エボラウイルス（フィロウイルス科）!

エボラ出血熱�
国立感染症研究所ウイルス第1部!
西條政幸�

エボラウイルスの電子顕微鏡所見とエボラ出血熱の流行国�

フィロウイルス科, エボラ（マールブルグ）ウイルス属: Zaire EBOV,Sudan EBOV, Tai Forest EBOV andReston EBOV, Bundibugyo EBOV/
Lake Victoria Marburg virus!

出血症状!
Oozing from gingiva!
Gengivorragia

フィロウイルス科, エボラ（マールブルグ）ウイルス属: Zaire EBOV, Sudan
EBOV, Ivory Coast EBOV and Reston
EBOV, Bundibugyo EBOV/LakeVictoria Marburg virus!

消化管出血!

血性嘔吐・血性下痢�

コンゴ民主共和国�)*$01

エボラ出血熱で亡くなられた修道女のひとり�

エボラ出血熱患者（生存者）�

エボラウイルスの宿主�
Fruit bats as reservoirs of Ebola virus"
Leroy EM, Kumulungui B, Pourrut X, Rouquet P, Hassanin A, Yaba P, Delicat A, Paweska JT, Gonzalez JP, Swanepoel RNature. 2005 Dec 1;438(7068):575-6''-%68 5<939+%$9."!
-Isolation of Genetically Diverse Marburg Viruses
from Egyptian Fruit Bats-

In the liver, viral antigens were distributed in and around hepatocytes in a dense (A) or loose (B) perimembranous pattern.
Rarely, entire hepatocytes were involved (C). These infected foci were characteristically sparse and were often associatedwith small collections of mononuclear inflammatory cells and hepatocyte necrosis (D and E), although infected cells could
also be identified without conspicuous inflammatory infiltrates. Only rare viral antigens were seen in a few mononuclear
cells of the spleen of 1 bat (F). Immunoalkaline phosphatase with napthol fast-red and hematoxylin counterstain (A–C, E,F), and hematoxylin and eosin (D); original magnifications ×100 (A, B, D, E) and ×258 (C, F).

エボラウイルスの宿主はオオコウモリ�Map of Guinea Showing Initial Locations of the Outbreak of Ebola Virus Disease."

Transmission Chains in the Outbreak of Ebola Virus Disease in Guinea."

Baize S et al. N Engl J Med 2014. DOI: 10.1056/
NEJMoa1404505"

Baize S et al. N Engl J Med 2014. DOI: 10.1056/NEJMoa1404505"

西アフリカにおけるEVD流行状況"
Guinea"（ギニア）�

Phylogenetic Analysis of the Ebolavirus Genus, Including the EBOV Strains from Guinea."

2500!

累積患者数�

2000!

1500!

1000!

500!

0!

一日の増加患者数�

100!

Baize S et al. N Engl J Med 2014. DOI: 10.1056/NEJMoa1404505"

西アフリカにおけるEVD流行状況"（シエラレオネ）�
Sierra Leone"

-50!

-100!

-150!

8000!

5000!

累積患者数�

累積患者数�

0!

西アフリカにおけるEVD流行状況"（リベリア）�

7000!
6000!

50!

4000!
3000!
2000!
1000!
0!

7000!
6000!
5000!
4000!
3000!
2000!
1000!
0!

300!
200!
100!
0!
29-May-14!
-100!
-200!

29-Jun-14!

29-Jul-14!

29-Aug-14!

29-Sep-14!

29-Oct-14!

一日の増加患者数�

一日の増加患者数�

400!

500!
400!
300!
200!
100!
0!
-100!

