmed,andPERollin.2001.“PassiveTransferofAnTbodiesProtectsImmunocompetentandImunodeficientMiceagainstLethalEbolaVirusInfecTonwithoutCompleteInhibiTonofViralReplicaTon.”JournalofVirology75(10):4649–54.doi:10.1128/JVI.75.10.4649-4654.2001.

•  Hartlieb,B.,T.Muziol,W.Weissenhorn,andS.Becker.2007.“CrystalStructureoftheC-TerminalDomainofEbolaVirusVP30RevealsaRoleinTranscripTonandNucleocapsidAssociaTon.”ProceedingsoftheNaMonalAcademyofSciences104(2):624–29.doi:10.1073/pnas.0606730104.

•  He,Shanshan,BillyLin,VirginiaChu,ZongyiHu,XinHu,JingboXiao,AmyQWang,etal.2015.“RepurposingoftheAnThistamineChlorcyclizineandRelatedCompoundsforTreatmentofHepaTTsCVirusInfecTon.”ScienceTranslaMonalMedicine7(282):282ra49.doi:10.1126/scitranslmed.3010286.

•  Heffernan,RichardT,BerTnPambo,RichardJHatcheb,PatriciaaLeman,RobertSwanepoel,andRobertWRyder.2005.“LowSeroprevalenceofIgGAnTbodiestoEbolaVirusinanEpidemicZone:Ogooué-IvindoRegion,NortheasternGabon,1997.”TheJournalofInfecMousDiseases191(6):964–68.doi:10.1086/427994.

•  Hewleb,BarryS.,andRichardP.Amolat.2003.“CulturalContextsofEbolainNorthernUganda.”EmergingInfecMousDiseases9(10):1242–48.doi:10.3201/eid0910.020493.

•  Hutchinson,KarenL,andPierreERollin.2007.“CytokineandChemokineExpressioninHumansInfectedwithSudanEbolaVirus.”TheJournalofInfecMousDiseases196Suppl(November):S357–63.doi:10.1086/520611.

•  Kouznetsova,Jennifer,WeiSun,CarlesMar�nez-Romero,GregoryTawa,PaulShinn,CatherineZChen,AaronSchimmer,etal.2014.“IdenTficaTonof53CompoundsThatBlockEbolaVirus-likeParTcleEntryviaaRepurposingScreenofApprovedDrugs.”EmergingMicrobes&InfecMons3(12):e84.doi:10.1038/emi.2014.88.

•  Lai,Lilin,RichardDavey,AllisonBeck,YongxianXu,AnthonyF.Suffredini,TaraPalmore,SarahKabbani,etal.2015.“EmergencyPostexposureVaccinaTonWithVesicularStomaTTsVirus–VectoredEbolaVaccineAmerNeedlesTck.”Jama30030(12):1249–55.doi:10.1001/jama.2015.1995.

•  Ledgerwood,JulieE,AdamDDeZure,DaphneaStanley,LauraNovik,MaryEEnama,NinaMBerkowitz,ZonghuiHu,etal.2014.“ChimpanzeeAdenovirusVectorEbolaVaccine-PreliminaryReport.”TheNewEnglandJournalofMedicine,1–9.doi:10.1056/NEJMoa1410863.

•  Lee,JeffreyE,TorreyPinesRoad,andLaJolla.2010.“NIHPublicAccess.”North4(6):621–35.doi:10.2217/fvl.09.56.Ebolavirus.•  Leroy,EM,SBaize,VEVolchkov,SPFisher-Hoch,MCGeorges-Courbot,JLansoud-Soukate,MCapron,PDebré,JBMcCormick,andaJ

Georges.2000.“HumanAsymptomaTcEbolaInfecTonandStrongInflammatoryResponse.”Lancet355(9222):2210–15.doi:10.1016/S0140-6736(00)02405-3.

•  Leroy,EricM,AlainEpelboin,VitalMondonge,XavierPourrut,Jean-PaulGonzalez,Jean-JacquesMuyembe-Tamfum,andPierreFormenty.2009.“HumanEbolaOutbreakResulTngfromDirectExposuretoFruitBatsinLuebo,DemocraTcRepublicofCongo,2007.”VectorBorneandZoonoMcDiseases(Larchmont,N.Y.)9(6):723–28.doi:10.1089/vbz.2008.0167.

•  Leroy,EricM,BriceKumulungui,XavierPourrut,PierreRouquet,AlexandreHassanin,PhilippeYaba,AndréDélicat,JanuszTPaweska,Jean-PaulGonzalez,andRobertSwanepoel.2005.“FruitBatsasReservoirsofEbolaVirus.”Nature438(7068):575–76.doi:10.1038/438575a.

•  Leung,DaisyW,KathleenCPrins,ChristopherFBasler,andGayaKAmarasinghe.“EbolavirusVP35IsaMulTfuncTonalVirulenceFactor.”Virulence1(6):526–31.hbp://www.pubmedcentral.nih.gov/arTclerender.fcgi?arTd=3061251&tool=pmcentrez&rendertype=abstract.

