Ebola medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Joseph Nasr, M.D.[2]; Marjan Khan M.B.B.S.[3]

Overview

The management of Ebola virus disease (EVD) has been transformed by the approval of two monoclonal antibody therapies in 2020. Inmazeb (atoltivimab, maftivimab, and odesivimab-ebgn; Regeneron Pharmaceuticals) was approved by the U.S. Food and Drug Administration (FDA) on October 14, 2020, and Ebanga (ansuvimab-zykl; Ridgeback Biotherapeutics) was approved on December 19, 2020, both for the treatment of infection caused by Orthoebolavirus zairense (formerly Zaire ebolavirus) in adult and pediatric patients, including neonates born to a mother who is RT-PCR positive for Orthoebolavirus zairense infection. Both agents are strongly recommended by the World Health Organization (WHO) as first-line therapies for patients with PCR-confirmed Orthoebolavirus zairense infection, as stated in the WHO Ebola virus disease therapeutic guideline released in August 2022.

Supportive care remains the foundation of EVD management. Early supportive care alone (e.g., intravenous fluids, electrolyte supplementation, and nutritional support) can reduce mortality rates to approximately 40%. The importance of early treatment cannot be overstated: the PALM trial demonstrated an 11% increase in the odds of death for each day that symptoms persisted before treatment initiation. A secondary analysis of 781 patients from the tenth DRC outbreak confirmed that delaying care and treatment at EVD treatment centres increased mortality risk by 5% for each day following symptom onset.

Limitation of use: The efficacy of both Inmazeb and Ebanga has not been established for other species of the Orthoebolavirus and Orthomarburgvirus genera (e.g., Sudan ebolavirus, Bundibugyo ebolavirus, Marburg virus). Orthoebolavirus zairense can change over time, and factors such as emergence of resistance or changes in viral virulence could diminish the clinical benefit of antiviral drugs.

Medical Therapy

FDA-Approved Monoclonal Antibody Therapies

The PALM Trial

The Pamoja Tulinde Maisha (PALM) trial (NCT03719586) was a multi-center, open-label, randomized controlled trial conducted in the Democratic Republic of the Congo during the 2018–2019 outbreak. A total of 681 patients of all ages, including pregnant women, with documented Orthoebolavirus zairense infection were enrolled. Patients were randomized to receive one of four investigational therapies: the triple monoclonal antibody cocktail ZMapp (control), the antiviral agent remdesivir, the single monoclonal antibody mAb114 (Ebanga), or the triple monoclonal antibody cocktail REGN-EB3 (Inmazeb). All patients received optimized standard of care (oSOC) consisting, at a minimum, of IV fluids, daily clinical laboratory testing, correction of hypoglycemia and electrolyte imbalances, and broad-spectrum antibiotics and antimalarials, as indicated.

The data and safety monitoring board recommended early termination of the ZMapp and remdesivir arms based on an interim analysis demonstrating superiority of mAb114 and REGN-EB3. Key results:

Treatment Arm	28-Day Mortality	Comparison
mAb114 (Ebanga)	35.1% (61/174)	vs ZMapp 49.7% (84/169); P=0.007
REGN-EB3 (Inmazeb)	33.5% (52/155)	vs ZMapp subgroup 51.3% (79/154); P=0.002
Remdesivir	53.1%	Not superior to ZMapp
ZMapp (control)	49.7%	Control arm

Mortality was strongly associated with viral load at baseline: among patients in the mAb114 and REGN-EB3 treatment groups, mortality was 67% among patients with cycle threshold (Ct) values ≤22 (high viraemia), compared with 11% among patients with Ct values >22 (low viraemia). Among patients with low viral loads, mortality rates were 9.9% (mAb114) and 11.2% (REGN-EB3).

A secondary analysis of 781 patients from four EVD treatment centres in North Kivu confirmed that, compared to standard treatment without antivirals, adjusted mortality rates were significantly reduced with mAb114 (adjusted hazard ratio 0.27, p0.001), REGN-EB3 (aHR 0.26, p0.001), and remdesivir (aHR 0.38, p=0.005). ZMapp also showed a reduction with borderline statistical significance (aHR 0.47, p=0.032). Vaccinated EVD patients were 1.7 times less likely to die compared to unvaccinated patients.

Four serious adverse events were judged to be potentially related to the trial drugs in the PALM trial.

