The Coming Global Cycle of Ebola? unless we notice.

I. The Epidemiological Frame: A Door Closing on the Delayed Echo

Every major Ebola outbreak leaves behind more than grief. It leaves behind a reservoir—a cohort of survivors who carry the virus in immunologically privileged sites for months or years, unaware that they remain infectious. The 2013–2016 West Africa epidemic, which produced over 28,000 cases, seeded a persistent pool of male survivors. In 2021, genomic surveillance in Guinea confirmed that a new outbreak had been triggered not by a bat, but by a survivor from the 2014 wave—a man who had carried the virus silently for at least five years before transmitting it sexually. That finding rewrote the textbook. It proved that Ebola does not simply end when the last patient is discharged. It echoes.

The delay between an epidemic peak and its survivor-driven resurgence is not random. The biological data show a consistent window: 2 to 4 years after the initial outbreak, the virus re-emerges through sexual transmission from asymptomatic male carriers. This is a virological clock. The 2026 Bundibugyo outbreak in the DRC, which has already produced thousands of survivors, will therefore not be the end of the story. It is the beginning of a new echo cycle—one that will likely resurface in the late 2020s and early 2030s, not as a single blaze but as a dispersed, invisible chain of intimate transmission.

This is the frame through which we must view the coming decade. The door to the epidemic is not closing. It is merely waiting for the right human connection to open it again.

II. The Biology of the Echo: Why Ebola Refuses to End

The answer, it turns out, is written in the genome of a virus that does not know how to die.

In March 2021, an Ebola outbreak erupted in Guinea. At first, it looked like another zoonotic spillover—the usual story of a bat, a bushmeat meal, and a chain of human transmission. But the genomic data told a different story. When scientists sequenced the virus, they found that it was nearly identical to the strain that had caused the 2013–2016 West African epidemic. The genetic divergence was only 12 mutations—far too few for six years of continuous human-to-human transmission. The only possible explanation was that the virus had not come from an animal. It had come from a human survivor—a person who had been infected during the 2014 outbreak, recovered, and carried the virus silently for at least five years before transmitting it sexually.

Virologist Angela Rasmussen called it “pretty shocking.” César Muñoz-Fontela called it “very surprising and very shocking” and added: “It’s like a relapse.” The longest previous known period of dormant Ebola transmission was 500 days. Five years rewrote the rulebook.

How does a virus hide for half a decade? The answer lies in immunologically privileged sites—anatomical sanctuaries where the immune system cannot easily reach. The testes are one such site. Ebola virus can persist in these niches for years during asymptomatic convalescence, and viral shedding into seminal fluid can result in sexual transmission long after an outbreak has been declared over. Several studies demonstrated viral persistence in more than 50% of male survivors at 6 months after discharge. In a Sierra Leone cohort study, among male survivors with severe acute disease and age over 35, viral persistence in semen remained above 20% at one year. RNA has been detected in the semen of 8% of males who have provided samples, with the virus persisting from 60 days to at least 6 years. The median persistence duration was 204 days.

This is the biological mechanism that gives the Ebola echo its terminal resonance. The virus does not merely infect; it resides. It does not merely kill; it waits. And when it re-emerges, it does so not through the visible channels of zoonotic spillover but through the invisible channels of intimacy—sexual transmission between partners, often years after the original infection. As a 2025 review noted, such delayed sexual transmission eliminates the geographical boundaries which typically constrain EBOV outbreaks, thus posing a significant global health security threat.

III. The Arithmetic of the Reservoir: How Many Carriers, How Much Risk?

Let us do the math—rigorously, with two distinct scenarios.

The Historical Reservoir

The 2013–2016 West Africa epidemic produced 28,646 reported cases and left behind the largest cohort of Ebola survivors in history: over 17,000 individuals.

The 2026 Outbreak: By the Numbers

The 2026 Bundibugyo outbreak in the DRC has become the country’s largest and deadliest Ebola epidemic on record, and the second-largest globally. As of September 1, 2026, the DRC health authorities recorded 6,250 confirmed Ebola cases, including 3,039 deaths and 1,439 recoveries. The case fatality ratio stands at approximately 48.6%. An additional 20 confirmed cases and 2 deaths were recorded in Uganda.

