Travel Medicine and Infectious Disease 18 (2017) 18e23

Contents lists available at ScienceDirect

Travel Medicine and Infectious Disease

journal homepage: www.elsevierhealth.com/journals/tmid

Review

Neuropsychological long-term sequelae of Ebola virus disease

survivors e A systematic review
€ tsch, Jenny Schnyder, Abraham Goorhuis, Martin P. Grobusch Prof *
Felix Lo
Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of
Amsterdam, 1100 DE Amsterdam, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Background: The recent West African Ebola virus disease (EVD) outbreak had catastrophic impact on
Received 17 March 2017 populations, health care systems and economies of the affected countries. Somatic symptoms have been
Received in revised form reported to persist long beyond the acute infection. This review was conducted to provide an overview
28 April 2017
on neuro- and socio-psychological long-term sequelae of EVD survivors.
Accepted 2 May 2017
Available online 4 May 2017
Methods: Utilizing Pubmed and PsycInfo databases, a systematic review prepared according to PRISMA
guidelines. Only studies reporting quantitative data on neuropsychological sequelae three weeks or later
after discharge from the Ebola-treating unit were included. Pooled proportions of common outcomes
Keywords:
Ebola virus disease
were calculated.
Viral haemorrhagic fever Results: In total, 224 papers were identified, of which 10 were included. Depression, insomnia, fatigue,
Neuro-psychological sequelae anxiety and post-traumatic stress were common sequelae in EVD survivors. However, data from high-
Socio-psychological sequelae quality studies were scarce.
Systematic review Conclusions: EVD survivors have been thought to commonly face neuropsychological long-term
sequelae. Methodological drawbacks and heterogeneity of current studies limit conclusions of the
impact and magnitude of such sequelae. We advocate the preparation of a prospective, controlled cohort
study protocol in preparation for a future outbreak.
© 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
The recent Ebola outbreak in West Africa, mainly affecting
Guinea, Liberia and Sierra Leone, has had catastrophic impact on
the affected patients, health care systems and countries, but has
also led to the development of vaccines [1,2]; allowed the evalua-
tion of interventions [3,4]; and provided new insights into Ebola
virus disease (EVD) and its consequences [5]. Now, in the aftermath
of the epidemic, there are over 10,000 survivors according to the
WHO [6]. The long recovery period of EVD was already noted
during the outbreak in Sudan in 1976 [7], and prolonged psycho-
logical problems were acknowledged after the Uganda outbreak in
2001 [8]. As recently reviewed by Vetter and colleagues, EVD sur-
vivors frequently struggle with long-term sequelae such as rheu-
matologic, ocular or neurological disorders [5]. However, patients
do not only suffer from somatic complaints but also from neuro-
psychological sequelae and stigmatization after discharge from the
* Corresponding author.
E-mail address: m.p.grobusch@amc.uva.nl (M.P. Grobusch).
Ebola treating unit (ETU). The aim of this review was to provide a
concise overview of published data on neuro- and socio-
psychological sequelae and to summarize the data on frequencies
and proportions of such complications in Ebola survivors.
2. Methods
A systematic literature search in line with PRISMA guidelines
was performed in PubMed and PsycINFO using “Ebola” AND
(“sequelae” OR “convalescent” OR “survivors”) as search terms.
Studies indexed up to January 30th, 2017 were included. No other
restrictions on publication date or language were applied. After
exclusion of double entries, two researchers (JS, FL) independently
assessed all publications. Studies were included if neuro- and socio-
psychological sequelae or stigmatization of survivors of a
confirmed or probable Ebola virus disease were reported quanti-
tatively 3 weeks (or more) after discharge. Reference lists of
included studies were also reviewed for potentially relevant articles
that were missed in the database search. Data was extracted by one
author and double-checked by another in a self-designed data