Inmazeb (REGN-EB3: Atoltivimab, Maftivimab, and Odesivimab-ebgn)

Mechanism of action: Inmazeb is a combination of three fully human monoclonal antibodies co-formulated in a 1:1:1 ratio. Each antibody targets a different epitope on the Orthoebolavirus zairense glycoprotein (GP):

• Atoltivimab (REGN3470) — targets the GP base*
• Maftivimab (REGN3479) — targets the GP head*
• Odesivimab (REGN3471) — targets the GP glycan cap*

Dosing and administration:

• Recommended dose: 50 mg of atoltivimab, 50 mg of maftivimab, and 50 mg of odesivimab per kg body weight*
• Administered as a single intravenous infusion*
• Available in two strength presentations: 16.67 mg/16.67 mg/16.67 mg per mL (withdraw 3 mL/kg) or 33.33 mg/33.33 mg/33.33 mg per mL (withdraw 1.5 mL/kg)*
• Must be diluted in 0.9% sodium chloride, 5% dextrose, or lactated Ringer's solution prior to infusion*
• For neonates, dilute in 5% dextrose*
• Administer through an IV line containing a sterile, in-line or add-on 0.2-micron filter*
• Approximately 99% of subjects in the PALM trial completed their dose within three hours*

Adverse reactions: The most common adverse events (incidence ≥20%) reported during infusion were pyrexia (elevation in fever) (54%), chills (39%), tachycardia (20%), tachypnea (19%), and vomiting (19%). Evaluation of adverse events may have been confounded by the signs and symptoms of the underlying Orthoebolavirus zairense infection. Infusion could not be completed in 1% of subjects due to infusion-associated adverse events.

Warnings: Hypersensitivity reactions including infusion-associated events have been reported during and post-infusion. These may include acute, life-threatening reactions. Monitor all patients for signs and symptoms including hypotension, chills, and elevation of fever during and following infusion. In the case of severe or life-threatening hypersensitivity reactions, discontinue administration immediately and administer appropriate emergency care. The rate of infusion may be slowed or interrupted if the patient develops any signs of infusion-associated events.

Ebanga (Ansuvimab-zykl, mAb114)

Mechanism of action: Ebanga is a single human immunoglobulin G1 (IgG1) monoclonal antibody that targets the receptor-binding domain of the Orthoebolavirus zairense glycoprotein (GP1). It blocks binding of EBOV GP1 to the [[[Niemann-Pick disease type C](https://www.openevidence.com/rare-disease/niemann-pick-disease-type-c)%7CNiemann-Pick C1]] (NPC1) receptor in host cells (EC50 value of 0.09 μg/mL), inhibiting virus entry into the host cell. Ebanga also exhibits Fc-mediated antibody-dependent cellular cytotoxicity (ADCC) activity against cells expressing EBOV GP.

Dosing and administration:

• Recommended dose: 50 mg/kg for adult and pediatric patients*
• Administered as a single intravenous infusion over 60 minutes*
• Must be reconstituted with Sterile Water for Injection, then further diluted in 0.9% sodium chloride or 5% dextrose prior to IV infusion*
• Do not administer as an IV push or bolus*
• Allow vials to reach ambient temperature (15°C to 27°C) for approximately 20 minutes prior to reconstitution*

Adverse reactions: The most common adverse events (incidence ≥10%) reported during infusion were pyrexia (54%), chills (31%), tachycardia (20%), tachypnea (17%), and vomiting (15%). Infusion could not be completed in 1% of participants due to infusion-associated adverse events.

Warnings: Hypersensitivity reactions including infusion-associated events have been reported. Monitor all patients for signs and symptoms including hypotension, chills, and elevation of fever during and following infusion. In the case of severe or life-threatening hypersensitivity reactions, discontinue administration immediately and administer appropriate emergency care.