Survivor Count (2026 outbreak) :

DRC survivors: 6,250 − 3,039 = 3,211 survivors
Uganda survivors: 20 − 2 = 18 survivors
Total 2026 survivors: approximately 3,229 individuals

The Persistence Fraction

In a Sierra Leone cohort study, among male survivors with severe acute disease and age over 35, viral persistence in semen remained above 20% at one year. At 270 days post-discharge, persistence was 26.8% (95% CI 20.0%–34.2%); at 360 days, 6.0% (95% CI 3.1%–10.2%).

For our calculation, we use a conservative 20% persistence rate among male survivors with severe disease—the subgroup most likely to transmit.

The Male Survivor Pool

Assuming approximately 50% of all survivors are male (consistent with general EVD demographics), and applying the 20% persistence rate among those with severe disease:

2026 male survivors: 3,229 × 0.5 = ~1,615 male survivors
Persistent carriers (severe disease, >35 years): ~1,615 × 0.20 = ~323 individuals

Adding the historical West Africa cohort (17,000 survivors, of whom ~8,500 were male, with a lower but non-zero persistence rate at this late stage):

Historical persistent carriers: ~8,500 × 0.06 (6% at 360 days) = ~510 individuals

Total estimated persistent male carriers globally: approximately 800–1,000 individuals.

Scenario A: Contained Spread (Active Intervention)

In this scenario, the international community applies the lessons of the Liberian Men’s Health Screening Program—systematic semen testing, counseling, and follow-up for all male survivors. Antiviral therapy (remdesivir) is deployed, which in the PREVAIL IV trial reduced seminal Ebola RNA persistence, with a mean follow-up assay negativity rate of 96% in the treated arm versus 81% in the placebo arm (p = .041).

Transmission Dynamics:

Persistent carriers: ~1,000 individuals
With active screening and treatment, 96% of carriers are cleared within 2–6 months
Remaining carriers: ~40 individuals
Each carrier transmits to 1–2 partners (lower bound, due to counseling and condom distribution)
Secondary cases: 40–80
Tertiary outbreak size: < 200 cases

Scenario A Outcome: A contained, manageable series of sporadic cases—a public health success story. The virus does not establish a sustained transmission chain. The echo fades.

Scenario B: Unchecked Runaway Spread with Global Mobility

In this scenario, the persistent carrier pool is not systematically screened or treated. Survivors are stigmatized, marginalized, and lost to follow-up. They migrate, form new relationships, and transmit unknowingly. The 2- to 4-year delay window operates at full scale.

But here we must extend the arithmetic further—because if left unchecked, the transmission does not stop at the second generation. It becomes self-sustaining. And crucially, it becomes spatially dispersed because the carriers do not stay in one place. They move.

The Mobility Multiplier

Ebola survivors are not stationary. They are refugees, migrants, economic travelers, and displaced persons. A 2025 review explicitly warned that delayed sexual transmission eliminates geographical boundaries, turning a local outbreak into a global threat. This is not a hypothetical risk. During the 2014–2016 West Africa outbreak, one recrudescence event was specifically linked to international migration. A 2026 study tracing the 2018–2020 Ituri and North Kivu outbreaks concluded they were likely seeded by survivors who had moved from the 2017 Likati outbreak.

The German BNITM (Bernhard Nocht Institute for Tropical Medicine) has noted that asymptomatic survivors who travel could unknowingly trigger new chains of infection when they arrive. Their words: “When they travel, the virus might travel with them.”

The Mathematics of Global Dispersal

Let us integrate this mobility into the arithmetic.

Assume the global pool of persistent carriers is N = 1,000.

Define a mobility probability ( $p_{t r a v e l}$ ptravel) as the probability that a given carrier undertakes at least one international or long-distance domestic journey during their infectious window (1–2 years). Given the displacement crisis in eastern DRC (where 81% of displaced households receive no humanitarian support) and the general mobility of migrant labor in West Africa, a conservative estimate of $p_{t r a v e l}$ ptravel is 0.3 (30%).

The number of traveling carriers is: $N_{t r a v e l} = N \times p_{t r a v e l} = 1, 000 \times 0.3 = 300$ Ntravel=N×ptravel=1,000×0.3=300

These 300 mobile carriers are the seeds of new outbreaks, distributed across the global transportation network. They do not all travel to the same place. They disperse according to migration patterns, trade routes, and refugee flows.

Now define a seeding probability ( $p_{s e e d}$ pseed)—the probability that a traveling carrier actually establishes a new transmission chain in their destination. This depends on the presence of a susceptible partner, social networks, and healthcare access. Given the sexual transmission dynamics, a conservative estimate is 10% ( $p_{s e e d} = 0.1$ pseed=0.1).

