Last November Flublogia’s very own Dr. Ian Mackay, along with Dr. Katherine Arden, penned a piece for The Lancet (see Mackay & Arden On Ebola In Semen Of Convalescent Men) on the risks of Ebola transmission via semen even months after apparent recovery from the disease.
A couple of weeks after The Lancet article appeared, the World Health Organization published their own review (see WHO On Ebola In Semen Of Convalescent Men), where they stated there was a potential danger of infection, although there were no documented cases of of sexual transmission of the ebolavirus.
They nonetheless recommended:
Because of the potential to transmit the virus sexually during this time, they should maintain good personal hygiene after masturbation, and either abstain from sex (including oral sex) for three months after onset of symptoms, or use condoms if abstinence is not possible.
Fast forward to March of this year, and we learned of a suspected case of sexual transmission of the Ebola virus from a male patient who had recovered in late August of last year.
Yesterday’s MMWR carried a report synopsizing that case.
WeeklyMay 8, 2015 / 64(17);479-481
On May 1, 2015, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr).
Athalia Christie, MIA1, Gloria J. Davies-Wayne, MPH2, Thierry Cordier-Lasalle, DESS2, David J. Blackley, DrPH1, A. Scott Laney, PhD1, Desmond E. Williams, MD, PhD1, Shivam A. Shinde, MBBS2, Moses Badio, MSc3, Terrence Lo, DrPH1, Suzanne E. Mate, PhD4, Jason T. Ladner, PhD4, Michael R. Wiley, PhD4, Jeffrey R. Kugelman, PhD4, Gustavo Palacios, PhD4, Michael R. Holbrook, PhD5, Krisztina B. Janosko, MS5, Emmie de Wit, PhD5, Neeltje van Doremalen, PhD5, Vincent J. Munster, PhD5, James Pettitt, MS5, Randal J. Schoepp, PhD4, Leen Verhenne, MD6, Iro Evlampidou, MD6, Karsor K Kollie, MPH3, Sonpon B. Sieh3, Alex Gasasira, MBChB2, Fatorma Bolay, PhD7, Francis N. Kateh, MD3, Tolbert G. Nyenswah, MPH3, Kevin M. De Cock, MD1
On March 20, 2015, 30 days after the most recent confirmed Ebola Virus Disease (Ebola) patient in Liberia was isolated, Ebola was laboratory confirmed in a woman in Monrovia. The investigation identified only one epidemiologic link to Ebola: unprotected vaginal intercourse with a survivor.
Published reports from previous outbreaks have demonstrated Ebola survivors can continue to harbor virus in immunologically privileged sites for a period of time after convalescence. Ebola virus has been isolated from semen as long as 82 days after symptom onset and viral RNA has been detected in semen up to 101 days after symptom onset (1). One instance of possible sexual transmission of Ebola has been reported, although the accompanying evidence was inconclusive (2). In addition, possible sexual transmission of Marburg virus, a filovirus related to Ebola, was documented in 1968 (3). This report describes the investigation by the Government of Liberia and international response partners of the source of Liberia's latest Ebola case and discusses the public health implications of possible sexual transmission of Ebola virus.
Based on information gathered in this investigation, CDC now recommends that contact with semen from male Ebola survivors be avoided until more information regarding the duration and infectiousness of viral shedding in body fluids is known. If male survivors have sex (oral, vaginal, or anal), a condom should be used correctly and consistently every time (4).
The CDC’s advice differs in that it is more open ended what than that proposed today the WHO, which calls for abstinence or protection until the male partner’s semen has tested negative twice.
Interim Advice on Sexual Transmission of Ebola Virus Disease
8 May 2015
Sexual transmission of the Ebola Virus, from males to females, is a strong possibility, but has not yet been proven. Less probable, but theoretically possible, is female to male transmission.
Studies have shown that Ebola virus can be isolated from semen up to 82 days after symptom onset and a recent case investigation identified genetic material (RNA) from the virus by nucleic acid amplification tests (such as RT-PCR) 199 days after symptom onset. This is well beyond the period of virus detectability in the blood of survivors and long after recovery from illness. The detection of virus genetic material many months after symptom onset is assumed to reflect the continuing, or at least very recent, presence of live and potentially transmissible Ebola virus.
In support of the view that Ebola virus can be transmitted via semen, a single instance of heterosexual transmission of the related Marburg filovirus, from a male survivor to a female partner, was reported during an outbreak in 1967.
Ebola virus RNA has also been detected by RT-PCR in vaginal fluid from one woman 33 days after symptom onset. Live virus has never been isolated from vaginal fluids. With such limited data, it is not known for how long virus typically persists in vaginal fluids, or whether it can be sexually transmitted from females to males.
More surveillance data and research are needed on the risks of sexual transmission, and particularly on the prevalence of viable and transmissible virus in semen over time. In the interim, and based on present evidence, WHO recommends that:
- All Ebola survivors and their sexual partners should receive counselling to ensure safe sexual practices until their semen has twice tested negative. Survivors should be provided with condoms.
- Male Ebola survivors should be offered semen testing at 3 months after onset of disease, and then, for those who test positive, every month thereafter until their semen tests negative for virus twice by RT-PCR, with an interval of one week between tests.
- Ebola survivors and their sexual partners should either (a) abstain from all types of sex or (b) observe safe sex through correct and consistent condom use until their semen has twice tested negative. Having tested negative, survivors can safely resume normal sexual practices without fear of Ebola virus transmission.
- If an Ebola survivor’s semen has not been tested, he should continue to practice safe sex for at least 6 months after the onset of symptoms; this interval may be adjusted as additional information becomes available on the prevalence of Ebola virus in the semen of survivors over time.
- Until such time as their semen has twice tested negative for Ebola, survivors should practise good hand and personal hygiene by immediately and thoroughly washing with soap and water after any physical contact with semen, including after masturbation. During this period used condoms should be handled safely, and safely disposed of, so as to prevent contact with seminal fluids.
- All survivors, their partners and families should be shown respect, dignity and compassion.