Comparison of FDA-Approved Monoclonal Antibody Therapies

Feature	Inmazeb (REGN-EB3)	Ebanga (mAb114)
Composition	Triple mAb cocktail (atoltivimab + maftivimab + odesivimab)	Single mAb (ansuvimab-zykl)
Target	Three distinct epitopes on EBOV glycoprotein	Receptor-binding domain of EBOV GP1
Dose	50 mg each of atoltivimab, maftivimab, and odesivimab per kg IV	50 mg/kg IV
Administration	Single IV infusion (within ~3 hours)	Single IV infusion over 60 minutes
FDA Approval Date	October 14, 2020	December 19, 2020
28-Day Mortality (PALM trial)	33.5%	35.1%
Mortality with Low Viral Load (Ct >22)	11.2%	9.9%
Species Coverage	Orthoebolavirus zairense only	Orthoebolavirus zairense only
Pediatric/Neonatal Use	Approved for all ages including neonates	Approved for all ages including neonates
Pregnancy	Not excluded; pregnant women were enrolled in PALM trial	Not excluded; pregnant women were enrolled in PALM trial
Resistance Concern	Lower theoretical risk (three epitopes)	Higher theoretical risk (single epitope); trend toward more escape mutants in GP1 and GP2 domains observed in NHP studies
Storage	Refrigerated (2°C to 8°C)	Lyophilized; requires reconstitution

Adapted from FDA prescribing information for Inmazeb and Ebanga, the PALM trial, and Prasad et al. (2025).

Post-Exposure Prophylaxis with Monoclonal Antibodies

The FDA-approved monoclonal antibodies ansuvimab (Ebanga) and REGN-EB3 (Inmazeb) are promising candidates for post-exposure prophylaxis (PEP) in individuals with high-risk exposure to Orthoebolavirus zairense. Their activity is immediate and not dependent on the host immune response, which may be advantageous over post-exposure vaccination with rVSV-ZEBOV.

During the tenth EVD outbreak in the Democratic Republic of the Congo, ansuvimab or REGN-EB3 was administered as PEP to 23 non-vaccinated individuals assessed as being at high or intermediate risk of developing EVD following community or occupational exposure through close contact with a confirmed case. The median time from contact to PEP administration was 1 day (interquartile range 1–2 days). None of the 23 individuals developed EVD, and all were negative for Ebola virus on PCR at day 14.

A strategic integration of monoclonal antibodies (for immediate protection) and vaccines (for long-term immunity) as PEP has been proposed. However, concurrent administration of rVSV-ZEBOV vaccine and monoclonal antibodies directed against the Ebola virus glycoprotein is not recommended, as the mAbs would be expected to interfere with vaccine replication and attenuate its immunogenicity. A clinical trial (PEBO trial) is underway to further evaluate the efficacy of mAb-based PEP and its interaction with vaccination.

Supportive Care

Supportive care remains the cornerstone of EVD management and should be initiated immediately, regardless of whether specific antiviral therapy is available. Care has traditionally had three components: (1) supportive care to maintain or restore normal physiology, (2) treatment of discomfort or distress, and (3) presumptive treatment of any concurrent, undiagnosed infections.

The first GRADE-based guidelines for supportive care of patients with EVD were published in 2018, in which eight interventions were strongly recommended (albeit with low-to-moderate confidence in the underlying evidence base, largely extrapolated from sepsis literature):

1. Oral rehydration solution when enteral intake is possible

1. Parenteral administration of fluids (clinically guided, balanced IV volume repletion)

1. Systematic monitoring and charting of vital signs and volume status

1. Measurement of serum biochemistry (electrolytes, renal function, hepatic function)

1. Prescribed staffing ratios

1. Regular communication with patients' family and friends

1. Analgesia and treatment of symptoms

1. Administration of antibiotics to patients with high illness severity

Among 27 patients with EVD who received care in U.S. and European hospitals from August 2014 through December 2015, close monitoring and aggressive supportive care that included intravenous fluid hydration, correction of electrolyte abnormalities, nutritional support, and critical care management for respiratory and renal failure were needed; 81.5% of these patients who received this care survived (mortality 18.5%).

Fluid Resuscitation

The most serious physiological derangement in EVD is hypoperfusion stemming from volume deficits due to gastrointestinal losses (up to 5–10 L/day) and vascular leakage, as well as intravascular coagulation. Volume replacement through oral rehydration or intravenous crystalloid infusion is the primary intervention.