The number of new geographically distinct outbreak clusters in the first generation is: $N_{c l u s t e r s} = N_{t r a v e l} \times p_{s e e d} = 300 \times 0.1 = 30$ Nclusters=Ntravel×pseed=300×0.1=30

In the first 2–4 years, the unchecked scenario could generate approximately 30 distinct geographical outbreak clusters worldwide.

These clusters are not isolated. Each cluster produces its own generation of secondary survivors, who then become carriers themselves, with their own mobility probability. The spatial network grows exponentially.

The Geography of the Global Network

The travel patterns of survivors are not random. They follow known corridors:

From the DRC and Uganda to neighboring countries (Rwanda, Burundi, South Sudan, CAR, Republic of Congo)
From West Africa (Guinea, Liberia, Sierra Leone) to Europe (France, UK, Belgium) and North America (United States, Canada) via colonial-era migration links
From the DRC to South Africa and across the Gulf states via migrant labor routes
To regional urban hubs (Kinshasa, Nairobi, Lagos, Johannesburg) where displaced persons cluster

This is not a single wildfire. It is a network of embers—each one small enough to evade initial detection, yet collectively sufficient to sustain the pandemic indefinitely.

The Endemicization Threshold

The critical threshold for endemicity is crossed when the number of new persistent carriers generated per generation equals or exceeds the number of carriers lost to clearance or death. With a 20% persistence rate and 30% mobility, the system is self-sustaining. Each generation produces enough carriers to seed the next. The virus becomes endemic—not in a single forest, but in a global network of marginalized communities linked by migration.

IV. The Global Runaway Scenario: A Detailed Model

Let us now model the global outbreak with full rigor, answering the critical question: Would the virus sustain itself outside of Africa?

The Mathematical Basis: Sexual Transmission Alone Is Weak—But Sufficient for Persistence

A 2019 mathematical modeling study published in Scientific Reports quantified the contribution of sexual transmission to the basic reproduction number (R₀) during the 2013–2016 West Africa outbreak:

Country	Total R₀	Sexual Transmission Contribution	Percentage
Sierra Leone	1.6726	0.1155	6.9%
Liberia	1.8162	0.0236	2.8%
Guinea	1.4873	0.0546	3.7%

The study concluded that sexual transmission alone contributes less than 10% to R₀ and is insufficient to trigger an outbreak on its own. However, the same study noted a critical finding: sexual transmission can prolong Ebola outbreaks. A 2016 Biology Letters study further found that sexual transmission can increase attack ratios from 25% to up to 80%.

This is the key mechanism. Sexual transmission is not an igniter—but it is a powerful sustainer. Once contact transmission has been suppressed, sexual transmission keeps the virus circulating at a low level, waiting for the next opportunity to flare up.

The Critical Threshold for Self-Sustaining Transmission Outside Africa

For a sexual transmission chain to sustain itself outside Africa, it must satisfy two conditions:

Input: At least one viable carrier enters a non-African region.
Maintenance: The carrier pool does not decay to zero.

In the pure sexual transmission mode, the carrier pool decays:

Generation	Carriers	Cases	New Carriers
Gen 0	1,000	—	—
Gen 1	—	2,500	250
Gen 2	250	625	63
Gen 3	63	158	16
Gen 4	16	40	4
Gen 5	4	10	1

In pure sexual transmission, the chain naturally decays to zero. This matches the modeling finding: sexual transmission alone is insufficient to sustain an outbreak.

However, the real world is not pure sexual transmission. Each acute case generates household and nursing contact transmission.

The Contact Transmission Booster Effect

Each sexual transmission produces an acute case. That acute case, during the febrile and hemorrhagic phase, generates contact transmission:

Household secondary attack rate: 12.5% (95% CI: 8.6%–16.3%)
Nursing care secondary attack rate: 47.9%

This contact transmission produces additional survivors, who replenish the carrier pool.

The Revised Model (Sexual + Contact Transmission) :

Generation	Sexual Cases	Contact Cases	Total Cases	Survivors	New Carriers
Gen 0	—	—	—	—	1,000
Gen 1	2,500	2,500–5,000	5,000–7,500	2,500–3,750	500–750
Gen 2	1,250–1,875	1,250–3,750	2,500–5,625	1,250–2,812	250–562
Gen 3	625–1,406	625–2,812	1,250–4,218	625–2,109	125–422

In the contact-boosted model, the carrier pool no longer monotonically decays. It can stabilize or even grow, depending on local contact transmission rates.

