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2020 05 07 NEJM Ebola.Pdf The new england journal of medicine Review Article Edward W. Campion, M.D., Editor Ebola Heinz Feldmann, M.D., Armand Sprecher, M.D., and Thomas W. Geisbert, Ph.D.​​ From the Laboratory of Virology, Division bola virus (EBOV) was the best-known and most extensively stud- of Intramural Research, National Insti- ied member of the Filoviridae family (Mononegavirales order) long before tute of Allergy and Infectious Diseases, Rocky Mountain Laboratories, Hamilton, the shattering 2013–2016 West African epidemic. The virologic taxon Filo- MT (H.F.); Médecins sans Frontières, E viridae was defined in 1982 and subsequently amended regularly to accommodate Brussels (A.S.); and the Department of changes.1,2 These amendments and the unfortunate renaming of commonly used Microbiology and Immunology and Gal- veston National Laboratory, University terms has made the filovirus taxonomy confusing. Today, EBOV refers to the spe- of Texas Medical Branch at Galveston, cific member virus of the type species Zaire ebolavirus in the genus ebolavirus Galveston (T.W.G.). Address reprint re- (Fig. 1). quests to Dr. Feldmann at Rocky Moun- tain Laboratories, 903 S. 4th St., Hamil- The history of filoviruses largely involves human outbreaks (Fig. 1). Marburg ton, MT 59840, or at feldmannh@ ​­niaid virus (MARV) was the first filovirus to be discovered, in 1967.3 EBOV and Sudan . nih . gov. virus (SUDV) were codiscovered in 1976 in the Democratic Republic of Congo N Engl J Med 2020;382:1832-42. (DRC) and South Sudan, respectively.4,5 Subsequently, two additional ebolaviruses DOI: 10.1056/NEJMra1901594 were found to be pathogenic in humans: Taï Forest virus (TAFV) in Côte d’Ivoire Copyright © 2020 Massachusetts Medical Society. in 1994 and Bundibugyo virus (BDBV) in Uganda in 2007.6,7 Reston virus (RESTV), imported into the United States from the Philippines in 1989–1990, has long been the exception, since it appears to infect humans only subclinically.8,9 Unexpect- edly, it emerged in swine in the Philippines, and RESTV sequences were detected in pigs in China, raising fear about food safety.10,11 The zoonotic potential of RESTV remains unclear, and investigation of that potential is urgently needed. More recently, genomes of new filoviruses were detected in bat and fish species. Lloviu virus (LLOV), genus cuevavirus, was sequenced from bats (Miniopterus schreibersii) in Spain and Hungary.12 Měnglà virus (MLAV) sequences were found in Chinese rousettus species representing the newly proposed genus, dianlovirus.13 Bombali virus (BOMV) sequences were discovered in bats from Sierra Leone, Guinea, and Kenya; the virus is considered to be a new ebolavirus species.14 Fi- nally, fish-derived filoviruses constitute members of two new genera, striavirus and thamnovirus.2,15 Since no isolates are available, the unknown zoonotic and pathogenic potential of these new filoviruses is a public health concern. Virologic Features Filoviruses are enveloped, filamentous particles with a nonsegmented, negative- sense RNA genome (Fig. 1).2,16-18 The genomic RNA is encapsidated by the nucleo- protein and, together with polymerase L, polymerase cofactor virion protein (VP) 35, and transcription activator VP30, constitutes the nucleocapsid with replicase and transcriptase function. This structure interacts with the nucleocapsid-associ- ated VP24 and is surrounded by the matrix protein VP40, the driver of particle formation. The viral spike is formed by the sole trimeric transmembrane glycopro- tein and mediates viral entry; it also represents an important target for host im- mune responses.2,16-18 With all ebolaviruses, unlike marburgviruses, RNA editing 1832 n engl j med 382;19 nejm.org May 7, 2020 The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF EXETER on May 6, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. Ebola A Transmembrane glycoproteins Matrix (VP40 and VP24) Single-stranded, negative-sense RNA (NP encapsidation and VP30) Polymerase complex Viral (VP35 and L) envelope Nucleocapsid B Epidemiology and Taxonomy GUINEA IVORY SOUTH REPUBLIC OF COAST SUDAN THE CONGO SIERRA UGANDA LEONE LIBERIA KENYA Genus Species Virus Country Origin (species) Isolate DEMOCRATIC GABON REPUBLIC OF CONGO Marburg Marburg virus Angola, Kenya, Uganda, Egyptian fruit bat, Yes marburgvirus (MARV) Zimbabwe human Marburgvirus Marburg Ravn virus Egyptian fruit bat, DRC, Kenya, Uganda Yes marburgvirus (RAVV) human ANGOLA Bundibugyo Bundibugyo virus DRC, Uganda Human Yes ebolavirus (BDBV) ZIMBABWE Sudan Sudan virus DRC, South Sudan Human Yes ebolavirus (SUDV) Ebolavirus Taï Forest Taï Forest virus Ivory Coast Human Yes