A systematic review of 32 clinical management guidelines for viral haemorrhagic fevers found:

• 11 (34%) advocated for fluid resuscitation with crystalloids (e.g., normal saline or Ringer's lactate)*
• 3 (9%) advised the use of human albumin solution in persistently hypovolaemic patients*
• 4 (12%) recommended fluid resuscitation with bolus infusions as part of a fluid challenge approach*
• One guideline specified that total fluid volume is not to exceed 60 mL/kg in the first 2 hours of presentation*
• Fluid resuscitation should continue until systolic blood pressure is >90 mmHg, with monitoring of target variables (heart rate 100 beats per minute, urinary output >30 mL/h, capillary refill time 3 seconds, absence of skin mottling, easily palpable pulses, and improved mental status)*

Caution: Aggressive fluid resuscitation requires careful monitoring, as vascular leakage or renal impairment can occur. In resource-limited settings where resources for follow-up of fluid resuscitation and management of complications (skilled staff, oxygen supplementation, mechanical ventilation, or renal replacement therapy) may be insufficient, caution is warranted.

Electrolyte and Metabolic Management

With the advent of on-site point-of-care biochemistry testing, care now involves correcting electrolyte levels and hypoglycemia, as well as meeting nutritional needs. Common electrolyte abnormalities include:

• Hypokalaemia*
• Hyponatraemia*
• Hypocalcaemia*
• Hypoglycaemia*

In a cohort of 73 children with EBOV infection in eastern DRC in 2019, 36% had hypokalaemia, 52% had hyperkalaemia, 74% had hyponatraemia, and 27% had hypoglycaemia, underscoring the importance of frequent biochemical monitoring in pediatric patients.

Among 27 patients treated in U.S. and European hospitals, the predominant metabolic findings included hypoalbuminemia, hyponatremia, hypokalemia, hypocalcemia, and hypomagnesemia; 14 patients (52%) had hypoxemia, and 9 (33%) had oliguria, of whom 5 had anuria. Nearly all patients received intravenous fluids and electrolyte supplementation.

Symptomatic Treatment

• Analgesics for headache, myalgias, and arthralgias*
• Antiemetics for nausea and vomiting*
• Antipyretics for fever*
• Anti-motility agents may be considered for severe diarrhea, though paralytic ileus is a known complication of EVD and a contraindication to loperamide use*
• Blood products if coagulopathy or active bleeding*
• Total parenteral nutrition if the patient has poor oral intake*
• Renal replacement therapy if renal failure develops (in advanced critical care settings)*
• Psychological support to help patients cope with anxiety, stress, and fear*

Critical Care

Although the EVD-specific evidence base for the care of critically ill patients is not extensive, treatments for critically ill patients in outbreaks after 2016 have evolved to provide higher levels of care. In a cohort of approximately 700 patients treated in eastern DRC (2018–19):

• 11% received inotropes/vasopressors*
• 38% received oxygen therapy*
• 14% received blood component transfusion*

Advanced critical care interventions include:

• More frequent-to-continuous monitoring of vital signs*
• IV fluid administration through durable venous access (e.g., central venous catheter)*
• IV vasoactive medications to support blood pressure*
• Oxygen administration, including through high-flow nasal cannulae*
• Non-invasive positive pressure ventilation*
• Invasive mechanical ventilation for respiratory failure*
• Renal replacement therapy*

Among 27 patients treated in U.S. and European hospitals, 9 (33%) received noninvasive or invasive mechanical ventilation, 5 (19%) received continuous renal replacement therapy, 22 (81%) received empirical antibiotics, and 23 (85%) received investigational therapies (19 [70%] received at least two experimental interventions). The overall mortality was 18.5% (5 of 27), including 3 who had respiratory and renal failure.

Prophylaxis Against Co-infections and Super-infections

Coinfection, whether a coincident tropical illness or a hospital-acquired infection, has been documented in EVD patients. The frequency of coinfections and the limited diagnostic options in most care settings have led to presumptive treatment with antimalarial agents and broad-spectrum antibiotics.

Empiric Antimalarial Therapy

Empiric antimalarial treatment is a component of protocol-based management of EVD. In a retrospective cohort study of 424 patients with confirmed EVD from five Ebola Treatment Units in Sierra Leone and Liberia (2014–2015), early oral antimalarial treatment (combination artemether-lumefantrine, twice daily for three days, within 48 hours of admission) was associated with reduced odds of mortality (adjusted OR 0.34; 95% CI: 0.12–0.92; p=0.039), with unadjusted mortality of 55.1% in treated patients versus 77.1% in untreated patients.

Co-infection with [[[malaria](https://www.openevidence.com/rare-disease/malaria)]] and EVD is associated with higher mortality. In a retrospective cohort study from Sierra Leone, patients with both EVD and malaria had higher mortality than those with EVD alone.