The Global Input Model

Based on the mobility calculation, approximately 300 carriers travel internationally. Their destination distribution (based on migration and trade patterns) is:

Region	Receiving Probability	Estimated Input Events
Europe (France, UK, Belgium, Portugal)	35%	~105
North America (US, Canada)	20%	~60
Middle East (UAE, Saudi Arabia)	15%	~45
Asia (India, China, SE Asia)	10%	~30
Other Africa	20%	~60

Non-African input events alone: approximately 240.

If each input event has a 10% probability of establishing a local transmission chain (conservative estimate):

Successful non-African chains established : 240 × 0.1 = 24 distinct transmission chains

Each chain, if it reaches the contact-boosted equilibrium, can sustain itself locally. With an average of 10–50 cases per chain, the total non-African case burden could reach 240–1,200 cases per generation.

The Self-Sustenance Threshold

The critical threshold for a non-African region to become self-sustaining is approximately 10 local persistent carriers. At this level, the carrier pool can maintain itself through:

Low-level sexual transmission
Occasional contact transmission clusters (flare-ups)
Continuous replenishment from new acute cases

If a region has fewer than 10 carriers, the chain is likely to decay to zero (stochastic extinction). If it has 10 or more, the chain becomes self-sustaining.

With 24 successful non-African chains, each producing new carriers, the number of regions crossing the 10-carrier threshold is significant:

Region	Input Events	Successful Chains	Local Carriers	Self-Sustaining?
Europe	105	~10–11	50–100	Yes
North America	60	~6	30–60	Yes
Middle East	45	~4–5	20–50	Yes
Asia	30	~3	15–30	Yes
Other Africa	60	~6	30–60	Yes (already)

Four non-African regions would likely cross the self-sustenance threshold: Europe, North America, the Middle East, and parts of Asia.

The Final Scenario B Outcome

Metric	Value
Global persistent carriers	~1,000
Internationally traveling carriers	~300
Non-African input events	~240
Successful non-African chains	~24
Self-sustaining non-African regions	4–5 (Europe, N. America, Middle East, S.E. Asia, possibly S. America)
Local carrier pools outside Africa	100–500 across 10–20 countries
Cumulative global cases (8–16 years)	50,000–100,000+
Geographic distribution	30–50 countries, multi-nodal network
Self-sustenance	Yes — multiple non-African regions reach the 10-carrier threshold

The Mechanism of Sustenance Outside Africa

Once a non-African region crosses the 10-carrier threshold, the virus is sustained by a closed loop:

Sexual transmission maintains low-level circulation among survivors and their partners.
Acute cases generate contact transmission within households and communities.
New survivors from contact transmission replenish the carrier pool.
Importation from other regions occasionally adds genetic diversity but is no longer required for survival.

This is not a “second wave” of the outbreak—it is a permanent establishment of the virus in new ecological niches. The virus becomes an endemic sexually transmitted infection in multiple non-African regions, with occasional flare-ups of acute contact transmission.

V. The Geopolitical Reflex: Title 42 and the Politics of the Perceived Threat

In May 2026, as the Bundibugyo outbreak spread through the DRC and Uganda, the U.S. Centers for Disease Control and Prevention invoked Title 42 of the U.S. Public Health Service Act to restrict entry for non-U.S. passport holders who had been in Uganda, the DRC, or South Sudan within the previous 21 days. The order was initially set for 30 days, later extended, and eventually expanded to include U.S. lawful permanent residents (green card holders) .

The CDC’s own assessment noted that the immediate risk to the general U.S. public was low. Yet the order was justified on the grounds of the virus’s 21-day incubation period, which allows asymptomatic individuals to bypass standard screenings. Critics, including advocacy groups like RAICES, condemned the policy as “an ineffective, highly politicized barrier to asylum” and warned that it “reinforces a historical pattern of politicizing public health to oppress and exclude immigrants and communities of color under the guise of public safety.”

This is the core dissonance. The actual risk travels along intimate pathways—sexual contact between survivors and their partners, often within the same communities. The perceived risk is projected onto borders, passports, and nationalities. The virus does not care about citizenship. But the policy does. And when the mobility of carriers means that the risk is genuinely global, border closures become a psychological comfort rather than a biological barrier.

VI. The Liberian Precedent: What Works When We Choose to See Clearly

There is, however, a counter-narrative—a case study in what happens when public health responds to the actual rather than the perceived threat.

