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 There are many unanswered questions surrounding the circumstances of
the woman's death in Democratic Republic of Congo, which has not
previously been reported.
But it has raised concerns because the woman, whose name has not
been released for confidentiality reasons, was thought to have had
immunity after surviving infection, but fell ill again with Ebola
and died.
"That was a big red flag event for all of us," said Janet Diaz, who
leads the World Health Organization's clinical management team for
the epidemic in Congo.
Congo's Ebola outbreak has infected over 3,000 people and killed
more than 2,000 since August last year. It is the second-worst
outbreak after one in West Africa between 2013 and 2016 that killed
more than 11,000 people.
The woman was working as a caregiver in the high-risk "red zone" of
a treatment center in Beni, eastern Congo, according to health
officials familiar with her case.
She was one of dozens of people assigned to care for Ebola patients
because it was assumed they would not get sick as Ebola survivors,
although some researchers have considered reinfection to be at least
a theoretical possibility.
Their presumed immunity allowed for closer contact with sufferers,
many of them children.
Alima, the medical charity that co-ran the Beni center where she
worked, said she tested positive for Ebola and died in July before
she could be readmitted for treatment.
But it is not yet known whether the woman received a false positive
result the first time she was tested, experienced a relapse or was
reinfected, health officials say.
Medical experts say it could be years before Ebola survivors'
immunity is fully understood. Yet the recent case is sufficiently
worrying for health authorities to rethink how care should be
provided to Ebola patients across eastern Congo.
The WHO and Congolese officials have drafted new guidelines, seen by
Reuters, that warn that some Ebola survivors may have "incomplete
immunity" and advise that additional measures should be taken to
protect them from possible reinfection.
The new protocols would set limits on which Ebola survivors can work
in treatment centers and standardize precautions that must be taken.
Survivors who had mild cases of Ebola and those who were found to
have low viral loads - or lower levels of the virus circulating in
their blood - while infected "need to be carefully assessed, as they
may be at risk for having incomplete immunity after infection," the
draft says.
Diaz said the protocols were still being discussed with health
organizations and could change in the drafting process.
QUESTIONS ABOUT IMMUNITY
Efforts to contain the Congo outbreak have been hampered by militia
violence and public mistrust, but aided by medical advances
including new vaccines and therapies.
Ebola survivors, known as "les vainqueurs" – French for "the
victorious" – have been at the forefront of treatment, offering
vital care, especially to children.
Their assumed immunity has meant they could spend extended time with
patients and provide much-needed human contact. The protective gear
they must wear is lighter and less restrictive than that worn by
other health workers.
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But the draft protocols being discussed by health authorities would
bar some survivors from working in the contaminated red zone.
These include people whose immune systems may be weaker because they
are pregnant or because they have other infections such as HIV or
tuberculosis, and those who had low viral loads during their Ebola
infection.
The woman who died was pregnant at the time, which she had not
disclosed to the treatment center, according to Nicolas Mouly,
Alima's emergencies coordinator. But it is not known if that played
a role in her falling sick again.
Mouly said Congo's biomedical research institute was running tests
to learn more about the case. Officials with Congo's Ebola response
and the institute did not respond to phone calls and text messages
seeking comment.
In response to the case, health authorities have reviewed the
clinical histories of all Ebola survivors working with Ebola
patients, the WHO's Diaz said. They have also reminded treatment
centers to ensure their employees are following biosafety rules.
Much remains unknown about how immunity works in Ebola survivors,
including how treatments might affect a patient's susceptibility to
reinfection.
"I think that's the big question: What is the true immunity of an
Ebola patient who survived?" Diaz said. "Everyone's working very
hard right now to both care for patients and also move science
along."
There have been several confirmed cases of relapse with Ebola,
including a Scottish nurse https://www.reuters.com/article/us-health-ebola-survivors/mystery-deaths-in-sierra-leone-spread-fear-of-ebola-relapses-idUSKCN0SF1YI20151021
who was infected in Sierra Leone in 2014 and fell ill again 10
months after recovery.
But the symptoms have tended to be localized in certain parts of the
body and are not known to have been fatal, according to Raina
MacIntyre, who heads the Biosecurity Program at the University of
New South Wales' Kirby Institute.
No case of reinfection has been confirmed since the disease was
discovered near the Ebola River in northern Congo in 1976.
Short-term immunity has largely been treated as a given. And a study
of 14 survivors of the first documented Ebola outbreak in 1976 found
that all were able to develop an immune reaction to at least one of
three Ebola virus proteins 40 years later.
Alima's Mouly said the creation of a standardized set of rules for
survivors working in treatment centers was a positive step, but
recommended further measures to ensure the physical and mental
well-being of all survivors.
(Additional reporting by Stanis Bujakera in Kinshasa; Editing by
Edward Mcallister, Kate Kelland, Alexandra Zavis and Mike Collett-White)
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