|Year : 2019 | Volume
| Issue : 7 | Page : 2189-2201
Ebola virus: A global public health menace: A narrative review
Shamimul Hasan1, Syed Ansar Ahmad2, Rahnuma Masood3, Shazina Saeed4
1 Department of Oral Medicine and Radiology, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
2 Department of Oral Surgery, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
3 Department of Conservative Dentistry, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
4 Department of Amity Institute of Public Health, Amity University, Noida, Uttar Pradesh, India
|Date of Submission||10-Apr-2019|
|Date of Decision||12-Apr-2019|
|Date of Acceptance||24-Apr-2019|
|Date of Web Publication||31-Jul-2019|
Dr. Shazina Saeed
Department of Amity Institute of Public Health, Amity University, Noida, Uttar Pradesh - 201 303
Source of Support: None, Conflict of Interest: None
Ebola virus disease (EVD), a fatal viral hemorrhagic illness, is due to infection with the Ebola virus of the Filoviridae family. The disease has evolved as a global public health menace due to a large immigrant population. Initially, the patients present with nonspecific influenza-like symptoms and eventually terminate into shock and multiorgan failure. There exists no specific treatment protocol for EVD and only supportive and symptomatic therapy is the line of treatment. This review article provides a detailed overview of the Ebola virus; it's clinical and oral manifestations, diagnostic aids, differential diagnosis, preventive aspects, and management protocol.
Keywords: Ebola virus, oral manifestations, public health menace, symptomatic therapy
|How to cite this article:|
Hasan S, Ahmad SA, Masood R, Saeed S. Ebola virus: A global public health menace: A narrative review. J Family Med Prim Care 2019;8:2189-201
|How to cite this URL:|
Hasan S, Ahmad SA, Masood R, Saeed S. Ebola virus: A global public health menace: A narrative review. J Family Med Prim Care [serial online] 2019 [cited 2019 Nov 13];8:2189-201. Available from: http://www.jfmpc.com/text.asp?2019/8/7/2189/263755
| Introduction|| |
Ebola, earlier termed as Ebola hemorrhagic fever (EHF), is a critically lethal ailment which primarily affects the humans and nonhuman primates. Ebola virus disease (EVD) occurs due to a virus infection which belongs to the family Filoviridae and genus Ebolavirus. EVDs has posed diagnostic challenges and has been a universal public health threat since its discovery. While investigating an alleged yellow fever case, Dr. Peter Piot in the year 1976 first detected the disease in Zaire, Africa (presently the Democratic Republic of Congo). The name “Ebola” was termed as the disease was noticed near the Ebola river in Congo.
Fruit bats of Pteropodidae family, such as Hypsignathus monstrous, Epomops franqueti, and Myonycteris torquata serve as the natural hosts of the EBOV in Africa. Nonhuman primates may develop the infection by eating the partly eaten fruits and may also transmit the infection to humans. Indian population is an impending threat to EVD, as India falls in the home range of Pteropodidae family of fruit bats.
Ebola virus transmission primarily takes place through close bodily contact with the infected patient or their fluids, contaminated tissue surfaces, and clothing from alive, infected or deceased individuals. Unsafe traditional burial practices also play a pivotal role in the disease transmission. There is documented evidence regarding the sexual mode of disease transmission, although transmission through the air is unlikely.
EVD present with bizarre and atypical manifestations mimicking other viral diseases, especially in the initial disease phase. Constitutional symptoms, such as fever, myalgia, headache, vomiting, and diarrhea are the early presenting features. Hemorrhagic rash, internal and external bleeding are usually the warning manifestations in the late stages. Bleeding from the body apertures is a distinguishing EVD manifestation. Gum bleeding, odynophagia, and atypical oral manifestations constitute the oral features of EVD.
Till date, there is no precise antiviral management or vaccination for EVD. The management protocol mainly relies on supportive and symptomatic therapy, along with monitoring coagulopathies and multiorgan dysfunction.
The World Health Organization (WHO) affirmed the EVD outbreak as a “Public Health Emergency of International Concern” on August 8th, 2014.