http://dx.doi.org/10.1016/j.tmaid.2017.05.001
1477-8939/© 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 €tsch et al. / Travel Medicine and Infectious Disease 18 (2017) 18e23
F. Lo
extraction form. Authors were contacted if important information
was missing. Data was extracted for all neuro-psychological and
psychosocial sequelae presented in the included studies Simple
pooled analysis was performed for the outcomes ‘depression’,
‘insomnia’ and ‘fatigue’. No other summary measure was used. Bias
evaluation of individual studies was performed using the original
Newcastle Ottawa scale for cohort studies and a modified version
for cross-sectional studies (Supplementary Materials 1,2;
Supplementary Tables 1e3). No bias evaluation was performed for
case-series, short reports without a method section and qualitative
studies reporting quantitative data only as secondary outcome. No
bias evaluation was performed for bias across studies. The review
protocol was registered with the University of Amsterdam.
3. Results
The search yielded 224 articles in total, of which 10 studies were
included in this review. A flow chart depicting the study selection
process is presented in Fig. 1. Eight studies stem from the recent
outbreak in West Africa; one study from the 1995 outbreak in
Kikwit, Democratic Republic of Congo, and one from the 2007
outbreak in Bundibugyo, Uganda. All studies were published in
English.
Four studies providing information on the interval between
discharge and assessment reported data on depression in EVD
survivors [9e12]. The largest of these studies by Etard et al. used
previously evaluated questionnaires and scales and found 124 out
of 713 participants (17%) to suffer from symptoms that may be
indicative for depression at study inclusion. The median delay be-
tween study inclusion and discharge from the Ebola-treating unit
was 350 days (IQR 223e491). Follow-up in this prospective study is
ongoing, and has not been published to date [9]. Only one study
compared depression in Ebola survivors with a seronegative con-
trol group. The authors found a depressed mood in 12/49 (24%)
survivors compared to 23/157 (15%) in the control group (RR 1.9;
95% CI 1.0e3.6; p ¼ 0.058) 29 months after the outbreak. The au-
thors also performed a sensitivity analysis including probable cases,
whereupon the results achieved statistical significance. Data were
collected retrospectively [13].
In a cross-sectional study by Qureshi et al., 34/104 (33%) patients
described a difference in mood; in one patient (1.0%), self-perceived
depression was documented [10]. The median time between
discharge and assessment was 103.5 days (SD 47.9). In another
Fig. 1. Flowchart depicting the study selection process.
19
cross-sectional study from Sierra Leone, Nanyonga et al. assessed
long-term sequelae four months or later after resolution of the
acute disease in a convenience sample of 81 survivors. Depression
was recorded in 30/81 (37%) survivors. However, no details on the
methods of data collection and tools used for assessment were
provided in this report [11].
In a case series of American survivors, ‘depression or anxiety’
was reported in 4/8 (50%) of patients. Symptoms started 0e12
weeks after discharge and lasted 4 weeks. A semi-structured
questionnaire by phone or face-to-face was used to evaluate pa-
tients [12]. A summary of frequency of depression across these four
studies is presented in Fig. 2.
Mohammed et al. assessed psychological distress in Ebola sur-
vivors using the General Health Questionnaire. Four survivors were
included and two (50%) reported that they had been feeling un-
happy or depressed [14]. In a study with survivors from Sierra
Leone, an attempt to assess long-term sequelae was made by
reviewing medical charts. Mental health counselling and depres-
sion was recorded in 2 out of 115 survivors. However, the authors
state that this was not recorded consistently in the medical charts
and that the numbers probably underestimate problem [15].
Another common symptom was insomnia, which was reported
in seven studies [10e16]. In a retrospective cohort study with
survivors of the outbreak in Bundibugyo, Uganda, and a control
group, symptoms were assessed using a standardized question-
naire; 28/49 (57%) individuals reported difficulties sleeping.
Sleeping difficulties were significantly more frequent in survivors
compared to the controls (RR 1.9, 95%CI 1.3e2.8; p < 0.001) 29
months after the outbreak [13]. In the recent outbreak, insomnia
was recorded in 55/115 (48%) survivors in Sierra Leone at one point
during the follow-up. The data were extracted retrospectively from
medical charts and records [15]. In a similar study by Tiffany et al.
based on routine data from a survivor clinic 20/104 (19%) of sur-
vivors presenting 30 days or later after discharge from the ETU to a
survivor clinical reported insomnia [16].
Qureshi et al. reported insomnia in 13/104 (13%) and difficulty
sleeping in 20/105 (19%) survivors in a cross sectional study using a
self-designed questionnaire [10]. Nanyonga et al. found 34/81 (42%)
survivors suffering from sleeplessness, although it is not described
how the symptoms were assessed [11]. Out of the eight American
survivors who were interviewed after convalescence, 4 (50%) re-
ported insomnia. In one additional patient, it had already resolved
at the time of assessment [12]. Furthermore, 3/4 (75%) survivors in
Nigeria reportedly had lost much sleep over worry [14] (see Fig. 3).
In a prospective cohort study from Kikwit, Democratic Republic
of the Congo, extreme fatigue was recorded 10 times in 123 con-
tacts (8%) with 29 survivors throughout a 6-month follow-up
Fig. 2. Frequency of depression per individual study, and pooled analysis of data. For
interval between discharge and assessment see Table 1.
20 €tsch et al. / Travel Medicine and Infectious Disease 18 (2017) 18e23
F. Lo
