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J Infect Dis. 2018 Mar 28;217(8):1214-1221. doi: 10.1093/infdis/jiy004.

Anatomy of a Hotspot: Chain and Seroepidemiology of Ebola Virus Transmission, Sukudu, Sierra Leone, 2015-16.

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Department of Medicine, UCSF, San Francisco, California.
Partners in Health, Freetown, Sierra Leone.
Department of Global Health and Social Medicine, HMS, Boston, Massachusetts.
Kono District Ebola Response, Koidu Town, Sierra Leone.
Department of Epidemiology and Biostatistics, UCSF, San Francisco, California.
Department of Earth Systems Science, Stanford University, San Francisco.
Department of HIV, ID, and Global Medicine, UCSF, San Francisco, California.
F.I. Proctor Foundation, UCSF, San Francisco.
Department of Anthropology, Stanford University, California.
Department of Medicine, BWH, Boston, Massachusetts.


Studies have yet to include minimally symptomatic Ebola virus (EBOV) infections and unrecognized Ebola virus disease (EVD) in Ebola-related transmission chains and epidemiologic risk estimates. We conducted a cross-sectional, sero-epidemiological survey from October 2015 to January 2016 among 221 individuals living in quarantined households from November 2014 to February 2015 during the Ebola outbreak in the village of Sukudu, Sierra Leone. Of 48 EBOV-infected persons, 25% (95% confidence interval [CI], 14%-40%) had minimally symptomatic EBOV infections and 4% (95% CI, 1%-14%) were unrecognized EVD cases. The pattern of minimally symptomatic EBOV infections in the transmission chain was nonrandom (P < .001, permutation test). Not having lived in the same house as an EVD case was significantly associated with minimally symptomatic infection. This is the first study to investigate a chain of EBOV transmission inclusive of minimally symptomatic EBOV infections and unrecognized EVD. Our findings provide new insights into Ebola transmission dynamics and quarantine practices.

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