With the enormous immigrant population, India is estimating the likelihood of a probable EVD outbreak. The Ministry of Health and Family Welfare, Government of India, in collaboration with other agencies has appraised the situation and recommended travel instructions by air, land, and sea and health care professionals.
| Taxonomy|| |
The virus belongs to the Ebola virus genus, Filoviridae family, and Mononegavirales order. The genus Ebolavirus includes the following species- Zaire ebolavirus (EBOV), Reston ebolavirus (RESTV), Bundibugyo ebolavirus (BDBV), Taï Forest ebolavirus (TAFV), Sudan ebolavirus (SUDV), and the newly identified Bombali ebolavirus (BOMV). Except for exclusive identification of RESTV in the Philippines, all the other species causes endemic West African EVD.
EBOV responsible for the EHF causes the highest human mortality (57%–90%), followed by SUDV (41%–65%) and Bundibugyo virus (40%). TAFV has caused only two nonlethal human infections to date, whereas RESTV causes asymptomatic human infections.
[Figure 1] shows the taxonomy of Ebola virus.
| Transmission|| |
Based on the Centers for Disease Control and Prevention (CDC) classification, Ebola virus is considered as a biosafety level 4 and category A bioterrorism pathogen with an immense likelihood for massive nationwide transmission.
| Source of Infection|| |
Intimate physical contact with the patients in the acute disease stages and contact with the blood/fluids from the dead individuals constitutes the most important modes of transmission.
The long-established funeral ceremonies in the African countries entail direct handling of the dead bodies, thus significantly contributing to the disease dissemination. Unsafe conventional burial procedures accounted for 68% infected cases in 2014 EVD outburst of Guinea.
EBOV RNA may be identified for up to a month in rectal, conjunctival, and vaginal discharges and semen specimens may demonstrate the virus presence up to 3 months, thus signifying the presence of EBOV in recuperating patients. The sexually transmitted case of EVD has been reported between a convalescent patient and close family member. Another study demonstrated a case in a recuperating male patient. The patient's semen specimen tested positive with Ebola viral antigen almost 3 months after the disease onset.
Asymptomatic EBOV carriers are not infectious and do not have a major role play in the EVD outburst, and the field practice in Western Africa supported this assumption. However, this presumption was refuted after the documentation of a pioneer asymptomatic carrier case in North Gabon epidemic (1996).
EBOV has been detected from blood, saliva, semen, and breast milk, while RNA has been isolated from sweat, tears, stool, and on the skin, vaginal, and rectal swabs, thus highlighting that exposure to infected blood and bodily secretions constitute the major means of dissemination.
Eating uncooked infected animal meat such as bats or chimpanzees account significantly to oral EVD transmission, especially in the African countries. The demonstration of the Ebola virus in the Filipino pigs in 2008 triggered the likelihood of an extensive range of possible animal hosts.
EVD dissemination has also been reported with hospital-acquired infections, particularly in areas with poor hygiene conditions. The infected needles usage was responsible for the 1976 EVD outbreak in Sudan and Zaire., Improper hygiene and sterilization were the crucial factors for the 1967 Yambuku EVD outburst.
EVD dissemination may also occur through the inanimate materials with infected body secretions (fomites). However, disease transmission through the airborne and droplet infection is ambiguous.
[Figure 2] shows the primary and secondary transmission of disease.
[Table 1] depicts the possible routes of transmission.
| Epidemiology|| |
The vast majority of EVD cases and outbursts have been endemic to African continent ever since the disease detection in 1976, and 36 such outbreaks have occurred in six African countries.
[Table 2] shows Ebola epidemiological outbreaks between 1976 and 2014.
The 2014–2016 EVD started in South East Guinea rural surroundings and eventually became a global public health menace by rapidly disseminating to urban localities and other countries.
[Figure 3] depicts the geographical distribution of Ebola virus disease.
The conducive environmental surroundings of the African continent facilitate EVD endemicity. However, intermittent imported Ebola cases have also been noticed in United States, United Kingdom, Canada, Spain, and Thailand.,
[Figure 4] depicts the distribution of Ebola virus disease in West African Countries.
Out of the unparalleled globally reported 28,616 cases and 11,310 casualties, Liberia accounted for almost 11,000 cases and over 4,800 deaths.