Fig. 3. Frequency of insomnia per individual study, and pooled analysis of data. For
interval between discharge and assessment see Table 1.
Fig. 4. Frequency of fatigue per individual study, and pooled analysis of data. For in-
terval between discharge and assessment see Table 1.
period. This was significantly more often than in household con-
tacts that were used as a control group (OR 3.2; 95% CI 1.2e8.8).
However, 21 months after enrolment, fatigue was not more com-
mon in survivors compared to the control group [17]. The propor-
tion of extreme fatigue was only reported per interviews, but not by
survivors. By contrast, Clark et al. found fatigue in 28/49 (57%) of
survivors 29 months after convalescence, which was higher than in
the control group with a RR of 1.9 (95% CI 1.3e2.8; p ¼ 0.001) [13].
In the cohort described by Etard et al., the prevalence of fatigue was
24% (190/802). No control group was available for this study.
However, fatigue was more common in older children aged 9e18
years compared to children younger than 9 years (30/101 (30%) vs.
6/57 (11%); p ¼ 0.0057) [9]. Among eight American survivors, six
reported fatigue after convalescence; however, six out of eight had
returned to normal daily activities eight weeks after discharge. Five
survivors reported full resolution of symptoms [12]. In the study by
Nanyonga et al., fatigue was reported in 24/81 (30%) of survivors
[11]. Again, assessment methods were not described in the latter
(see Fig. 4).
Anxiety was documented in 17/115 (15%) survivors, based on
clinical routine data [15], and in 17/81 (21%) in the survey of
Nanyonga et al. [11]. Furthermore, clinically significant arousal re-
actions were detected in 5/24 (21%) survivors as measured by the
trauma-screening questionnaire. Follow-up time in the latter was
short with a median of 28 days [18]. Other less commonly and
anecdotally reported neuropsychological and psychosocial
sequelae are summarized in Table 1.
4. Discussion
EVD is a highly lethal infection with both somatic and psycho-
logical long-term consequences reported in survivors. Neuropsy-
chological sequelae have been thought to be common and diverse
in EVD survivors and may be prevalent weeks after discharge. In
this review, depression was found to occur in 17e50% (21% pooled),
insomnia in 13e75% (34% pooled) and fatigue in 24e75% (29%
pooled) of EVD survivors. Although the recent outbreak has pro-
vided many new insights and a lot of novel data, methodologically
sound studies are still scarce. In total, only 2 studies compared their
findings to a control group [13,17]. Thus, the remaining studies do
not allow for conclusion on whether such symptoms are more
common in comparison to the general population or whether these
may be attributed to other common conditions such as malaria. In a
pooled analysis with patients from studies reporting on symptoms
that persisted beyond acute infection, 21% (195/910) suffered from
depression. However, the only study with a control group could not
clearly detect a higher risk of depression. Of note, depression was in
none of the studies formally diagnosed by a psychiatrist. Compa-
rability was further limited by the fact that patients were assessed
at different time points during follow-up, within studies and be-
tween studies.
With fatigue, the picture is not very clear either. Although one
controlled study found fatigue to be persistent 29 months after the
outbreak [13], the other did not detect a difference at 21 months
[17]. However, survivors reported more often that their capacity to
work was lower compared to household contacts 21 months after
the outbreak. That notwithstanding, in the limited sample of
American survivors, three quarters had returned to their usual daily
activities 8 weeks after discharge [12]. Also in the study of Qureshi
et al., virtually all survivors had been able to resume work, ulti-
mately (100/104; 96%) [10]. Besides age and sex, none of the studies
tried to control for confounders, and the pooled frequency of fa-
tigue was not dramatically high at 26%. As no controlled studies
attempting to differentiate between fatigue arising from Ebola and
other reasons (such as malaria for example) were available, it may
be speculated that the fraction of fatigue attributable to Ebola is
possibly relatively low. This is also supported by the findings of
Mohammed et al. that a very large proportion of visits to a survivor
clinic were due to other medical problems such as malaria, respi-
ratory tract infections or typhoid fever [15].
Similar limitations also apply to the outcome of insomnia.
However, the only controlled study found a significantly higher risk
almost 2.5 years after convalescence [13]. Unfortunately, no
attempt to control for possible confounders besides age and sex
was made.
The origin of neuropsychological long-term sequelae is multi-
factorial, of which the acute disease and the immune response, the
psychological trauma facing and observing death or loosing friends
or family members, and the stigmatization of survivors by their
communities all may contribute to problem [19e21]; with such
stigmatization that include avoidance and maintaining distance,
refusal to shake hands or hug, verbal abuse, rejection, difficulty to
access shops or loosing jobs [18,22,23]. Furthermore, survivors have
been accused of having invented their disease and husbands have
rejected their cured wives [22]. However, re-integration rituals can
increase the acceptance of the community and may also be useful in
reducing the psychosocial burden [24]. Post-traumatic stress and
symptoms indicative for depression were found to be linked to the
experience of death in the EVD treating units and to stigmatization
in the communities after discharge [18,21]. Suicide of a survivor of
the Uganda outbreak in 2001 was reported by Hewlett et al. [20].
Table 1
Summary of studies included.