Liberia"西アフリカで流行している"EVDの背景を考える．�
.,<9
! #28(!
&47  • 地域の住民の感染症に対する知識!
• 感染予防策の実施の可能性!
• 死者を弔う風習：決して特別ではない．!
• 社会・経済的な背景：例えば救急車，道路事情!
• 感染経路：接触感染，飛沫感染，空気感染!
• 診断!
• 治療・予防�エボラ出血熱回復者の血液の輸血による治療"

Mupapa K, et al. Treatment of Ebola Hemorrhagic Fever with Blood Transfusions
from"Patients. JID 179 (supplement):S18-23, 1999�
TableConvalescent
2．回復期エボラ出血熱患者血液の輸血を受けた8人の患者概要�

Mupapa K, et al. Treatment of Ebola Hemorrhagic Fever with BloodTransfusions from Convalescent Patients. JID 179 (supplement):S18-23, 1999�

患者�

Age(y)�

発症から輸血までに日数�

輸血量（cm3)�

血液提供者�

予後�

1�
2�

27�

7�

400�

1�

生存�

12�

11�

150�

2�

生存�

3�

15�

13�

150�

3�

生存�

4�

54�

9�250�

2�

生存�5�44�

15�

250�

4�

生存�

6�

25�

13�

250�

4�

生存�

7�

40�

11�

450�

5�

生存�

8�

48�

4�

400�

2�

死亡�

Table 1．血液を提供した，回復期エボラ出血熱患者の概要�
エボラステータス�
血液提供者�
1�2�

Age(y)�
27�
33�

発症から採血までに日数�
37�
45�

ウイル
ス抗原�
-�
-�

IgG�
+�
+�

IgM�
+�
+�

3�

32�

45�

-�

+�

+�

4�

30�

55�

-�

+�

+�

5�

27�

65�

-�

+�

-�

この流行での致死率は80％�

抗体製剤が治療薬として有効であることを示唆する（発症予防，症状の低減）．�
1. 水痘の発症予防!
2. A型肝炎ウイルス感染症の予防!
3. B型肝炎ウイルスの母子感染予防!
4. サイトメガロウイルス感染予防（骨髄移植時など）!
5. 麻疹ウイルス感染予防!
6. 狂犬病!
7. 小児のRSウイルス感染予防（未熟児や心疾患を有する小児（人型抗RSウイルスモノクローナル抗体）�

•エボラ治療法の開発"

ウイルス増殖を抑制する抗ウイルス薬! �–T-705!
•!
•Oestereich L, Lüdtke A, Wurr S, Rieger T, Muñoz-Fontela C, Günther S. Successful treatment ofadvanced Ebola virus infection with T-705 (favipiravir) in a small animal model. Antiviral Res.
105:17-21, 2014 !
Smither SJ, Eastaugh LS, Steward JA, Nelson M, Lenk RP, Lever MS. Post-exposure efficacy of oral
T-705 (Favipiravir) against inhalational Ebola virus infection in a mouse model. Antiviral Res.
104:153-5, 2014!

!
!

• 中和活性を有する抗体製剤による治療薬の開発!
– ZMapp!
• Qui X, Wang G, Audet J, et al. Successful Treatment of Ebola Virus–
Infected Cynomolgus Macaques with Monoclonal Antibodies. Sci
Transl Med 13 June 2012: Vol. 4, Issue 138, p. 138ra81""• Qui X, Wang G, Audet J, et al. Reversion of advanced Ebola virus disease
in nonhuman primates with ZMapp. Nature (doi:10.1038/nature13777)�

RESEARCH ARTICLE

Qiu X, et al. Reversion of advanced Ebola virus disease in nonhumanprimates with Zmapp. Nature (advanced publication)�

a
EBOV
1,000 p.f.u.

ZMapp, 50 mg kg–1

714CcD50

42104038

210TO
N
80
70

71421

Viraemia (TCID50 ml–1)

f90

Total bilirubin (mg dl–1)

500

0

21

28

71421

Platelets per mm3(×103)

25
15
1050
714
21
Days post-infection

28

71421

28

0

71421

28

71421

28

800
600
400
2000

j
4
32
100

l0

1,000

28

5

28

20021

g0

1,000

14

14i

1,500

77108
107
106
105
104
103
102
101
100

282,00003628

Ala aminotransferase(U l–1)

14

Lymphocytes per mm3(×103)

7110
1000Neutrophils per mm3(×103)

28d2000120hk2130Clinical score

1000eB

ATemperature (°C)

0b
Per cent survival• 抗体製剤非投与群（1個体）は死亡!
• エボラウイルス感染24時間後に抗体製剤を投与すると100％の生存率!
• エボラウイルス感染48時間後に抗体製剤を投与すると50％の生存率!