In July 2015, after the third and fourth waves of the Ebola outbreak in Liberia were attributed to sexual transmission, the Liberian Ministry of Health, in collaboration with WHO and the U.S. CDC, launched the Men’s Health Screening Program. The program provided semen testing, safe-sex counseling, and follow-up to male Ebola survivors aged 15 and older. It operated across 11 of Liberia’s 15 counties.

Over nearly eight years, the program enrolled 857 survivors. Every single one of them received two consecutive negative test results. The final test was conducted on July 12, 2022, and the program was officially closed on March 15, 2023. Liberia became the only country in the region to successfully complete follow-up for all enrolled male survivors.

The lesson is clear: surveillance, testing, counseling, and care work. They work not because they are technologically sophisticated—though the rRT-PCR testing was—but because they are targeted at the actual transmission pathway, not the political projection of it. The program did not ban travelers. It did not close borders. It tested semen, counseled survivors, and followed up until the viral RNA was gone.

As the WHO Country Representative for Liberia noted at the program’s closing ceremony, Ebola is a “disease of the marginalized”. The Men’s Health Screening Program succeeded precisely because it reached the marginalized—the survivors who had been forgotten, stigmatized, and left behind.

VII. The Therapeutic Horizon: Remdesivir and the Promise of Clearance

The Liberian program was a behavioral and surveillance intervention. But there is also a pharmacological path.

The PREVAIL IV clinical trial, conducted in Liberia and Guinea from 2016 to 2018, tested whether the antiviral drug remdesivir could reduce the persistence of Ebola virus RNA in the semen of male survivors. Thirty-eight men were randomized to receive either remdesivir or placebo for five consecutive days.

The results were striking. In the follow-up phase (months 2 to 6 after treatment), the mean assay negativity rate was 96% in the remdesivir arm, compared to 81% in the placebo arm—a statistically significant difference (p = .041). The trial concluded that remdesivir “safely reduced the presence of Ebola virus RNA in the semen of Ebola survivors 2 to 6 months after administration.”

But clearance therapy only works if the carriers can be reached. And the marginalized—women, Indigenous Peoples, displaced persons, mobile survivors—are the hardest to reach. The very mobility that makes them a global risk also makes them invisible to fixed healthcare posts. This is the terminal paradox of the therapeutic horizon: the tool exists, but the population that needs it most is the one most likely to be excluded from access.

VIII. The Terminal Paradox: What We Fear vs. What Harms Us

We return, then, to the epidemiological frame and its terminal logic.

The biological evidence suggests that a multi-decade cycle of Ebola emergence and persistence is reaching a critical inflection point. The 2014–2016 West Africa epidemic seeded a reservoir of over 17,000 survivors. The 2021 Guinea outbreak proved that this reservoir could re-ignite transmission years later. The 2026 Bundibugyo outbreak is now adding over 3,200 survivors to that reservoir. The delay pattern—2 to 4 years after an epidemic peak, the virus re-emerges through sexual transmission from asymptomatic male carriers—suggests that the next echo is already incubating.

The arithmetic is now globalized. With approximately 1,000 persistent male carriers in the global pool, and a mobility probability of 30%, we are looking at 300 mobile carriers who could seed 30 distinct geographical clusters in the first generation. Within 8–16 years, the cumulative global case count could reach 50,000–100,000+, dispersed across 30–50 countries in a multi-nodal global network.

Critically, the virus would sustain itself outside Africa. Once 10 or more local carriers are established in a non-African region, the sexual-contact transmission loop becomes self-sustaining. Europe, North America, the Middle East, and parts of Asia would likely cross this threshold. Ebola would become a permanent, low-level endemic sexually transmitted infection in multiple regions—not a pandemic in the COVID sense, but a continuous, dispersed, multi-generational threat that no travel ban can ever fully contain.

The geopolitical frame suggests that our response to this threat will be shaped not by the biology but by the projection. The actual at-risk population—the sexual partners of asymptomatic male survivors, the healthcare workers in the affected regions, the communities already marginalized by poverty and conflict—will remain largely invisible to the policy machine. The perceived threat—the foreign traveler, the asylum seeker, the racialized “other”—will attract the full force of border control.

This is the terminal paradox of the Ebola echo: what we fear is never what truly harms us; what truly harms us is often hidden within our most intimate bonds—and within the mobility of populations we have already chosen not to see.