Study Design Control Outbreak N of Time of assessment Methods Depression Insomnia Fatigue Others
group survivors/ after discharge
controls

Clark et al., Retrospective Yes Bundibugyo 49/157 approx. 29 months Standardized questionnaire 12/49 (24%); 28/49 (57%); RR 1.9 (1.3 28/49 (57%); RR -Limited due to difficulty
2015 [13] cohort study ’07-‘08 RR1.9 (1.0e3.6; e2.8; p ¼ 0.001) 1.9 (1.3e2.8; remembering or confusion 7/49
p ¼ 0.058) p ¼ 0.001) (14%); RR 5.8 (1.5e22.4; p ¼ 0.010)
Epstein Case series No West- 8 median 5 months Semi-structured questionnaire 4/8 (50%)a 4/8 (50%) þ resolved in 6/8 (75%) -peripheral paraesthesia or
et al., African ‘13- (range: 4e7) one additional patient dysaesthesia 3/8 (38%)
2015 [12] ‘15
Mohammed Retrospective No West- 115 median 261 days Review of medical charts 5/115 (4%)b 55/115 (48%) 28/115 (24%)c -Anxiety 17/115 (15%)
H. et al., cohort study African ’13- (range 4e504) -Dizziness 44/115 (38%)
2017 [15] ‘15
Mohammed Cross- Yes, but no West- 4/113 2-4 weeks -General Health Questionnaire 2/4 (50%) 3/4 (75%) Not reported -Inability to concentrate 4/4 (100%)
A. et al., sectional statistical African ‘13- 12-item version; -Oslo 3-item -Felt constantly under strain 1/4
2015 [14] study analyses ‘15 Social Support Scale (25%)
-Not been able to enjoy normal day to

