There has been a mixed success in the use of post exposure treatment for Ebola virus infection and the activity of antibodies against filoviruses is not well understood. It is thought that neutralizing antibodies are produced but at a relatively low frequency. Treatment involving the passive transfer of serum from survivors of Lassa virus soon after infection has been effective. In treating filoviruses like Ebola antibody treatment has been unsuccessful using antibody passive transfer. In a 1995 outbreak in the Democratic Republic of the Congo, much success was observed when whole blood was administered from patients that had resolved the infection. ‘Antibodies reactive with nucleoprotein (NP), envelope glycoprotein (GP), and secreted envelope glycoprotein (sGP) were characterized by immunofluorescence and radioimmunoprecipitation assays. Four antibodies reacting strongly with sGP and weakly with GP and two antibodies reacting with NP were not neutralizing. An antibody specific for GP neutralized Ebola virus to 50% at 0.4 μg/ml as the recombinant Fab fragment and to 50% at 0.3 μg/ml (90% at 2.6 μg/ml) as the corresponding whole immunoglobulin G1 molecule.’ Mupapa K, et al., International Scientific and Technical Committee (1999) Treatment of Ebola hemorrhagic fever with blood transfusions from convalescent patients. J Infect Dis 179(suppl 1):S18–S23 Jahrling PB, Peters CJ (1984) Passive antibody therapy of Lassa fever in cynomolgus monkeys: importance of neutralizing antibody and Lassa virus strain. Infect Immun 44:528–533. Jahrling PB, Frame JD, Rhoderick JB, Monson MH (1985) Endemic Lassa fever in Liberia. IV. Selection of optimally effective plasma for treatment by passive immunization. Trans R Soc Trop Med Hyg 79:380–384. Jahrling PB, Geisbert JB, Swearengen JR, Larsen T, Geisbert TW (2007) Ebola hemorrhagic fever: Evaluation of passive immunotherapy in nonhuman primates. J Infect Dis 196(suppl 2):S400–S403. Jahrling PB, et al. (1996) Passive immunization of Ebola virus-infected cynomolgus monkeys with immunoglobulin from hyperimmune horses. Arch Virol Suppl 11:135–140. Krasnianskiĭ VP, et al. (1994) [The isolation of hyperimmune horse serum to the Ebola virus] Vopr Virusol 39:91–92. Borisevich IV, et al. (1995) [Development and study of the properties of immunoglobulin against Ebola fever] Vopr Virusol 40:270–273. Mikhaĭlov VV, Borisevich IV, Chernikova NK, Potryvaeva NV, Krasnianskiĭ VP (1994) [The evaluation in hamadryas baboons of the possibility for the specific prevention of Ebola fever] Vopr Virusol 39:82–84. Jahrling PB, et al. (1999) Evaluation of immune globulin and recombinant interferon-alpha2b for treatment of experimental Ebola virus infections. J Infect Dis 179(suppl 1):S224–S234.

Hi Annwyne, some of the people infected with the Ebola virus have been treated with serum donated by Ebola survivors but so far there seems to be no guided effort to extract antibodies and characterise antigens.

Hi Axel,

Thank you for your response. SO far antibodies are not reported to resolve ebola viral infection every well. Whole blood samples have had much greater success in the 1995 outbreak in a small sample of patients. The abstract below describes the therapy. It concerns me that the collection of bloods from patients that have resolved Ebola  infection may not be given a very high priority in the current epidemic.

Treatment of Ebola Hemorrhagic Fever with Blood Transfusions from Convalescent Patients . K. Mupapa, M. Massamba, K. Kibadi, K. Kuvula, A. Bwaka, M. Kipasa, R. Colebunders and J. J. Muyembe-Tamfum on behalf of the International Scientific and Technical Committee + Author Affiliations . Kinshasa University, Ministry of Public Health, and Kikwit General Hospital, Kikwit, and National Institute for Biomedical Research, Kinshasa, Democratic Republic of the Congo; Institute of Tropical Medicine, Antwerp, Belgium .