[Table 3] shows the statistics of the 2014–16 West African outbreak.
| Pathogenesis|| |
Ebola viruses penetrate the human body through mucous membranes, skin lacerations/tear, close contact with infected patients/corpse, or by direct parental dissemination. EBOV has a predilection to infect various cells of immune system (dendritic cells, monocytes, and macrophages), endothelial and epithelial cells, hepatocytes, and fibroblasts where it actively replicates by gene modulation and apoptosis and demonstrate significantly high viremia. The virus reaches the regional lymph nodes causing lymphadenopathy and hematogenous spread to the liver and spleen promote an active inflammatory response. Release of chemical mediators of inflammation (cytokines and chemokines) causes a dysregulated immune response by disrupting the vasculature system harmony, eventually causing disseminated intravascular coagulation and multiple organ dysfunction.
[Figure 5] demonstrates the pathogenesis of Ebola virus disease.
| Clinical Features|| |
Due to the bizarre and atypical manifestations in the initial phase, mimicking dengue fever, typhoid fever, malaria, meningococcemia, and other bacterial infections, EVD poses diagnostic dilemmas.
The incubation period ranges from 2 to 21 days. However, symptoms usually develop 8–11 days following infection.,
The initial disease phase is represented by constitutional symptoms. High-grade fever of >38o C is the most frequently reported symptom (85–95%), followed by other vague symptoms such as general malaise (85–95%), headaches (52–74%), dysphagia, sore throat (56–58%), and dry cough., The progressively advanced disease is accompanied by abdominal pain (62–68%), myalgia (50–79%), nausea, vomiting, and diarrhea (84–86%).
Variety of hemorrhagic manifestations forms an integral component of the late disease phase. Gastrointestinal tract bleeding manifests as petechiae, hematuria, melena, conjunctival bleeding, contusion, or intraperitoneal bleeding. Mucous membrane and venipuncture site bleeding, along with excess clot formation may also occur. As the features advances with time, the patients experience dehydration, confusion, stupor, hypotension, and multiorgan dysfunction, resulting in fulminant shock and ultimately death.,
Maculopapular exanthema constitutes a characteristic manifestation of all Filovirus infection, including EVD. The rash usually appears during the 5th to 7th day of disease and occur in 25–52% of patients in the past EVD outbreaks.
[Table 4] shows the clinical manifestations of Ebola virus disease.
Although EVD has a number of similar features with other viral hemorrhagic fevers (e.g. dengue), there are differences that set them apart.
[Table 5] depicts the differentiating features of the Ebola virus and dengue virus infection.
Gum bleeding, atypical mucosal lesions, and odynophagia comprise the distinctive oral manifestations. Epistaxis (nasal bleed), bleeding from venipuncture sites, conjunctivitis, and cutaneous exanthema are the other manifestations. Bleeding tendencies and gum bleeding is not seen in asymptomatic or initial EBOV patients reporting to the dental hospital.
EVD dissemination in the field of oral and dental health may appear nonsignificant; although, probable situations which may pose a risk to dental health professional have been appraised by Samaranayake et al. and Galvin et al.
[Table 6] depicts the various orofacial manifestations of Ebola virus disease
| Diagnosis|| |
EVD patients usually demonstrate altered laboratory parameters based on the stage of the disease.
[Table 7] shows the laboratory findings in Ebola virus disease.
The WHO (2014) recommended the sample collection of whole blood or oral swab at suitable centres called Ebola treatment centers. Reverse transcriptase polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA) are the most frequently utilized tests for laboratory affirmation of the EVD. RT-PCR is capable of detecting viral RNA in the blood samples of infected patients immediately after the commencement of signs and symptoms,, has a high sensitivity (up to 100%), and gives results within 1–2 days in cases of epidemics. ELISA detects the immunoglobulins G and M in samples of infected patients, has a low sensitivity (91%) and is not suitable for initial affirmation during an outbreak.,
| Prevention|| |
The most imperative strategy in EVD is to avert the vulnerable population from getting infected and limit the transmission. These preventive strategies entail intensive and rigorous endeavors from the Government, public health amenities, medical units, and personals.
