Intended for healthcare professionals


Ebola survivors: not out of the woods yet

BMJ 2016; 352 doi: (Published 22 January 2016) Cite this as: BMJ 2016;352:i178
  1. Jenny Harries, director, South of England1,
  2. Michael Jacobs, consultant in infectious diseases2,
  3. Sally C Davies, chief medical officer for England3
  1. 1Public Health England, London, UK
  2. 2Royal Free London NHS Foundation Trust, London, UK
  3. 3Department of Health, London, UK
  1. Correspondence to: J Harries jenny.harries{at}

CMO’s advice on managing the risk of viral persistence and relapse

The recent outbreak of Ebola virus disease in west Africa was unprecedented in scale, with over 28 600 cases and 11 300 deaths.1 Survivors may have a range of continuing health problems, including viral persistence and disease recrudescence. If they present with illness, or for certain interventional procedures, they could put others at risk of infection. Clinicians therefore need to know what action to take, and here we lay out the current evidence and expert advice for England.

Studies of survivors from previous smaller outbreaks, corroborated recently, suggest that post-infection sequelae are not uncommon.2 3 4 5 Fatigue, arthralgia, and ocular complications (including uveitis) are particular problems. The pathogenesis of post-disease complications, and in particular the presence and role of viral persistence, is unknown.

It now seems that earlier prevalence studies underestimated the duration of viral persistence in several immune privileged body sites, such as the testes,6 eye, and central nervous system. A recent small observational study showed persisting Ebola virus genome in the semen of 26% of male survivors up to nine months after disease onset, much longer than the 91 days previously recognised.7 In one case, Ebola virus was detected in aqueous humour 14 weeks after the initial diagnosis.8 There has also been a patient who developed meningoencephalitis due to recrudescence of Ebola virus in the central nervous system 10 months after the initial diagnosis.9 No survivor samples have yet shown viral persistence beyond 12 months, but systematic longitudinal data are needed to investigate this further.

From this emerging evidence it seems likely that Ebola virus persists in some survivors after they recover. In some limited circumstances it also seems that such viral persistence can lead to onwards transmission of the disease. Genetic sequencing of one case showed probable male to female sexual transmission through the semen of a survivor,10 but sexual transmission from female to male has not been reported. The World Health Organization has reported that the most recent cluster of cases in Liberia was the result of the re-emergence of Ebola virus in a previously infected individual.1 Nevertheless, the infectivity of survivors in general seems to be very low. Despite the thousands of survivors in west Africa, there are few known linked cases of transmission, and previous outbreaks have been followed by prolonged disease-free periods.

A few patients treated in resource rich countries received intensive support and experimental therapies, including monoclonal antibodies, and survived particularly severe illness with high viral loads. They may be at particular risk of viral persistence or disease recrudescence.5 Studies are ongoing, and there is much more for us to learn about the Ebola virus; it will take several years to accrue robust data.

Current advice for clinicians in England

The box summarises the principles behind current advice for clinicians in England, produced following advice from Public Health England and the Advisory Committee on Dangerous Pathogens. Known Ebola survivors in England should have an assigned infectious disease unit. Survivors will receive individual advice, including on safer sex for at least 12 months after recovery, and be offered testing for Ebola virus (for example, in semen) as appropriate. They will be given a letter for their general practitioner and asked to advise all healthcare professional contacts that they have had Ebola. Survivors are currently prohibited from donating blood, tissue, and organs; the period for this will be kept under review.

Principles for management of Ebola survivors

  • Alignment with international survivor management objectives

  • Use of routine treatment settings and interventions whenever it is safe to do so, using meticulous standard infection prevention and control

  • Maintain readiness to use personal protective equipment in healthcare settings if required

  • Focus on sensitivity, dignity, respect, confidentiality, and compassion to survivors and their close contacts

  • Voluntary access to specialist follow-up and testing at least equivalent to that offered to in-country survivors

  • Advice and management should be aligned rationally with advice for other bloodborne viruses

  • Aim to return and maintain patients to their normal lives, communities, and community services whenever possible

  • Where evidence is limited and risk is uncertain the precautionary principle should apply

  • Active contribution to research and knowledge dissemination with appropriate consents

All healthcare professionals should remain alert to new entrants and travellers who have survived Ebola. Local Public Health England teams can advise on the initial referral of previously unknown survivors to infectious disease units and related public health matters.

If survivors become ill, they should contact their assigned infectious disease unit by telephone for initial advice and further risk assessment, rather than directly presenting to primary care. When this is impossible (for example, after a car crash), the treating clinician should always seek support from the assigned infectious disease unit. This is true for elective surgery, including dentistry, and particularly for procedures on immune privileged sites such as the eye, central nervous system, and male genital tract. Standard universal infection control precautions should provide adequate protection in most circumstances.

Survivors presenting with a relapse of Ebola, and therefore potentially able to transmit disease, seem to be rare and will be symptomatic. Healthcare providers must ensure that they can be identified safely and isolated quickly.

Many Ebola survivors have endured stigma as they try to resume their normal lives. Emotional distress, lost livelihoods, and community rejection have not been uncommon.11 12 13 Current evidence suggests that asymptomatic survivors can safely live in the community, use health services, and work normally. This includes roles in healthcare.

The UK has an excellent record of managing haemorrhagic fevers as part of its routine public health response to imported pathogens. It is important that we build on this and use new evidence on Ebola virus recrudescence and transmission as it emerges to protect the health and wellbeing of survivors and the public.


Cite this as: BMJ 2016;352:i178


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Similar arrangements to those described for England are in place across the UK. Relevant local health protection teams for Scotland, Wales, and Northern Ireland can be accessed through Health Protection Scotland (, Public Health Wales (, and Northern Ireland Public Health Agency ( respectively.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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