MMWR & WHO On Risks Of Sexual Transmission Of Ebola

Credit WHO

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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.

 

Possible Sexual Transmission of Ebola Virus — Liberia, 2015

Weekly

May 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).

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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.

WHO On Ebola In Semen Of Convalescent Men

Credit CDC PHIL

 

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One of the more unusual aspects of an Ebola virus infection is that even after a man has recovered, he can shed the virus in his semen for up the three months.   This is a topic that we’ve looked at in the past, most recently in Lancet: Mackay & Arden On Ebola In Semen Of Convalescent Men, and prior to that in a pair of VDU blogs Ebola virus in semen is the real deal.... &  Ebola: Blood, sweat and tears.

While it has been recommended that men are counseled to use condoms to protect their partners for 3 months post-infection, earlier this month we saw India isolate a man with Ebola-infected semen, more than six weeks after he was pronounced cured (Sept 30th) and released from a Liberian hospital.

 

Today the World Health Organization has published their own review of the evidence, and while they find there is a potential danger of infection, there are no documented cases of of sexual transmission of the ebolavirus. They reiterate the opinion that there is no need to isolate men during this convalescent period. 

 

Ebola virus in semen of men who have recovered from Ebola virus disease

Key messages

26 November 2014

Survivors of Ebola working with WHO, Sierra Leone

• Sexual transmission of Ebola virus disease (EVD) has not been documented
• In four studies that investigated persistence of Ebola virus in seminal fluid from convalescent patients (a total of 43 patients), three men who had recovered from Ebola virus disease were reported to shed live virus in semen 40 days, 61 days and 82 days after onset of symptoms, respectively.
• In two studies, Ebola virus was isolated from semen, but subsequent infections were not identified in household contacts.
• Men who have recovered from Ebola virus disease should be aware that seminal fluid may be infectious for as long as three months after onset of symptoms.
• 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.
• WHO does not recommend isolation of male convalescent patients whose blood has been tested negative for EVD.

The Ebola virus is shed in bodily fluids such as blood, vomit, faeces, saliva, urine, tears, and vaginal and seminal fluids. There is evidence that seminal fluids of convalescing men can shed the Ebola virus for at least 82 days after onset of symptoms. Although the scientific evidence is limited, it is clear that semen is a potential source of infection and could therefore cause transmission of the virus through delivery of the infectious virus on a mucosal surface.

1. How long is Ebola virus present in semen?

In a study performed during the Ebola outbreak in Gulu, Uganda, in 2000, the authors tested the semen of a single convalescent patient and were able to isolate Ebola virus up to 40 days after the onset of illness. One study in 1977 (Edmond et al., laboratory infection in England) detected live Ebola virus in semen of one convalescent man 61 days after onset of symptoms. One study in1995 (Rodriguez et al. Ebola outbreak in Kikwit, Democratic Republic of Congo) also detected live Ebola virus in semen in one convalescent man 82 days after disease onset. Therefore, it is possible for Ebola virus to be present in semen for 3 months after disease onset.

2. Is semen that tests positive for Ebola virus infectious?

The evidence is inconclusive. One study (Rowe et al.) that followed four men recovering from Ebola virus disease and their sexual partners found that no sexual partner developed symptoms.

References

• Bausch, D. et al. (2007) Assessment of the risk of Ebola virus transmission from bodily fluids and fomites, The Journal of Infectious Diseases, 196, pp. S142-7.
• Emond, R. et al. (1977) A case of Ebola virus infection, British Medical Journal, 2, pp. 541-544.
• Rodriguez, L. et al. (1999) Persistence and genetic stability of Ebola virus during the outbreak in Kikwit, Democratic Republic of Congo, 1995, The Journal of Infectious Diseases, 179(1), pp. S170-6.
• Rowe, A. et al. (1999) Clinical, Virologic, and Immunologic Follow-up of Convalescent Ebola Hemorrhagic Fever Patients and their Household Contacts, Kikwit, Democratic Republic of the Congo, The Journal of Infectious Diseases, 179(1), pp.S28-35.

Lancet: Mackay & Arden On Ebola In Semen Of Convalescent Men

Credit CDC PHIL

 

 

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Last August, Dr. Ian Mackay writing on his VDU Blog, posted Ebola virus in semen is the real deal...., which he followed up 10 days later with  Ebola: Blood, sweat and tears, where Ian described the (somewhat limited) research to date on the level of EBOV detection in other body fluids – like tears, sweat and saliva.

Given how easily Ebola has spread these past few months in Africa – and all apparently via infected body fluids – the more we know about the risks, the better.

This week we’ve seen India isolate a man with Ebola-infected semen, more than six weeks after he was pronounced cured (Sept 30th) and released from a Liberian hospital. While this may provide additional data on the duration of viral shedding via semen, as a public health measure, many consider his isolation both excessive and unnecessary.

In a case of exceedingly good timing, yesterday Ian Mackay  and Dr. Katherine Arden published a review of the potential for semen to carry the EBOV in The Lancet.

 

 

Ebola virus in the semen of convalescent men

Ian M Mackay,Katherine E Arden
The Lancet Infectious Diseases - 19 November 2014
DOI: 10.1016/S1473-3099(14)71033-3

Semen is one of the body fluids from which Ebola virus disease can be contracted, presumably by delivery of the infectious virus to a mucosal surface. WHO notes that Ebola viruses can be transmitted via the semen of a man who is convalescing, for up to 7 weeks after recovery from an Ebola virus infection.1 The European Centre for Disease Prevention and Control2 and Public Health Agency of Canada3 both report the 7 week figure, and the latter also refers to a period of 61 days. The United States Army Medical Research Institute of Infectious Diseases4 suggests a 3 month period, recommending that survivors avoid sexual contact.

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