The most essential aspect to curb EVD transmission is to avert direct bodily contact with infected individuals and their body fluids.
Health caregivers are extremely vulnerable and experience an augmented professional threat for EVD. Thus, scrupulous adherence to the universal infection control measures is fundamental in all the hospitals, laboratories, and other health care services. The U.S. CDC has advocated the appropriate use of various personal protective equipment as a mandate for health care professionals.
The risk of rapid importation of Ebola virus into human beings can be prevented by averting the direct bush meat and bats contact.
Unsafe traditional burial procedures, especially in the African continent significantly contributed to the EVD transmission. Hence, it is essential to practice safe and guarded funeral rituals to prevent the disease spread.
WHO recommends the implementation of safe sex practices to combat the sexual transmission of EVD. Strict abstinence or proper and regular condom use in male EVD survivors at least for a period of 12 months of the symptom onset or until their semen has twice tested negative should be followed.
Dental health care personals are extremely susceptible to EVD as they are in regular contact with blood and saliva during the routine diagnostic procedures. There is no documented case of EVD through saliva till date. A study on the identification of EBOV in oral fluids affirmed that patients presenting with demonstrable serum levels of EBOV RNA also exhibit identifiable salivary levels. The incubation period for all body fluids including saliva is 21 days; hence, oral health personals are vulnerable to develop the disease if universal infection control protocol is not followed.
[Table 8] demonstrates the various infection control measures to prevent the Ebola virus spread.
[Box 1] shows the travel guidelines to EBOV affected regions.
| Treatment|| |
Till date, there is no precise antiviral management or vaccination for EVD. The management protocol mainly relies on supportive and symptomatic therapy. Public health strategies emphasizing on epidemiological surveillance, contact tracing, and quarantine of the patient have been recommended to combat the dissemination of EVD.
Rehydration, adequate nourishment, analgesics, and blood transfusion form a keystone supportive treatment of EVD patient. Intravenous fluids and oral rehydration solution endow with proper electrolytes substitute and maintain the intravascular volume. Unrelenting vomiting and diarrhea are taken care of by the use of antiemetics and antidiarrheal drugs.,, Suspected cases of secondary bacterial infections and septicemia are best managed by the use of prophylactic antibiotic regimen (third generation I.V. cephalosporins). Concurrent parasitic coinfections may also be seen and require prompt investigations and management.
A number of investigative clinical trials emphasizing on the development of vaccine, antibody therapies, and antiviral drugs have been conducted for EVD.
[Table 9] shows experimental treatment for Ebola virus disease.
Various clinical trials in Africa, Europe, and the United States suggest that Ebola vaccines are in various development stages (Phase I–III). A number of candidate vaccines employ diverse platforms, including recombinant viral vectors (most evolved vaccine candidate), DNA vaccines, inactivated viral particles, subunit proteins, recombinant proteins, and virus-like particles. Example of viral vectors expressing ebolavirus glycoproteins include recombinant simian adenovirus (cAd3), recombinant vaccinia virus, recombinant human adenovirus (Ad26), and a live vesicular stomatitis virus used alone or in prime-booster regimens.
However, Ebola virus having the glycosylated surface proteins and preferentially infecting the immune cells impedes the development of an effective vaccine.
| Dental Management|| |
Dental health care professionals in Europe have not encountered a case of EVD so far. However, health care personals (including dental surgeons) are more prone to EVD while treating patients in West or sub-Saharan Africa. Dental professionals are more likely to encounter asymptomatic EVD patients or those with early-stage vague symptoms.
Individuals with a travel history to Ebola endemic regions, but with no direct intimate contact with the disease fall in the low-risk category and may undergo any medical/dental health care procedures without restrictions. However, all the nonessential procedures should be postponed for 21 days in individuals with direct exposure to the virus. The regional Health Service Executive Department of Public Health needs to be notified when the exposed patient's treatment cannot be deferred or controlled with pharmacotherapy.
| Conclusion|| |
EVD has emerged as a significant global public health menace due to multiple disease outbreaks in the last 25 years. Recent advancements are being carried out in the form of effective Ebola virus vaccine and anti-Ebola virus drugs. However, rapid geographic dissemination, nonspecific clinical presentation, lack of vaccine, and specific diagnostic test are the possible challenges to combat this dreaded public health menace.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arinola AA, Joel SA, Tubosun OE, Folagbade OA. Ebola virus disease (EVD) information awareness among the people of Ogbomoso Environs. Int J Library Information Sci 2015;4:55-69.