•  Mohan,GopiS.,WenfangLi,LingYe,RichardW.Compans,andChinglaiYang.2012.“AnTgenicSubversion:ANovelMechanismofHostImmuneEvasionbyEbolaVirus.”PLoSPathogens8(12).doi:10.1371/journal.ppat.1003065.

•  Muyembe-Tamfum,J.J.,S.Mulangu,JusTnMasumu,J.M.Kayembe,a.Kemp,andJanuszT.Paweska.2012.“EbolaVirusOutbreaksinAfrica:PastandPresent.”OnderstepoortJournalofVeterinaryResearch79(2):1–8.doi:10.4102/ojvr.v79i2.451.

•  Ndhlovu,ZazaM,AlicjaPiechocka-Trocha,SeannaVine,AshleyMcMullen,KegakilweCKoo�ethile,PhillipJRGoulder,ThumbiNdung’u,DanHBarouch,andBruceDWalker.2011.“MosaicHIV-1GagAnTgensCanBeProcessedandPresentedtoHumanHIV-SpecificCD8+TCells.”JournalofImmunology(BalMmore,Md. :1950)186(12):6914–24.doi:10.4049/jimmunol.1004231.

•  Ng,S,NEBasta,andBJCowling.2014.“AssociaTonbetweenTemperature,HumidityandEbolavirusDiseaseOutbreaksinAfrica,1976to2014,”1–11.

•  Oestereich,Lisa,AnjaLüdtke,StephanieWurr,ToniRieger,CésarMuñoz-Fontela,andStephanGünther.2014.“SuccessfulTreatmentofAdvancedEbolaVirusInfecTonwithT-705(favipiravir)inaSmallAnimalModel.”AnMviralResearch105(1).ElsevierB.V.:17–21.doi:10.1016/j.anTviral.2014.02.014.

•  Oswald,WendelienB.,ThomasW.Geisbert,KellyJ.Davis,JoanB.Geisbert,NancyJ.Sullivan,PeterB.Jahrling,PaulWHIParren,andDennisR.Burton.2007.“NeutralizingAnTbodyFailstoImpacttheCourseofEbolaVirusInfecToninMonkeys.”PLoSPathogens3(1):0062–0066.doi:10.1371/journal.ppat.0030009.

•  Prab,WilliamD,DanherWang,DonaldKNichols,MinLuo,JanWoraratanadharm,JohnMDye,DavidHHolman,JohnYDong,AshleyAve,andSouthCarolina.2010.“ProtecTonofNonhumanPrimatesagainstTwoSpeciesofEbolaVirusInfecTonwithaSingleComplexAdenovirusVector”17(4):572–81.doi:10.1128/CVI.00467-09.

•  Qiu,X.,J.Audet,G.Wong,S.Pillet,a.Bello,T.Cabral,J.E.Strong,etal.2012.“SuccessfulTreatmentofEbolaVirus-InfectedCynomolgusMacaqueswithMonoclonalAnTbodies.”ScienceTranslaMonalMedicine4(138):138ra81–138ra81.doi:10.1126/scitranslmed.3003876.

•  Qiu,Xiangguo,GaryWong,JonathanAudet,AlexanderBello,LisaFernando,JudieB.AlimonT,HuguesFausther-Bovendo,etal.2014.“ReversionofAdvancedEbolaVirusDiseaseinNonhumanPrimateswithZMapp.”Nature.NaturePublishingGroup.doi:10.1038/nature13777.

•  “SierraLeoneTrialtoIntroduceaVaccineagainstEbola(STRIVE)Q&A|EbolaHemorrhagicFever|CDC.”2015.AccessedMay5.hbp://www.cdc.gov/vhf/ebola/strive/qa.html.

•  SituaTon,Ebola.2015.“EBOLASITUATIONREPORT,”no.April:1–16.•  Stanley,Daphnea,AnnaNHonko,ClementAsiedu,JohnCTrefry,AnnieWLau-Kilby,JoshuaCJohnson,LisaHensley,etal.2014.“Chimpanzee

AdenovirusVaccineGeneratesAcuteandDurableProtecTveImmunityagainstEbolavirusChallenge.”NatureMedicine,no.September.NaturePublishingGroup:18–23.doi:10.1038/nm.3702.

•  Takada,Ayato,andYoshihiroKawaoka.2001.“ThePathogenesisofEbolaHemorrhagicFever.”TrendsinMicrobiology9(10):506–11.doi:10.1016/S0966-842X(01)02201-6.

•  Taylor,DerekJ.,MabhewJ.Ballinger,JackJ.Zhan,LauraE.Hanzly,andJeremya.Bruenn.2014.“EvidenceThatEbolavirusesandCuevavirusesHaveBeenDivergingfromMarburgvirusessincetheMiocene.”PeerJ2:e556.doi:10.7717/peerj.556.

•  Timmins,Joanna,RobWHRuigrok,andWinfriedWeissenhorn.2004.“StructuralStudiesontheEbolaVirusMatrixProteinVP40IndicateThatMatrixProteinsofEnvelopedRNAVirusesAreAnaloguesbutNotHomologues.”FEMSMicrobiologyLe^ers233(2):179–86.doi:10.1016/j.femsle.2004.03.002.