A natural experiment at an Ebola treatment center in Liberia found that patients who received artesunate-amodiaquine (during a 12-day stock-out of artemether-lumefantrine) had lower mortality than those who received artemether-lumefantrine, possibly due to the in vitro anti-EBOV activity of [[amodiaquine### Ebola Virus Disease - Medical Therapy (Continuation)

]]. However, a subsequent non-human primate study of amodiaquine alone did not demonstrate a survival benefit.

Empiric Antibiotic Therapy

Broad-spectrum antibiotics should be administered to patients with high illness severity. Adequate Gram-negative coverage is recommended, with Gram-positive coverage added if the patient has any catheter or hospital-acquired pneumonia. Among 27 patients treated in U.S. and European hospitals, 22 (81%) received empirical antibiotics. Overwhelming sepsis is associated with the majority of deaths due to Ebola virus disease. Gram-negative septicemia has been documented as a complication of EVD.

The administration of antiviral agents such as acyclovir or ribavirin has not demonstrated efficacy against EVD.

Convalescent Plasma

Convalescent plasma from EVD survivors was first tried during the 1995 Kikwit outbreak. However, the Ebola-Tx trial, a nonrandomized comparative study in Guinea, found that transfusion of up to 500 mL of convalescent plasma with unknown levels of neutralizing antibodies in 84 patients with confirmed EVD was not associated with a significant improvement in survival (adjusted risk difference −3 percentage points; 95% CI: −13 to 8). Subsequent analysis of antibody titres in the transfused plasma found that concentrations of neutralizing antibody were generally low, and no significant association was found between antibody concentrations and patient survival.

Convalescent plasma is no longer recommended as a treatment for EVD given the availability of FDA-approved monoclonal antibody therapies, which achieve far greater and more reliable concentrations of specific antibody.

Special Populations

Pregnant Women with Ebola Virus Disease

• Pregnancy was identified as a specific risk factor during the early DRC Ebola disease epidemics in 1976 and 1995, during which the pregnancy-related mortality rate was 90%. However, mortality rates in pregnancy during the West Africa and 2018–2020 DRC outbreaks were lower, at 64% and 56%, respectively. Subsequent reviews have been inconclusive regarding mortality risk in pregnant women, hampered by the scarcity of high-quality data.*
• The foundation of treatment for pregnant patients remains optimal supportive care. Pregnant women were included in the PALM trial. Although the sample size of pregnant women was too small to draw specific conclusions about efficacy in this subpopulation, it is considered good clinical and ethical practice to offer mAb114 and REGN-EB3 to pregnant patients.*
• There is no evidence to suggest that pregnant women are more susceptible to infection from Ebola virus (EBOV) than the general population. However, limited evidence does suggest that pregnant women are likely to be at increased risk of severe illness and death when infected with EBOV.*
• Pregnant women with EVD appear to be at an increased risk of fetal loss and pregnancy-associated hemorrhage.*
• EBOV can cross the placenta, and a pregnant woman infected with the virus will likely transmit it to the fetus. Viral RNA has been detected in amniotic fluid, placental tissue, and fetal tissue.*
• Healthcare providers caring for pregnant women in U.S. hospitals should be prepared to screen patients for EVD and have a plan in place to triage these patients. Obstetric management of pregnant women with EVD, particularly decisions about mode of delivery for women in labor, needs to consider risks to the woman, risks of exposure for healthcare providers, and potential benefits to the neonate.*
• Healthcare workers who are pregnant should not care for patients with EVD.*
• Pregnant patients under investigation (PUIs) or patients with confirmed EVD should be hospitalized, and CDC guidance for hospitalized PUIs or patients with confirmed EVD should be followed.*

Pediatric Patients

• Children accounted for a significant proportion of EVD cases during the 2018–2020 DRC outbreak. In a cohort of 73 children with confirmed EBOV infection in eastern DRC, the overall case fatality rate was high, particularly among children under 2 years of age.*
• Both Inmazeb and Ebanga are approved for use in pediatric patients of all ages, including neonates born to a mother who is RT-PCR positive for Orthoebolavirus zairense infection.*
• Pediatric patients require particular attention to fluid and electrolyte management, as they are at higher risk for dehydration, hypoglycemia, and electrolyte derangements. Frequent biochemical monitoring is essential.*
• Dosing of both Inmazeb and Ebanga is weight-based (50 mg/kg) and applies equally to pediatric patients.*