Rajak H, Jain DK, Singh A, Sharma AK, Dixit A. Ebola virus disease: Past, present and future. Asian Pac J Trop Biomed 2015;5:337-43.
Rabiah M, Khan A, Fatima M, Ashfaq M, Chaudhry HW, Zafar M. Knowledge and awareness of ebola virus disease among medical students. Pak J Med Health Sci 2015;9:852-5.
Yobsan D, Walkite F, Nesradin Y. Ebola virus and it's public health significance: A review. J Vet Sci Res 2018;3:1-10.
Daral S, Singh SK, Khokhar A. Ebola virus: Awareness about the disease and personal protective measures among junior doctors of a tertiary hospital in Delhi, India. Int J Med Public Health 2015;5:217-21. [Full text]
Luo D, Zheng R, Wang D, Zhang X, Yin Y, Wang K, et al.
Effect of sexual transmission on the West Africa Ebola outbreak in 2014: A mathematical modeling study. Sci Rep 2019;9:1653.
Petti S, Messano GA, Vingolo EM, Marsella LT, Scully C. The face of Ebola: Changing frequency of hemorrhage in the West African compared with Eastern-Central African outbreaks. BMC Infect Dis 2015;15:564.
Naieni KH, Ahmad A, Raza O, Assan A, Elduma AH, Jammeh A, et al.
Assessing the knowledge, attitudes, and practices of students regarding ebola virus disease outbreak. Iran J Public Health 2015;44:1670-6.
Samaranayake L, Scully C, Nair RG, Petti S. Viral hemorrhagic fevers with emphasis on Ebola virus disease and oro-dental healthcare. Oral Dis 2015;21:1-6.
Galvin S, Flint SR, Healy CM. Ebola virus disease: Review and implications for dentistry in Ireland. J Ir Dent Assoc 2015;61:141-3.
Vailaya CGR, Kumar S, Moideen S. Ebola virus disease: Knowledge, attitude, and practices of health care professionals in a tertiary care hospital. J Pub Health Med Res 2014;2:13-18.
Gebretadik FA, Seifu MF, Gelaw BK. Review on Ebola virus disease: Its outbreak and current status. Epidemiology (Sunnyvale) 2015;5:1-8.
Schindell BG, Webb AL, Kindrachuk J. Persistence and sexual transmission of filoviruses. Viruses 2018;10:1-22.
Liu WB, Li ZX, Du Y, Cao GW. Ebola virus disease: From epidemiology to prophylaxis. Mil Med Res 2015;2:7.
Moghadam SRJ, Omidi N, Bayrami S, Moghadam SJ, Alinaghi SAS. Asian Pac J Trop Biomed 2015;5:260-7.
Lai KY, Ng WY, Cheng FF. Human Ebola virus infection in West Africa: A review of available therapeutic agents that target different steps of the life cycle of the Ebola virus. Infect Dis Poverty 2014;3:43.
Rodriguez LL, Roo AD, Guimard Y, Trappier SG, Sanchez A, Bressler D, et al.
Persistence and genetic stability of Ebola virus during the outbreak in Kikwit, the Democratic Republic of the Congo 1995. J Infect Dis 1999;179:170-6.
Chan M. Ebola virus disease in West Africa–no early end to the outbreak. N Engl J Med 2014;371:1183-5.
Rewar S. Transmission of Ebola virus disease: An overview. Ann Glob Health 2014;80:444-51.
Drazen JM, Kanapathipillai R, Campion EW, Rubin EJ, Hammer SM, Morrissey S, et al.
Ebola and quarantine. N Engl J Med 2014;371:2029-30.
Samaranayake LP, Peiris JS, Scully C. Ebola virus infection: An overview. Br Dent J 1996;180:264-6.
Judson S, Prescott J, Munster V. Understanding ebola virus transmission. Viruses 2015;7:511-21.