F. Lo
day activities 1/4 (25%)

€tsch et al. / Travel Medicine and Infectious Disease 18 (2017) 18e23

-Not been feeling reasonably happy
1/4 (25%)
-Felt not playing a useful part in
things 1/4 (25%)
-Incapable of making decision 2/4
(50%)
-Been able to face up to problems 1/4
(25%)
-Felt unable to overcome difficulties
1/4 (25%)
-Difficult getting help from
neighbours 1/4 (25%)
Nanyonga Cross No West- 81 >4 months not reported 36% 43% 30% -Anxiety (21%)
et al., sectional African ‘13- -Confusion (2%)
2016 [11] ‘15 -Rejection by community (96%)
-Numbness (1%)
Qureshi Cross- No West- 105 103.5 ± 47.9 Self-designed questionnaire 1/105 (1%) with 13/104 (12.5%) with Not reported -Loss of balance 1/102 (1%)
et al., sectional African ‘13- self- perceived insomnia20/105 (19%) -Changes in smell 1/105 (1%)
2015 [10] study ‘15 depression with sleep difficulty -Changes in taste 3/104 (3%)
34/104 (33%) -Dizziness 11/104 (10.6%)
with difference -Difficulty concentrating 45/105
in mood (43%)
-Difficulty with short-term memory
28/104 (27%)
-Difficulty with long-term memory 8/
104 (8%)
-Difficulty waking up 4/105 (4%)
-Lack of acceptance from family 8/
104 (8%)
-Lack of acceptance from friends 102/
105 (97%)
-Lack of acceptance from village 17/
105 (16%)
-Lack of acceptance from community
63/104 (61%)
-Less confident 103/105 (98%)
-Negative impact on social life 101/
105 (96%)
Kikwit ‘95 29/152 Interviews Not reported Not reported
(continued on next page)

21
 22 €tsch et al. / Travel Medicine and Infectious Disease 18 (2017) 18e23
F. Lo

5. Conclusions

interviews (8%) 21 months after enrolment compared

65/104d (63%) -Feeling ashamed or embarrassed 31/

Fatigue was not reported more often

-Clinically significant post-traumatic

-Avoided by others 29/113 (26%)
In summary, although neuropsychological long-term conse-
quences in survivors have been a concern in the recent post-Ebola

-Irritable mood 4/166 (2%)e

-Hallucinations 5/166 (3%)e
outbreak period and a substantial amount of data has become

190/802 (24%) -Dizziness 19/802 (2%)

available, we think that the current quality of studies is not suffi-

reactions 5/24 (21%)

cient to conclude that neuropsychological sequelae are a para-
mount problem. A substantial knowledge gain can be expected by
the results of the Postebogui-study, which includes more than 800
to controls.

145 (27%)

survivors and is the largest study by far [9]. Following the partici-
Others

pants over a long period of time will provide new insights in the
dynamics of post-Ebola sequelae. Unfortunately, the opportunity
was missed to include a control group, which is necessary to
Not reported

determine whether long-term consequences are really Ebola

related.
Fatigue

10/123

In fact, although neuropsychological long-term sequelae have

received considerable attention politically and in the media as a
post-Ebola public health problem, the scientific basis for such
claims is relatively weak. In our opinion, currently available data do
not allow to draw a conclusion on how important and significant
20/104d (19%)

they really are. We suggest that with regard to future outbreaks,

Not reported

Not reported

ideally, that is if circumstances allow, a prospective cohort study

Insomnia

with confirmed EVD patients as cases and e most essentially - with

a control group (e.g. malaria patients) should be prepared. Opti-
mally, this study should evaluate participants periodically over a
124/713 (17%)

prolonged period of time and make use of previously evaluated

Not reported

Trauma screening questionnaire Not reported

Depression

tools (such as the PHQ-9 for depression for example). Assessors

should be blinded to the Ebola status of the participant, and opti-
mally, psychiatric diagnoses should be confirmed by psychiatrists.
Based upon the findings of such a study, we are confident that the
very limited resources available in long-term care of Ebola survi-
vors could be used more efficiently, benefiting patients and limiting
55,8 days (mean) Routine data from visits to

4.3% with depression reported, but authors state that this was not reported consequently due to methodology.

the burden on ravaged health care systems.

Clinical assessment &

Funding
Questionnaires
survivor clinic

This research did not receive any specific grant from funding
Time of assessment Methods

agencies in the public, commercial, or not-for-profit sectors.

Declaration of conflict of interests

Visits during first 6
months and after

Median 305 days

Median 28 days
(IQR 223e491)f
survivors/ after discharge

29 patients (3.6%) were included 21 days or earlier (personal communication).

None of the authors has any conflict of interest to declare.