Ebola Virus Disease Survivors

• People who recover from Ebola infection develop antibodies that last for at least 10 years, possibly longer. It is not known if people who recover are immune for life or if they can become infected with a different species of Ebola.*
• Viral persistence: Ebola virus can persist in immune-privileged sites after clinical recovery. Viral RNA and, in some cases, replication-competent virus have been detected in semen, aqueous humor, cerebrospinal fluid, and breast milk for months to years after recovery. The longest documented persistence of EBOV RNA in semen is over 500 days after symptom onset. Sexual transmission from a male survivor has been documented.*
• Post-Ebola syndrome: Many survivors develop long-term sequelae collectively termed "post-Ebola syndrome." In a prospective cohort study of 1,290 EVD survivors and 1,735 close contacts in Guinea (POSTEBOGUI study), survivors had significantly higher rates of:*
  • Arthralgias and myalgias**
  • Uveitis and other ocular complications (including blindness)**
  • Hearing loss**
  • Neurological symptoms (including headache, insomnia, memory loss)**
  • Fatigue**
  • Depression and anxiety**

• A prospective cohort study of 280 EVD survivors treated with mAb114 or REGN-EB3 during the tenth DRC outbreak found that at 12 months post-discharge, the most common sequelae were arthralgia (52.5%), myalgia (47.5%), headache (42.5%), abdominal pain (40.0%), and ocular symptoms (37.5%). Patients treated with REGN-EB3 had a lower frequency of some sequelae compared with mAb114, though the study was not powered to detect differences between treatment groups.*
• Survivors should receive regular follow-up care including ophthalmologic examination, semen testing for viral RNA (in male survivors), and screening for mental health disorders.*

Nutritional Support

• The nutritional needs and approach to nutritional care in any individual will be determined by the patient's preceding nutritional status, severity of illness, and age.*
• Intake of high nutrient-dense foods may be important in patients in the early phase of the disease who still have appetite and no eating difficulties.*
• In patients who are ill for a longer time period, nutritional support should continue through the convalescence phase and following discharge.*
• Breastfeeding guidance:*

• • When both the lactating woman and child are positive for EVD, and where replacement feeding with liquid ready-to-use infant formula (RUIF) is acceptable, feasible, and provision is guaranteed, suspend breastfeeding until breast milk tests are negative for Ebola virus RNA.**

• • When the lactating woman is positive for EVD and the child is negative for EVD, suspend breastfeeding.**

• • When the lactating woman is negative for EVD and the child is positive for EVD, suspend breastfeeding.**

Summary of Treatment Approach

Phase of Illness	Key Interventions
Presentation / Early Phase	Immediate isolation and infection control measures* Obtain RT-PCR for Orthoebolavirus zairense confirmation* Initiate aggressive IV fluid resuscitation with crystalloids* Correct electrolyte abnormalities and hypoglycemia* Empiric antimalarial therapy (e.g., artemether-lumefantrine)* Empiric broad-spectrum antibiotics* Administer Inmazeb or Ebanga as soon as PCR-confirmed (do not delay for confirmatory testing if high clinical suspicion and local health department concurs)*
Acute / Progressive Phase	Continued aggressive fluid and electrolyte management* Antiemetics, antipyretics, analgesics* Blood product transfusion if coagulopathy or hemorrhage* Escalate to critical care if needed (vasopressors, oxygen therapy, mechanical ventilation, renal replacement therapy)* Frequent point-of-care biochemistry monitoring*
Critical / Severe Phase	Full critical care support as available* Mechanical ventilation for respiratory failure* Renal replacement therapy for renal failure* Vasopressor support for shock* Continued monitoring for coagulopathy and disseminated intravascular coagulation*
Convalescence / Recovery	Nutritional rehabilitation* Screening for post-Ebola syndrome (arthralgia, uveitis, hearing loss, neuropsychiatric symptoms)* Semen testing for viral RNA persistence (male survivors)* Ophthalmologic examination* Mental health screening and support* Discharge planning with public health coordination*
Post-Exposure (Uninfected Contacts)	Risk stratification (high, intermediate, low)* Consider monoclonal antibody PEP (ansuvimab or REGN-EB3) for high-risk exposures* Do not co-administer mAb PEP with rVSV-ZEBOV vaccine simultaneously* Monitor for fever and symptoms for 21 days after last exposure*