Leroy EM, Kumulungui B, Pourrut X, Rouquet P, Hassanin A, Yaba P, et al.
Fruit bats as reservoirs of Ebola virus. Nature 2005;438:575-6.
Barrette RW, Metwally SA, Rowland JM, Xu L, Zaki SR, Nichol ST, et al.
Discovery of swine as a host for the Reston ebolavirus. Science 2009;325:204-6.
Ebola hemorrhagic fever in Sudan, 1976. Report of a WHO/International Study Team. Bull World Health Organ 1978;56:247-70.
Ebola hemorrhagic fever in Zaire, 1976. Bull World Health Organ 1978;56:271-93.
Reichart PA, Gelderblom HR, Khongkhunthian P, Westhausen AS. Ebola virus disease: Any risk for oral and maxillofacial surgery? An overview. Oral Maxillofac Surg 2016;20:111-4.
Amundsen, S. Historical analysis of the Ebola virus: Prospective implications for primary care nursing today. Clin Excell Nurse Pract 1998;2:343-51.
Aurelie KK, Guy MM, Bona NF, Charles KM, Mawupemor AP, Shixue L, et al
. A historical review of Ebola outbreaks. Advances in Ebola control. InTech Open 2017;2:1-27.
Feldmann H, Geisbert TW. Ebola hemorrhagic fever. Lancet 2011;377:849-62.
Maganga GD, Kapetshi J, Berthet N, Kebela Ilunga B, Kabange F, et al.
Ebola virus disease in the Democratic Republic of Congo. N Engl J Med 2014;371:2083-91.
Raftery P, Condell O, Wasunna C, Kpaka J, Zwizwai R, Nuha M, et al.
Establishing Ebola Virus Disease (EVD) diagnostics using GeneXpert technology at a mobile laboratory in Liberia: Impact on outbreak response, case management, and laboratory systems strengthening. PLoS Negl Trop Dis 2018;12:1-20.
Hofmann-Winkler H, Kaup F, Pohlmann S. Host cell factors in filovirus entry: Novel players, new insights. Viruses 2012;4:3336-62.
Mahanty S, Bray M. Pathogenesis of filoviral hemorrhagic fevers. Lancet Infect Dis 2004;4:487-98.
Fowler RA, Fletcher T, Fischer WA 2nd
, Lamontagne F, Jacob S, Brett-Major D, et al.
Caring for critically ill patients with Ebola virus disease. Perspectives from West Africa. Am J Respir Crit Care Med 2014;190:733-7.
Ansari AA. Clinical features and pathobiology of Ebolavirus infection. J Autoimmun 2014;55:1-9.
Beeching NJ, Fenech M, Houlihan CF. Ebola virus disease. BMJ 2014;349:7348.
WHO Ebola Response Team. Ebola virus disease in West Africa-the first 9 months of the epidemic and forward projections. N Engl J Med 2014;371:1481-95.
Dallatomasina S, Crestani R, Squire JS, Declerk H, Caleo GM, Wolz A, et al.
Ebola outbreak in rural West Africa: Epidemiology, clinical features, and outcomes. Trop Med Int Health 2015;10:448-54.
Gostin LO, Friedman EA. A retrospective and prospective analysis of the West African Ebola virus disease epidemic: Robust national health systems at the foundation and an empowered WHO at the apex. Lancet 2015;385:1902-9.
Wong SS-Y, Wong SC-Y. Ebola virus disease in nonendemic countries. J Formos Med Assoc 2015;114:384-98.
Meyers L, Frawley T, Goss S, Kang C. Ebola virus outbreak 2014: Clinical review for emergency physicians. Ann Emerg Med 2015;65:101-8.
Sarwar UN, Sitar S, Ledgerwood JE. Filovirus emergence and vaccine development: A perspective for health in travel medicine. Travel Med Infect Dis 2011;9:126-34.
Wiwanitkit V. Ebola virus infection: Be known? N
Am J Med Sci 2014;6:549-52.
Bwaka MA, Bonnet MJ, Calain P, Colebunders R, Roo AD, Guimard Y, et al.
Ebola hemorrhagic fever in the Kikwit Democratic Republic of the Congo: Clinical observations in 103 patients. J Infect Dis 1999;179:1-7.