Abstract Between 6 and 22 June 1995, 8 patients in Kikwit, Democratic Republic of the Congo, who met the case definition used in Kikwit for Ebola (EBO) hemorrhagic fever, were transfused with blood donated by 5 convalescent patients. The donated blood contained IgG EBO antibodies but no EBO antigen. EBO antigens were detected in all the transfusion recipients just before transfusion. The 8 transfused patients had clinical symptoms similar to those of other EBO patients seen during the epidemic. All were seriously ill with severe asthenia, 4 presented with hemorrhagic manifestations, and 2 became comatose as their disease progressed. Only 1 transfused patient (12.5%) died; this number is significantly lower than the overall case fatality rate (80%) for the EBO epidemic in Kikwit and than the rates for other EBO epidemics. The reason for this low fatality rate remains to be explained. The transfused patients did receive better care than those in the initial phase of the epidemic. Plans should be made to prepare for a more thorough evaluation of passive immune therapy during a new EBO outbreak. © 1999 by the Infectious Diseases Society of America

There are two problems with using human serum as anti-serum for treatment of disease. Antibody levels are not terribly high, and antibodies do not eradicate viruses, cellular immunity does. If leukocytes were separated from whole blood and given to Ebola patients, that should work.

1. A few weeks post-infection antibody titers are dropping, and they are never terribly high. In hyperimmune animals created by special protocols for antivenin production, at most, perhaps 2% of the antibody present is to the challenge antigen. Human hyperimmunity to antigen is quite rare and only seen in venomous snake handlers who inject venom to protect themselves from dying of snakebite. It takes them 6-12 months to develop hyper-immunity, and they usually go through a period of anaphylactic reaction to the dilute venom injections before working up to full hyper-immunity. I've started studying them and there are some indications that initially, hyperimmunity is hard to produce in humans.

2. The bigger problem is that antibodies are not the primary defense that eradicates viruses. Cellular immunity does that. For instance, if you knock out the ability of a mouse to mount a cellular response to infection, it doesn't matter how high the antibody titers are that you create by vaccination. If you inoculate that mouse with a virus normally fatal to mice, it will die. Period. Antibodies are strictly secondary to eradication of viruses.

Conversely, if you generate a strict cellular immune response, that mouse will survive even if its antibody titers remain extremely low. There are strong historical indications that native Americans had evolved to optimize humoral immune response to infection. There are early records from the settlement of Massachussets that showed 95% total mortality of Native Americans to illnesses that merely inconvenienced the European settlers. In fact, this phenomenon is the origin of the phrase, "Manifest destiny." The phrase was first used in a sermon that said that it was the manifest destiny of the colonists to take over the land because god was yielding it up this way.

This is why DNA vaccines work for viruses, but DNA vaccines do not produce high titers of neutralizing antibodies. DNA vaccines produce cellular immunity, which protects against the disease.

This is a letter to the BMJ addressing the concept of clinical trials on this subject.

http://www.bmj.com/content/349/bmj.g4997/rr/778286

http://www.bmj.com/content/349/bmj.g4997/rr/778286

I appreciate the expression in that article, but it is far too tentative. I don't think I would pass that from a grad student in an oral exam, but I understand that for reasons unknown to me, the medical community considers it appropriate to express things that way. Similarly, I am familiar with the apparent allergy to education about how the immune system works that editors and reviewers of medical journal seem to have if an article attempts to do that to address common deficiencies in immunology understanding that result from a typical medical school education. While there are some differences between human and animal immunology, they are mostly minor.

The biggest difference is the mutation of siglec-13 that prevents control of the TLR4 response and makes humans 3,000 times more sensitive to sepsis. Also, humans and primates have some differences with mouse immunology such as producing CD4/CD8 cells and some subgroups of humans tend to tilt strongly toward Th1 or Th2 immune response. This last probably has the biggest effect on viral infection survival, but has been handled pretty well by adjuvants that tilt the response one way or the other.

Animal production of antibodies for research use is nothing but vaccination, the same is true for production of things like antivenin. This is done day in, day out, on a small industrial scale by many companies that provide such. This article makes clear exactly what we should do to create a group of volunteers with hyper-immunity to Ebola. This is also what we obviously should be making at every hospital in the country to immunize personnel against Ebola in the absence of an approved vaccine. Yes, I am familiar with the FDA regulations, but those weren't intended to kill people by trapping them into being unable to fight disease.

http://ilarjournal.oxfordjournals.org/content/37/3/93.long

I'm being rather sharp here, but I have been absolutely appalled at how this Ebola outbreak has been handled both here and in Africa. In Africa, it's criminal how atrocious it all is. Here it's just a bungle. Don't take it too personally. At least you are trying to push.