ebolavirus (TAFV) Zaire Ebola virus DRC, Gabon, Guinea, Human Yes ebolavirus (EBOV) Liberia, RC, Sierra Leone Figure 1. Biology, Epidemiology, and Taxonomy of Filoviruses. In Panel A, the electron micrograph (left) includes a computer-annotated viral particle (Ebola virus, Makona strain) showing the typical filamentous shape (blue) and the core structure (yellow). The core structure (right) comprises the genomic RNA encapsidated with the viral nucleoprotein (NP) and linked with the viral transcriptase–replicase complex, which consists of virion proteins 30 and 35 (VP30 and VP35) and RNA-dependent RNA polymerase, which is further associated with VP24. The structure is surrounded by a cell-derived membrane associated with VP40 on the inside, with the glycoprotein forming spikes on the outside of the viral envelope. In Panel B, the table shows the taxonomy and some epidemiologic, ecologic, and biologic properties of the members of the Filoviridae family that are pathogenic in humans. The map shows regions in Africa with reported outbreaks. DRC denotes Democratic Republic of Congo, and RC Republic of the Congo. results in glycoprotein expression. The primary macropinocytosis. Subsequently, cysteine pro- product of the glycoprotein gene is a secreted, teases in the endosome cleave the glycoprotein, nonstructural, soluble glycoprotein that has been allowing it to bind to the receptor Niemann– implicated in antigenic subversion.16 Pick C1 and initiating membrane fusion. This Filoviruses replicate in the cytoplasm of their process releases the genome into the cytosol, target cells.16-18 Viral particles attach to the cell where transcription and replication by the viral surface through the binding of glycoprotein to replicase occur through a positive-sense antige- multiple attachment factors, such as C-type lec- nome intermediate that functions as the tem- tins, and cell uptake occurs largely through plate for progeny negative-sense genomes. Viral n engl j med 382;19 nejm.org May 7, 2020 1833 The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF EXETER on May 6, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. The new england journal of medicine Pre-Outbreak Outbreak Post-Outbreak Outbreak end Death surveillance Education Capacity building Surveillance Education Vaccination Bat Reservoir host Index case Zoonotic Human-to-human Safe burial transmission transmission Education Vaccination Intermediate or amplifying hosts (end hosts) Triage Convalescent Isolation Follow-up Chimpanzee Infection prevention and control Counseling Treatment Treatment Counseling Gorilla (persistence) Duiker Figure 2. Outbreak Phases. Shown are the key elements of the three phases of an Ebola virus outbreak, including control measures. positive-sense RNA transcripts are translated by foster therapeutic development. Future efforts host ribosomes, leading to intracellular assem- should focus on studying differences between bly of the nucleocapsid and budding from the these viruses and the more recently discovered plasma membrane.2,16-18 filoviruses with unknown pathogenic potential. Knowledge of filoviruses is largely based on studies of EBOV and MARV, but all filoviruses Epidemiologic and Ecologic are thought to follow similar principles in cell Features biology, with certain distinctions such as altera- tions in genomic structure, interferon antago- Filoviruses are zoonotic pathogens maintained nistic property, and RNA editing.2,16-18 Over the in reservoir species, perhaps bats, with occasional years, life-cycle modeling systems have been es- spillover into humans and other mammals, tablished for EBOV and MARV that can be safely which may serve as end, intermediate, or ampli- used in biosafety level 1 and 2 laboratories.17 fying hosts (Fig. 2).19 This concept, however, has These systems have been instrumental in the been established only for MARV, with isolation understanding of filovirus replication and will from Rousettus aegyptiacus.20 Multiple bat species 1834 n engl j med 382;19 nejm.org May 7, 2020 The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF EXETER on May 6, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. Ebola have been implicated as harboring ebolaviruses, route.18,25,26 Initially, infection is manifested as a but viral isolation has yet to be successful.21 This nonspecific febrile illness characterized by mal- is rather uncommon and may be explained by aise, fatigue, and myalgia. A few days later, low viral loads, low susceptibility of cell lines, or gastrointestinal manifestations develop in many inhibitors in bat tissue. Since bats are probably patients, with anorexia, nausea,
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