21 months

Contributions

All authors contributed to the conception and design of this

controls

review; FL and JS performed the systematic search and data

‘Weakness’ was reported and used as surrogate for fatigue.
N of

104

802

Only patients presenting 30 days or later were included.

Depression and anxiety were reported as joint outcome.

extraction; FL drafted the first version of this manuscript; all au-

24

Not clear how long after discharge this was assessed.

thors reviewed the manuscript and approve of the final version.

African ‘13-

African ‘13-

African ‘13-
Outbreak

West-

West-

West-

Appendix A. Supplementary data

‘15

‘15

‘15

Supplementary data related to this article can be found at http://

(household
contacts)

dx.doi.org/10.1016/j.tmaid.2017.05.001.
Control
group

Yes

No

No

No

References
1999 [17] cohort study

2016 [16] cohort study

cohort study

2015 [18] cohort study

Rowe et al., Prospective

Tiffany et al., Prospective

Prospective

Hugo et al., Prospective

[1] Agnandji ST, Huttner A, Zinser ME, Njuguna P, Dahlke C, Fernandes JF, et al.
Phase 1 trials of rVSV ebola vaccine in Africa and europe. N Engl J Med
Design

2016;374:1647e60. http://dx.doi.org/10.1056/NEJMoa1502924.
Table 1 (continued )

[2] Henao-Restrepo AM, Camacho A, Longini IM, Watson CH, Edmunds WJ,
Egger M, et al. Efficacy and effectiveness of an rVSV-vectored vaccine in
Etard et al.,
2017 [9]

preventing Ebola virus disease: final results from the Guinea ring vaccination,
open-label, cluster-randomised trial (Ebola Ça Suffit!). Lancet Lond Engl 2016.
Study

http://dx.doi.org/10.1016/S0140-6736(16)32621-6.
[3] Moekotte AL, Huson MaM, van der Ende AJ, Agnandji ST, Huizenga E,
a