The IL-10 problem is due to VP35 and VP24 controlling immune response more in some people than in others. What this indicates is that we should be injecting people testing  positive for Ebola with interferon-gamma and with interleukins 2 and 15, to kick the immune system into gear. VP35 and VP24 both prevent activation of the intracellular receptors and hence prevents the IFN cascade from activating the immune system.  IFN-gamma is available as Actimmune http://www.actimmune.com/ . IL-2 is available as Aldesleukin or Proleukin. http://www.proleukin.com/ IL-15 is not available as an approved product.

Thanks Brian, I very much appreciate your comments and your detailed knowledge.

I share your sentiment and passion as a scientist but we may describe too much scientific detail to communicate effectively to a less scientific clinical community. Some of my own research highlighted that the expression of IL12 was an important factor to mounting a cytotoxic response to virus infection (HCV) and some genotypes did this better than others. Unfortunately systemic IL-12 therapy cannot be tolerated clinically by patients, except when delivered to a specific organ as in liver tumour treatment. There is a strong emphasis on IFN free therapy in HCV concentrating on inhibiting viral replication but I think that we should still be looking to factors boosting the human immune response.

Yes, however, IFN-gamma is well tolerated, and it has been known for a long time that Ebola interferes with IFN-gamma production. Similarly, IL-2 is generally well tolerated. People have recieved IFN-gamma for years to combat fibrosis subsequent to gamma radiation burns. So there is no reason not to use it in clinical practice.

This gets to the primary issue I have with response to this Ebola outbreak. When people are dying on the streets and governments are in danger of breaking down, you do what you can - now. Unfortunately, the research attitude is the opposite, and that is what is running things.

We can use IFN-gamma and IL-2 boost early in infection, make that part of a protocol for treatment. Similarly, we can do the same with ghrelin. The proximate cause of death in Ebola is multi-organ failure/septic shock (though not from TLR-4). Ghrelin both rescues from shock, and it controls diarrhea. Profound ghrelin suppression happens with GI compromise. Diarrhea in Ebola is a major problem. So this should also be part of the treatment protocol.

LIkewise, leukocytes harvested from survivors should be part of treatment protocol, along with serum from antibody boosted volunteers. We could also make horse, goat, donkey, or some other anti-serum in-country using killed Ebola virus from patients who died. Those protocols are very well known. We could do them, concentrating on VP24 and VP35, because those immune modulating proteins are key to Ebola's success as a virus.

Too much focus on silver-bullets and cookbook medicine.

And how on earth it is that nobody is pointing out the blindingly obvious--that flying insects have to be spreading Ebola in Africa, is beyond me.

It seems that the recruitment of convalescent patients has begun as several have been trained in care skills recently

http://www.breakingnews.ie/world/ebola-survivors-now-immune-given-care-training-for-outbreak-645760.html 

http://www.breakingnews.ie/world/ebola-survivors-now-immune-given-care-training-for-outbreak-645760.html

Hopefully this is the beginning of transfusion therapy for Ebola infected patients

http://www.usatoday.com/story/news/nation/2014/10/08/camerman-ebola-transfusion/16906983/

It will be interesting to see if the infrastructure of clinics, and laboratories is possible to recruit, donate, HIV/HCV test, and transfuse infected patients.

http://www.usatoday.com/story/news/nation/2014/10/08/camerman-ebola-transfusion/16906983/

Thought about this more and emailed with an interested party who asked the question about whether small amounts of blood might work as treatment.

In reference to the Mupapa paper (1999) on blood transfusion:

Normal white blood cell count (WBC) is in the 5-10 million per ml range. Using the low end for conservatism, the total WBC for 450 ml and 50 ml is 2.25 billion and 250 million cells respectively, which is about 1 order of magnitude. Is that factor of ten going to prevent the treatment from working? I tend to doubt it, although the effect may not be as strong.

