Local accounts
Epidemiologists identified the index case of the West African epidemic to be an infant in the small village of Meliandou in Guinea’s Forest Region,2 and a multidisciplinary team suggested he was infected from a Mops condylurus bat colony.3
During DM’s scoping visits in 2016, however, some villagers, including Meliandou’s community health-worker, explained that a woman named ‘Fanta’ seeking treatment from a noted village healer brought EVD to the village. She had come from the diamond region of Sefadou in nearby Sierra Leone immediately before the outbreak in December 2013, but had first visited several months earlier after being referred to the healer by doctors at Gueckedou hospital. The healer said that Fanta suffered from Gnangafoo in his Kissi language, for which he was a specialist. Understood usually as a socially caused affliction, this manifests in itchy skin over much of the body and hair loss; Fanta had these symptoms.
Fanta initially lodged with the healer for about 2 months but also befriended the mother and grandmother of the infant ‘index case’. The healer recalled how Fanta and this infant’s mother ‘ate, slept and did everything together’ with Fanta often carrying the infant on her back. After recovering somewhat, Fanta left for Sierra Leone but returned to finish treatment just prior to the outbreak. As the healer was travelling, his wife said that she only stayed 5 days or less and had ‘no symptoms of disease’. The residential community health-worker explained how:
In my humble opinion, it is a certain Fanta … who brought us this illness. She suffered from a severe skin complaint that she came to treat here. She was healed. She left back to Sierra Leone and then returned for a second time. She slept in the same bed, cooked and ate with [the index case’s grandmother]… Several days after she left, [the grandmother] fell ill with joint pains and headaches. She recovered initially. A few days later deaths struck the family. Six died rapidly in the family that welcomed Fanta.
Variants of this narrative circulate in the region (Gbanace et al, 2014)4 describing Fanta’s friendship with a former Sierra Leonean soldier who had returned from the Democratic Republic of Congo (DRC). Villagers told DM, too, that Fanta was linked to a diamond dealing or mining family across the border. The virus phylogenetics suggest that the West African outbreak has a common origin with the virus circulating in diamondiferous regions of the Luebo outbreak in DRC in 2007/2008, diverging from it in c.2004.5
Researchers who traced EVD to Meliandou heard narratives concerning Fanta but rejected them as she had no Ebola symptoms as then known, and had arrived with Gnangafoo months before the outbreak, far longer than the EVD incubation and infection period. It was then believed that Ebola patients either died or recovered, clearing active virus from their body. This reasoning cannot now be upheld. First, the symptoms that brought Fanta to Meliandou are now known to be common sequelae of post-Ebola syndrome.6 Second, flare-ups of EVD have been traced to ‘survivors’ in at least 13 instances during or within 2 years of the West African epidemic, with the new evidence now extending this to 7.7 8 Third, oral accounts link Fanta with DRC and despite their ambiguities, they render infection from DRC plausible when combined with evidence of longer-term persistence.
Modes of Ebola virus (EBOV) persistence and latency are inadequately known but are associated with immune-privileged organs. Published research on persistence in women and children is lacking but EBOV genomic material in semen can correlate with eye and joint pain9 and has also been detected in asymptomatic survivors and even following multiple prior negative samples.10 Resurgence may be associated with immunocompromised states, including pregnancy, poverty and poor nutrition, and co-infections such as with HIV.11 The epidemiological team speculated that Fanta may have been suffering AIDS but had no reason to contemplate co-infection with EBOV. Transmission from resurgence can occur from men’s sperm and from mother to baby through breastfeeding.12 The potential for congenital infection has not been considered.