•  “Treatment|EbolaHemorrhagicFever|CDC.”2015.AccessedMay5.hbp://www.cdc.gov/vhf/ebola/treatment/index.html.•  Victory,KertonR,FáTmaCoronado,SâaOIfono,ThereseSoropogui,andBenjaminADahl.2015.“EbolaTransmissionLinkedtoaSingle

TradiTonalFuneralCeremony-Kissidougou,Guinea,December,2014-January2015.”MMWR.MorbidityandMortalityWeeklyReport64(14):386–88.hbp://www.ncbi.nlm.nih.gov/pubmed/25879897.

•  Virnik,KonstanTn,MaxHockenbury,YishengNi,JoelBeren,GeorgeNPavlakis,BarbaraKFelber,andIraBerkower.2013.“LiveAbenuatedRubellaVectorsExpressingSIVandHIVVaccineAnTgensReplicateandElicitDurableImmuneResponsesinRhesusMacaques.”Retrovirology10(1).Retrovirology:99.doi:10.1186/1742-4690-10-99.

•  Volchkov,VE,VAVolchkova,AAChepurnov,VMBlinov,ODolnik,SVNetesov,andHFeldmann.1999.“CharacterizaTonoftheLGeneand5’TrailerRegionofEbolaVirus.”TheJournalofGeneralVirology80(Pt2)(February):355–62.hbp://www.ncbi.nlm.nih.gov/pubmed/10073695.

•  Warren,TravisK,JayWells,RekhaGPanchal,KellySStuthman,NicoleLGarza,SeanaVanTongeren,LianDong,etal.2014.“ProtecTonagainstFilovirusDiseasesbyaNovelBroad-SpectrumNucleosideAnalogueBCX4430.”Nature508(7496).NaturePublishingGroup:402–5.doi:10.1038/nature13027.

•  Watkins,DavidI,DennisRBurton,EsperGKallas,JohnPMoore,andWayneCKoff.2008.“NonhumanPrimateModelsandtheFailureoftheMerckHIV-1VaccineinHumans.”NatureMedicine14(6):617–21.doi:10.1038/nm.f.1759.

•  Weyer,Jacqueline,LucilleHellenBlumberg,andJanuszTPaweska.2014.“EbolaVirusDiseaseinWestAfrica-anUnprecedentedOutbreak.”SouthAfricanMedicalJournal=Suid-AfrikaanseTydskrifVirGeneeskunde104(8):555–56.hbp://www.ncbi.nlm.nih.gov/pubmed/25213844.

•  “WHO|EbolaVaccines,Therapies,andDiagnosTcs.”2015.WorldHealthOrganizaTon.AccessedMay5.hbp://www.who.int/medicines/emp_ebola_q_as/en/.

•  “WHO|EbolaVirusDisease.”2015.WorldHealthOrganizaTon.AccessedMay5.hbp://www.who.int/mediacentre/factsheets/fs103/en/.•  “WHO|NigeriaIsNowFreeofEbolaVirusTransmission.”2014.WorldHealthOrganizaTon.hbp://www.who.int/mediacentre/news/ebola/

20-october-2014/en/.•  “WHO|SierraLeone:ATradiTonalHealerandaFuneral.”2015.WorldHealthOrganizaTon.AccessedMay5.hbp://www.who.int/csr/

disease/ebola/ebola-6-months/sierra-leone/en/.•  “WhyEbolaIsNotLikelytoBecomeAirborne?”2015.AccessedMay5.hbp://www.cdc.gov/vhf/ebola/pdf/mutaTons.pdf.•  Wong,Gary,GaryPKobinger,andXiangguoQiu.2014.“CharacterizaTonofHostImmuneResponsesinEbolaVirusInfecTons.”ExpertReview

ofClinicalImmunology10(6):781–90.doi:10.1586/1744666X.2014.908705.•  Wong,Gary,XiangguoQiu,JasonS.Richardson,ToddCubs,BradCollignon,JasonGren,JennaAviles,CarissaEmbury-Hyab,andGaryP.

Kobinger.2015.“EbolaVirusTransmissioninGuineaPigs.”JournalofVirology89(2):1314–23.doi:10.1128/JVI.02836-14.•  “WorldBankGroupEbolaResponseFactSheet.”2015.AccessedMay5.hbp://www.worldbank.org/en/topic/health/brief/world-bank-group-

ebola-fact-sheet.•  Zak,DanielE,EricaAndersen-Nissen,EricRPeterson,AliciaSato,MKrisTnaHamilton,JoleenBorgerding,AkshayTKrishnamurty,etal.2012.

“MerckAd5/HIVInducesBroadInnateImmuneAcTvaTonThatPredictsCD8+T-CellResponsesbutIsAbenuatedbyPreexisTngAd5Immunity.”ProceedingsoftheNaMonalAcademyofSciencesoftheUnitedStatesofAmerica109(50):E3503–12.doi:10.1073/pnas.1208972109.