The majority (70%-80%) of those white blood cells are CD8's and CD4's, absent a bacterial infection. (Although, unlike mice, humans have cells that are both. Most immunology texts should be subtitled, "Immunology of the rodent".) About 15%-20% are NK cells, which also play a major role in fighting intracellular infection. NK's and CD8's should play the most obvious direct role, and unlike antibodies, those cells are not used up. They just go on killing infected cells, one after another.

And after thinking about it, another major role will be played by CD4 cells responding to Ebola presence with appropriate signalling. It doesn't take much of that to get the immune system to expand B cells and T-cells that target the Ebola antigens.

So it well may be that much smaller amounts of whole blood, on the order of 50 ml, may work. And if it doesn't work to cure, it should still buy time and one should be able to observe patients well enough to follow up with more.

If the people are from the same tribal group, their HLA type should be fairly well matched. But, it is conceivable that if the therapy is given too early, the recipient's immune system could attack it and destroy the non-self cells, then be primed to do so later, which might interfere with the treatment method.  It's hard to say exactly, but I would lean toward those donor cells having a fairly long life-span of at least weeks.

What is required is the need for all personnel involved in this Ebola crisis to join up the dots, taking note of the immunology and applying it to this subject, as Brian so eloquently does in the previous communication. This kind of immune response is reflected in several other known viral infections that are better understood, based on T-helper cell adaptive responses. We know from HCV infection how inadequate some humoral human responses can be during viral infection and how significant the T-cell responses and cytokine profiles are, often individual to a patient’s genotype. In the ‘Treatment of Ebola Hemorrhagic Fever with Blood Transfusions from Convalescent Patients’ by K. Mupapa paper, the clinical details of transfusion are described where 150-450 cm3 of blood volume have been administered. It is not clear if this is calculated from BMI or age but I am awaiting a reply as an answer to this from the authors. Also it is not clear in the paper if any blood matching took place and that query has also been made. I would like to emphasize that 7 out of 8 patients survived the infection in this paper although other confounding factors existed, such as standard of health care. It may be sobering to remember that patients have still died of Ebola when treated in excellent healthcare environments in the West. In answer to Brian’s comment on establishment of infection and the time lapse before transfusion and after initial infection, a patient were transfused between 4 and 15 days after infection and as Brian suggested it was the 4th day transfusion that resulted in a fatality.

It's a 1999 paper, and if the authors are still in Africa, email service is often spotty, to put it mildly. I have tried to reach a scientist I know there for a year with no success. But a friend of his told me he is in the field and has no internet access. I heard he was recently married.

Good point. I was thinking that blood type might be homogenous in a tribal group. But looking at this distribution map, http://anthro.palomar.edu/vary/vary_3.htm West Africa is about 10%-20% A, ~20% B, the rest O. (Which doesn't mean there isn't a fair amount of tribal homogeneity.)

A dose of 400 cc of incompatible blood is enough to be quite problematic, though not necessarily fatal. However, if the person was not given the incompatible blood type before, it may take a few days to see a reaction. Her symptoms were compatible with transfusion reaction, though not classical. It is interesting she had no fever the day she died. The description reads like a stroke to me. It's even plausible that she was cured and she just had a stroke, separate from her illness. Things like that happen.

The classical reaction to blood type mismatch is similar to symptoms of Ebola, which itself causes hemolysis. Hemolysis causes back pain, bloody urine, chills, fainting or dizziness, fever, flank pain, flushing of the skin.

I could see this going both ways. I think it's likely that they typed the blood by a simple hemagglutanation field test, combining the blood in a vial, or adding patient serum to the donor material. But for a delayed reaction, that won't work. Did they have more sophisticated tests available? I suspect so, given their other data present in the paper, but maybe they used older methods and got archived blood analyzed later. Did they have the equipment to spin down whole blood to get serum? Probably, looking at the paper's other data.  Either way, if it was me out there in the field, faced with a probable death, I'd decide to give the blood and risk it.

It is also possible that the physicians knew the tribes, and that they had experience that told them that a person from a tribe was going to be a particular type. That's a "who knows?" kind of thing.

http://www.scientificamerican.com/article/blood-transfusions-from-survivors-best-way-to-fight-ebola/