In this experiment, rhesus macaques were assigned into three treatmentgroups of six and a control group of three animals, with all treatment
NHPs receiving three doses of ZMapp (c13C61c2G41c4G7, 50 mg kg21per dose) spaced 3 days apart. After a lethal intramuscular challenge with

Weight (% change)

Sci Transl Med 13 June 2012: Vol. 4, Issue 138, p. 138ra81 "Successful Treatment of Ebola Virus–Infected Cynomolgus Macaques with Monoclonal Antibodies�

FOO
RPL
A
NI
F

Monoclonal antibodyによる"治療法の開発（改良）"ZMapp-treated NHPs

Alkaline phosphatase(U l–1)

Monoclonal antibodyによる"治療法の開発"

1,000 3 TCID50 (or 628 p.f.u.) of EBOV-K18, we treated the animals with
ZMapp at 3, 6 and 9 dpi (Group D); 4, 7, and 10 dpi (Group E); or 5, 8and 11 dpi (Group F). The control animals (Group G) were given mAb
4E10 as an IgG isotype control (n 5 1) or PBS (n 5 2) in place of ZMapp
starting at 4 dpi (Fig. 2a). All animals treated with ZMapp survived theinfection, whereas the three control NHPs (G1, G2 and G3) succumbed
to EBOV-K infection at 4, 8 and 8 dpi, respectively (P 5 3.58 3 1025,log-rank test, x2 5 23.25, d.f. 5 3, comparing all groups) (Fig. 2b). At
the time ZMapp treatment was initiated, fever, leukocytosis, thrombocytopenia and viraemia could be detected in the majority of the animals(Fig. 2c–f, Table 3, Extended Data Table 5). All animals presented withdetectable abnormalities in blood counts and serum biochemistry during the course of the experiment (Fig. 2g–l, Table 3).
The Group F animals did not seem to be as sick as animals E4 andE6 on the basis of clinical scores (Fig. 2c, Extended Data Fig. 1), bothanimals E4 and E6 were near the clinical limit for IACUC mandated
euthanasia at 5 and 7 dpi, respectively. Animal E4 had a flushed face andsevere rash on more than 40% of its body surface between 5 and 8 dpi
in addition to nasal haemorrhage at 7 dpi, and animal E6 had a flushed
face and petechiae on its arms and legs between 7 and 9 dpi, in addition
to jaundice between 10 and 14 dpi. This indicates that host genetic factors may have a role in the differential susceptibility of individual NHPs
to EBOV-K infections. Fever, leukocytosis, thrombocytopenia and ain addition to a drastic drop in body temperature shortly before death(Fig. 1c). At the time of death, animal B3 had elevated levels of alanine
aminotransferase, total bilirubin, blood urea nitrogen and creatinine, inaddition to decreased levels of glucose, suggesting multiple organ failure(Fig. 1). All six Group B animals showed fever in addition to viraemia
at 3 dpi by TCID50 and RT–qPCR (Fig. 1d, Extended Data Table 1). It
was interesting to note that in B3, the viraemia reached approximately
106 TCID50 after 3 dpi (Fig. 1d), suggesting that this NHP was particularly susceptible to EBOV infection. No escape mutants were detectedwith this animal. The administration of ZMapp2 at the reported concentrations was unable to effectively control viraemia at this level. Virus
shedding was also detected from the oral and rectal swabs by RT–qPCR
in the moribund NHP B3 (Extended Data Tables 2–4). Since ZMapp1
demonstrated superior protection to ZMapp2 in this survival study,
ZMapp1 (now trademarked as ZMapp by MappBio Pharmaceuticals)
was carried forward to test the limits of protection conferred by thismAb cocktail in a subsequent investigation.

714212520151050028

Days post-infection
800600D1E1F1G1400200

D2E2F2G2D3E3F3G3D4E4F4D5E5F5D6E6F60071421
Days post-infection

Figure 2 | Post-exposure protection of EBOV-infected nonhuman primateswith ZMapp. a–f, Rhesus macaques (n 5 6 per ZMapp treatment group, n 5 3for controls) were challenged with EBOV-K, and 50 mg kg21 of ZMapp
were administered beginning at 3 (Group A), 4 (Group B) or 5 (Group C) daysafter challenge. Non-specific IgG mAb or PBS was administered as a control(Group D). a, Timeline of infection, treatment and sample days. b, Kaplan–Meier survival curves (log-rank test: overall comparison P 5 3.58 3 1025).