e
b

f
c
d

Goorhuis A, et al. Monoclonal antibodies for the treatment of Ebola virus

 €tsch et al. / Travel Medicine and Infectious Disease 18 (2017) 18e23
F. Lo
disease. Expert Opin Investig Drugs 2016:1e11. http://dx.doi.org/10.1080/
13543784.2016.1240785.
[4] Grobusch M, Visser BJ, Boersma J, Huson MA, Janssen S, Greve P, et al. Ebola
virus disease: basics the medical specialist should know. Neth J Crit Care
2015;22:6e14.
[5] Vetter P, Kaiser L, Schibler M, Ciglenecki I, Bausch DG. Sequelae of Ebola virus
disease: the emergency within the emergency. Lancet Infect Dis 2016;16:
e82e91. http://dx.doi.org/10.1016/S1473-3099(16)00077-3.
[6] World Health Organization. Ebola virus disease. Situat Rep 2016:1e2.
[7] Ebola haemorrhagic fever in Sudan. Bull World Health Organ 1976;1978(56):
247e70.
[8] Wendo C. Caring for the survivors of Uganda's Ebola epidemic one year on.
Lancet 2001;358:1350. http://dx.doi.org/10.1016/S0140-6736(01)06467-4.
[9] Etard J-F, Sow MS, Leroy S, Toure  A, Taverne B, Keita AK, et al. Multidisci-
plinary assessment of post-Ebola sequelae in Guinea (Postebogui): an obser-
vational cohort study. Lancet Infect Dis 2017:0. http://dx.doi.org/10.1016/
S1473-3099(16)30516-3.
[10] Qureshi AI, Chughtai M, Loua TO, Pe Kolie J, Camara HFS, Ishfaq MF, et al.
Study of ebola virus disease survivors in Guinea. Clin Infect Dis Off Publ Infect
Dis Soc Am 2015;61:1035e42. http://dx.doi.org/10.1093/cid/civ453.
[11] Nanyonga M, Saidu J, Ramsay A, Shindo N, Bausch DG. Sequelae of ebola virus
disease, kenema district, Sierra Leone. Clin Infect Dis 2015. http://dx.doi.org/
10.1093/cid/civ795. :civ795.
[12] Epstein L, Wong KK, Kallen AJ, Uyeki TM. Post-Ebola signs and symptoms in
U.S. Survivors. N Engl J Med 2015;373:2484e6. http://dx.doi.org/10.1056/
NEJMc1506576.
[13] Clark DV, Kibuuka H, Millard M, Wakabi S, Lukwago L, Taylor A, et al. Long-
term sequelae after Ebola virus disease in Bundibugyo, Uganda: a retrospec-
tive cohort study. Lancet Infect Dis 2015;15:905e12. http://dx.doi.org/
10.1016/S1473-3099(15)70152-0.
[14] Mohammed A, Sheikh TL, Gidado S, Poggensee G, Nguku P, Olayinka A, et al.
An evaluation of psychological distress and social support of survivors and
contacts of Ebola virus disease infection and their relatives in Lagos, Nigeria: a
cross sectional studye2014. BMC Public Health 2015;15:824. http://
dx.doi.org/10.1186/s12889-015-2167-6.
[15] Mohammed H, Vandy AO, Stretch R, Otieno D, Prajapati M, Calderon M, et al.
23
Sequelae and other conditions in ebola virus disease survivors, Sierra Leone.
Emerg Infect Dis 2015;2017(23):66e73. http://dx.doi.org/10.3201/
eid2301.160631.
[16] Tiffany A, Vetter P, Mattia J, Dayer J-A, Bartsch M, Kasztura M, et al. Ebola virus
disease complications as experienced by survivors in Sierra Leone. Clin Infect
Dis Off Publ Infect Dis Soc Am 2016;62:1360e6. http://dx.doi.org/10.1093/cid/
ciw158.
[17] Rowe AK, Bertolli J, Khan AS, Mukunu R, Muyembe-Tamfum JJ, Bressler D,
et al. Clinical, virologic, and immunologic follow-up of convalescent Ebola
hemorrhagic fever patients and their household contacts, Kikwit, Democratic
Republic of the Congo. Commission de Lutte contre les Epide mies a  Kikwit.
J Infect Dis 1999;179(Suppl 1):S28e35. http://dx.doi.org/10.1086/514318.
[18] Hugo M, Declerck H, Fitzpatrick G, Severy N, Gbabai OB-M, Decroo T, et al.
Post-traumatic stress reactions in Ebola virus disease survivors in Sierra
Leone. Emerg Med Open Access 2015:2015.
[19] Gidado S, Oladimeji AM, Roberts AA, Nguku P, Nwangwu IG, Waziri NE, et al.
Public knowledge, perception and source of information on ebola virus dis-
easeelagos, Nigeria; september, 2014. PLoS Curr Outbreaks 2015 Apr 8;7. http://
dx.doi.org/10.1371/currents.outbreaks.0b805cac244d700a47d6a3713ef2d6db.
pii: ecurrents.outbreaks.0b805cac244d700a47d6a3713ef2d6db, pubmed-id:
25914860.
[20] Hewlett BS, Amola RP. Cultural contexts of Ebola in northern Uganda. Emerg
Infect Dis 2003;9:1242e8. http://dx.doi.org/10.3201/eid0910.020493.
[21] Rabelo I, Lee V, Fallah MP, Massaquoi M, Evlampidou I, Crestani R, et al.
Psychological distress among ebola survivors discharged from an ebola
treatment unit in monrovia, Liberia - a qualitative study. Front Public Health
2016;4:142. http://dx.doi.org/10.3389/fpubh.2016.00142.
[22] Sow S, Desclaux A, Taverne B. Groupe d’e tude PostEboGui. [Ebola in Guinea:
experience of stigma among health professional survivors]. Bull Soc Pathol
Exot 1990;2016(109):309e13. http://dx.doi.org/10.1007/s13149-016-0510-5.
[23] Lee-Kwan L-K, DeLuca N, Adams M, Dalling M, Drevlow E, Gassama G, et al.
Support services for survivors of ebola virus disease - Sierra Leone. MMWR
Morb Mortal Wkly Rep 2014;2014(63):1205e6.
[24] Arwady MA, Garcia EL, Wollor B, Mabande LG, Reaves EJ, Montgomery JM,
et al. Reintegration of ebola survivors into their communities - firestone
District, Liberia. MMWR Morb Mortal Wkly Rep 2014;2014(63):1207e9.