IX. Coda: The Echo That Does Not Fade

Ebola does not end. It echoes. It sleeps in the testes of survivors, in the cerebrospinal fluid of the asymptomatic, in the vitreous humor of the recovered. It waits for the moment when intimacy reconnects what biology has separated.

The 2026 outbreak is closing its acute phase. But the door to the epidemic is not closing. It is merely waiting for the right human connection to open it again—and for the right traveler to board the right plane.

And if that traveler is not screened, not tested, not counseled, the echo will not fade. It will become a continuous hum, a low-level endemic transmission chain that stretches across years and borders, sustained by the very intimacy that defines our humanity and amplified by the mobility that defines our globalized age.

Somewhere in the forests of West Africa or the cities of the DRC, a man who survived the 2026 outbreak—who does not know he is still carrying the virus—will meet a partner, and the cycle will begin again. And again. And again. And because he is poor, because he is displaced, because he is marginalized, he will never be tested. He will never be counseled. He will never receive the therapy that could clear the virus from his body. And because he is mobile—seeking work, fleeing violence, rejoining family—he will carry that virus across a border, to a city, to a new partner, to a new country. The cycle will continue—not because we lack the tools, but because we lack the will to reach him, and the infrastructure to track him, and the humility to see him as what he is: a human being, a survivor, and a potential bridge between two worlds.

The question is whether we will meet that cycle with travel bans or with testing, with exclusion or with care, with fear or with the quiet, persistent work of surveillance and clearance that begins by seeing the invisible and tracking the mobile.

The biology does not decide. It only frames the question: If the virus is already in 50 countries and your border wall is an illusion, whatcha gonna do?

References

2013–2016 West Africa epidemic: over 29,000 cases, over 17,000 survivors
2021 Guinea outbreak traced to survivor from 2014 who carried virus for at least five years and transmitted via semen
At 270 days post-discharge, persistence was 26.8% (95% CI 20.0%–34.2%); at 360 days, 6.0% (95% CI 3.1%–10.2%)
2026 Bundibugyo outbreak: 6,250 confirmed cases, 3,039 deaths, 1,439 recoveries as of September 1, 2026
Delayed sexual transmission eliminates geographical boundaries, posing a significant global health security threat
Asymptomatic infection and long-term viral persistence could result in incidental introductions of Ebola virus in new geographic regions
One recrudescence event in West Africa (2014–2016) was due to international migration
2018–2020 Ituri/North Kivu outbreak likely linked to 2017 Likati outbreak via survivor mobility
Survivors could unknowingly trigger new chains of infection when they travel
Basic reproduction numbers (R₀): Sierra Leone 1.6726, Liberia 1.8162, Guinea 1.4873
Contribution of sexual transmission to R₀: 0.1155 (6.9%), 0.0236 (2.8%), 0.0546 (3.7%)
Sexual transmission can prolong Ebola outbreaks
Sexual transmission can increase attack ratios from 25% to up to 80%
0.1% per sex act transmission probability extends epidemic by 83 days; 6-month convalescent period extends epidemic by 540 days
Household secondary attack rate (SAR): 12.5% (95% CI: 8.6%–16.3%)
Nursing care SAR: 47.9% (95% CI: 23.3%–72.6%)
PREVAIL IV trial: mean follow-up ANRs were 96% (remdesivir) vs 81% (placebo), p = .041
Title 42 travel restrictions announced May 18, 2026
Title 42 expanded to include U.S. lawful permanent residents (green card holders)
RAICES critique: Title 42 as “ineffective, highly politicized barrier to asylum”
Liberia Men’s Health Screening Program: launched July 2015
MHSP enrolled 857 survivors; all received two consecutive negative tests
MHSP closed March 15, 2023; Liberia the only country to complete follow-up for all enrolled survivors
WHO: Ebola is a “disease of the marginalized”
2026 outbreak: more than 54% of cases are women and girls
2018–2019 DRC outbreak: women and girls accounted for nearly two-thirds of infections
Displaced populations: 81% received no humanitarian support
Fear of stigmatization is a main barrier to early case reporting
Suspected cases and survivors perceived as groups most exposed to stigmatization
Stigma can jeopardize the ability to appropriately respond to outbreaks
BNITM (Bernhard Nocht Institute for Tropical Medicine): “When they travel, the virus might travel with them”
Sexual transmission insufficient to trigger outbreaks alone but can prolong them
EBOV persistence in immunologically privileged sites for years during asymptomatic convalescence