28• 最適化された中和活性のあるヒト型単クローン抗体（3種類）のカクテル!
• 症状出現が既に出現している感染5日後からZMapp投与が開始された個体（6頭）すべてで回復が認められた．!
• コントロール群（3頭）はすべて8日以内に死亡した（1頭は4日後に死亡）．�

c, Clinical scores; the dashed line indicates the minimum score requiring
mandatory euthanasia. d, Rectal temperature. e, Percentage body weightchange. f, EBOV viraemia by TCID50. g–l, Selected clinical parameters ofGroup A to D animals. g, Alanine aminotransferase; h, alkaline phosphatase;i, total bilirubin. j–l, Counts for lymphocytes (j), neutrophils (k) and platelets(l) over the course of the experiment.

4 | N AT U R E | VO L 0 0 0 | 0 0 M O N T H 2 0 1 4

エボラ治療法の開発"

�• ウイルス増殖を抑制する抗ウイルス薬!
– T-705!

• Oestereich L, Lüdtke A, Wurr S, Rieger T, Muñoz-Fontela C, Günther S.
Successful treatment of advanced Ebola virus infection with T-705(favipiravir) in a small animal model. Antiviral Res. 105:17-21, 2014 !
!
• Smither SJ, Eastaugh LS, Steward JA, Nelson M, Lenk RP, Lever MS.
Post-exposure efficacy of oral T-705 (Favipiravir) against inhalational
Ebola virus infection in a mouse model. Antiviral Res.104:153-5, 2014!
!
!

•

中和活性を有する抗体製剤による治療薬の開発!
–ZMapp!
•"•Qui X, Wang G, Audet J, et al. Successful Treatment of Ebola Virus–Infected Cynomolgus
Macaques with Monoclonal Antibodies. Sci Transl Med 13 June 2012: Vol. 4, Issue 138, p. 138ra81"
Qui X, Wang G, Audet J, et al. Reversion of advanced Ebola virus disease in nonhuman primates withZMapp. Nature (doi:10.1038/nature13777)�

Fig. 2 Treatment of EBOV-infected IFNAR − / − C57BL/6 mice with T-705. Groups of 5 mice were inoculated intranasally with 1000
FFU of EBOV. Mice were treated with a T-705 dose of 300 mg/(kg × d). The drug was administered twice daily per os using a stom...
Lisa Oestereich , Anja Lüdtke , Stephanie Wurr , Toni Rieger , César Muñoz-Fontela , Stephan Günther. Successful treatmentof advanced Ebola virus infection with T-705 (favipiravir) in a small animal model. Antiviral Research, Volume 105, 2014, 17 –21（http://dx.doi.org/10.1016/j.antiviral.2014.02.014）&47

:*/;

Vesicular stomatitis virus• Replication-competent VSV-with EBOVGP or with MARV: promising
Live attenuated recombinant vaccine
protects nonhuman primates against Ebola
and Marburg viruses
Steven M Jones, Heinz Feldmann,Ute Stroher, Joan B
Geisbert, Lisa Fernando, Allen Grolla, Hans-Dieter
Klenk, Nancy J Sullivan, Viktor E Volchkov,Elizabeth A Fritz, Kathleen M Daddario, Lisa E
Hensley, Peter B Jahrling &Thomas W Geisbert!
!
Nature Medicine 2005

VSV
Zaire EBOVVSV-ZEBOV/GP

Lake Victoria MARV

VSV-MARV/GP動物実験デザイン

GSK-ebola vaccine�• Prime: Chimpanzee adenovirus-EBOVGP• Boost: MVA-EBOV-GP�

西アフリカにおける"エボラ出血熱の流行�
• 感染症対策：決して私たちは流行に敗れてはいない．!
• 感染症には国境はない：エボラ出血熱は決して海外（アフリカだけ）の問題ではなく，私たち自身の問題でもある．!
• 希少感染症であっても，診断・治療・予防法の研究および開発は重要である．!
• 研究の重要性を強調したい．