Ebola Virus Transmission Initiated by Relapse of Systemic Ebola Virus Disease

Abstract

During the 2018-2020 Ebola virus disease (EVD) outbreak in North Kivu province in the Democratic Republic of Congo, EVD was diagnosed in a patient who had received the recombinant vesicular stomatitis virus-based vaccine expressing a ZEBOV glycoprotein (rVSV-ZEBOV) (Merck). His treatment included an Ebola virus (EBOV)-specific monoclonal antibody (mAb114), and he recovered within 14 days. However, 6 months later, he presented again with severe EVD-like illness and EBOV viremia, and he died. We initiated epidemiologic and genomic investigations that showed that the patient had had a relapse of acute EVD that led to a transmission chain resulting in 91 cases across six health zones over 4 months. (Funded by the Bill and Melinda Gates Foundation and others.) H uman-to-human transmission of Ebola virus (EBOV) typically occurs through direct contact with infectious blood or bodily fluids (e.g., semen or breast milk). 1 EBOV persistence has been well documented in survivors of Ebola virus disease (EVD). Although secondary transmission through contact with infectious bodily fluids is relatively rare, it has been linked to flare-up events. 2 In two survivors of EVD, meningoencephalitis and uveitis syndromes have been associated with infectious EBOV in cerebrospinal fluid and aqueous humor, respectively; neither case led to further transmission. Here, we report the relapse of acute EVD in a patient who was infected with the EBOV Ituri variant during the 2018-2020 North Kivu EVD outbreak in the Democratic Republic of Congo (DRC). he relapse, which occurred 149 days after the patient was discharged from an Ebola treatment unit, sparked a transmission chain of 91 cases.