Kortepeter MG, Bausch DG, Bray M. Basic clinical and laboratory features of filoviral hemorrhagic fever. J Infect Dis 2011;204:810-6.
Balami LG, Ismail S, Saliluddin SM, Garba SH. Ebola virus disease: Epidemiology, clinical feature and the way forward. Int J Community Med Public Health 2017;4:1372-8.
Park SW, Lee YJ, Lee WJ, Jee Y, Choi W. One-step reverse transcription-polymerase chain reaction for Ebola and Marburg viruses. Osong Public Heal Res Perspect 2016;7:205-9.
To KK, Chan JF, Tsang AK, Cheng VC, Yuen KY. Ebola virus disease: A highly fatal infectious disease reemerging in West Africa. Microbes Infect 2015;17:84-97.
Omonzejele PF. Ethical challenges posed by the Ebola virus epidemic in West Africa. J Bioeth Inq 2014;11:417-20.
Scully C. Ebola: A very dangerous viral hemorrhagic fever. Dent Update 2015;42:7-12.
Matanock A, Arwady MA, Ayscue P, Forrester JD, Gaddis B, Hunter JC, et al.
Ebola virus disease cases among health care workers not working in Ebola treatment units-Liberia, June-August, 2014. MMWR Morb Mortal Wkly Rep 2014;63:1077-81.
Katz LM, Tobian AA. Ebola virus disease, transmission risk to laboratory personnel, and pre transfusion testing. Transfusion 2014;54:3247-51.
Dixon MG, Schafer IJ. Ebola viral disease outbreak--West Africa 2014. Morb Mortal Wkly Rep 2014;63:548-51.
Nielsen CF, Kidd S, Sillah AR, Davis E, Mermin J, Kilmarx PH. Improving burial practices and cemetery management during an Ebola virus disease epidemic-Sierra Leone, 2014. MMWR Morb Mortal Wkly Rep 2015;64:20-7.
Boon SD, Marston BJ, Nyenswah TG, Jambai A, Barry M, Keita S, et al.
Ebola virus infection associated with transmission from survivors. Emerg Infect Dis 2019;25:240-6.
Formenty P, Leroy EM, Epelboin A, Libama F, Lenzi M, Sudeck H, et al.
Detection of Ebola virus in oral fluid specimens during outbreaks of Ebola virus hemorrhagic fever in the Republic of Congo. Clin Infect Dis 2006;42:1521-6.
Samaranayake LP, Scully C, Nair RG, Petti S. The Ebola virus epidemic: A concern for dentistry? Dent Trib News Asia Pac 2014;15:8-10.
Pandey A, Atkins KE, Medlock J, Wenzel N, Townsend JP, Childs JE, et al.
Strategies for containing Ebola in West Africa. Science 2014;346:991-5.
Schieffelin JS, Shaffer JG, Goba A, Gbakie M, Gire SK, Colubri A, et al.
Clinical illness and outcomes in patients with Ebola in Sierra Leone. N Engl J Med 2014;371:2092-2100.
Chertow DS, Kleine C, Edwards JK, Scaini R, Giuliani R, Sprecher A, et al.
Ebola virus disease in West Africa—Clinical manifestations and management. N Engl J Med 2014;371:2054-7.
Plachouras D, Monnet DL, Catchpole M. Severe Ebola virus infection complicated by gram-negative septicemia. N Engl J Med 2015;372:1376-7.
O'Shea MK, Clay KA, Craig DG, Matthews SW, Kao RL, Fletcher TE, et al.
Diagnosis of febrile illnesses other than Ebola virus disease at an Ebola treatment unit in Sierra Leone. Clin Infect Dis 2015;61:795-8.
Bishop BM. Potential and emerging treatment options for Ebola virus disease. Ann Pharmacother 2015;49:196-206.
Espeland EM, Tsai CW, Larsen J, Disbrow GL. Safeguarding against Ebola: Vaccines and therapeutics to be stockpiled for future outbreaks. PLoS Negl Trop Dis 2018;12:1-4.
Hwang ES. Preparedness for the prevention of Ebola virus disease. J Korean Med Sci 2014;29:1185.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]