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Pam Sonnenberg, Nigel Field, Sexual and Mother-to-Child Transmission of Ebola Virus in the Postconvalescent Period, Clinical Infectious Diseases, Volume 60, Issue 6, 15 March 2015, Pages 974–975, https://doi.org/10.1093/cid/ciu981
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To the Editor—During the exponential phase of the current Ebola epidemic in West Africa, public health and infection control guidelines are necessarily being developed in real time using available evidence. This means making recommendations using data from previous smaller outbreaks of Ebola or other viral hemorrhagic fevers, and from selected patients who may not be representative of outbreak populations. We consider the evidence base for recommendations in the postconvalescent period and implications for infection control.
Ebola virus has been detected in semen [1–5], vaginal secretions [2], and breast milk [5] after patients no longer have detectable virus in other bodily fluids, such as blood, feces, and vomitus. The most likely explanation for viral persistence (eg, in testes, mammary glands) is that these are immunologically protected sites with delayed viral clearance.
The World Health Organization recommends using condoms during any sexual intercourse for 3 months after onset of symptoms. Yet, our understanding about the frequency and duration of, and risk associated with, viral persistence in semen is limited to findings from just 12 patients and for vaginal samples to just 1 patient (Table 1). Viral persistence has been shown up to 101 days for semen and 33 days for vaginal samples, without later samples in these individuals. However, no study with sufficient sample size has systematically tested consecutive urogenital samples over an extended time period. There is currently no specific guidance on breastfeeding for convalescing patients. Ebola virus has been detected in breast milk at 15 days after disease onset in 1 lactating woman (again without later samples) [5]. If safe alternatives exist, Centers for Disease Control and Prevention guidance states that mothers should avoid breastfeeding, but risks of not breastfeeding must also be considered.
Cases With Documented Ebola Virus in Vaginal Secretions, Semen, and Breast Milk in the Postconvalescent Period
| Patient . | Sample Type . | Latest Day After Disease Onset: Positive Sample . | Earliest Day After Disease Onset: Negative Sample . | Assay . | Reference . |
|---|---|---|---|---|---|
| 1 | Semen | 61 | 76 | Guinea pig infective units | Edmond et al [1] |
| 2 | Vaginal | 33 | Not done | RT-PCR | Rodriguez et al [2] |
| 3 | Semen | 82 | 704 | RT-PCR | Rodriguez et al [2] |
| 4 | Semen | 101 | Not done | RT-PCR | Rodriguez et al [2] |
| 5 | Semen | 97 | 700 | RT-PCR | Rodriguez et al [2] |
| 6 | Semen | 63 | 707 | RT-PCR | Rodriguez et al [2] |
| 7 | Semen | 82 | 697 | RT-PCR | Rowe et al [3] |
| 8 | Semen | 91 | Not done | RT-PCR | Rowe et al [3] |
| 9 | Semen | 63 | 97 | RT-PCR | Rowe et al [3] |
| 10 | Semen | 63 | 701 | RT-PCR | Rowe et al [3] |
| 11 | Semen | 62 | Not done | RT-PCR | Rowe et al [3] |
| 12 | Semen | 19 | Not done | Not stated | Richards et al [4] |
| 13 | Semen | 40 | 45 | RT-PCR | Bausch et al [5] |
| 14 | Breast milk | 15 | Not done | RT-PCR | Bausch et al [5] |
| Patient . | Sample Type . | Latest Day After Disease Onset: Positive Sample . | Earliest Day After Disease Onset: Negative Sample . | Assay . | Reference . |
|---|---|---|---|---|---|
| 1 | Semen | 61 | 76 | Guinea pig infective units | Edmond et al [1] |
| 2 | Vaginal | 33 | Not done | RT-PCR | Rodriguez et al [2] |
| 3 | Semen | 82 | 704 | RT-PCR | Rodriguez et al [2] |
| 4 | Semen | 101 | Not done | RT-PCR | Rodriguez et al [2] |
| 5 | Semen | 97 | 700 | RT-PCR | Rodriguez et al [2] |
| 6 | Semen | 63 | 707 | RT-PCR | Rodriguez et al [2] |
| 7 | Semen | 82 | 697 | RT-PCR | Rowe et al [3] |
| 8 | Semen | 91 | Not done | RT-PCR | Rowe et al [3] |
| 9 | Semen | 63 | 97 | RT-PCR | Rowe et al [3] |
| 10 | Semen | 63 | 701 | RT-PCR | Rowe et al [3] |
| 11 | Semen | 62 | Not done | RT-PCR | Rowe et al [3] |
| 12 | Semen | 19 | Not done | Not stated | Richards et al [4] |
| 13 | Semen | 40 | 45 | RT-PCR | Bausch et al [5] |
| 14 | Breast milk | 15 | Not done | RT-PCR | Bausch et al [5] |
Abbreviation: RT-PCR, reverse transcription polymerase chain reaction.
Cases With Documented Ebola Virus in Vaginal Secretions, Semen, and Breast Milk in the Postconvalescent Period
| Patient . | Sample Type . | Latest Day After Disease Onset: Positive Sample . | Earliest Day After Disease Onset: Negative Sample . | Assay . | Reference . |
|---|---|---|---|---|---|
| 1 | Semen | 61 | 76 | Guinea pig infective units | Edmond et al [1] |
| 2 | Vaginal | 33 | Not done | RT-PCR | Rodriguez et al [2] |
| 3 | Semen | 82 | 704 | RT-PCR | Rodriguez et al [2] |
| 4 | Semen | 101 | Not done | RT-PCR | Rodriguez et al [2] |
| 5 | Semen | 97 | 700 | RT-PCR | Rodriguez et al [2] |
| 6 | Semen | 63 | 707 | RT-PCR | Rodriguez et al [2] |
| 7 | Semen | 82 | 697 | RT-PCR | Rowe et al [3] |
| 8 | Semen | 91 | Not done | RT-PCR | Rowe et al [3] |
| 9 | Semen | 63 | 97 | RT-PCR | Rowe et al [3] |
| 10 | Semen | 63 | 701 | RT-PCR | Rowe et al [3] |
| 11 | Semen | 62 | Not done | RT-PCR | Rowe et al [3] |
| 12 | Semen | 19 | Not done | Not stated | Richards et al [4] |
| 13 | Semen | 40 | 45 | RT-PCR | Bausch et al [5] |
| 14 | Breast milk | 15 | Not done | RT-PCR | Bausch et al [5] |
| Patient . | Sample Type . | Latest Day After Disease Onset: Positive Sample . | Earliest Day After Disease Onset: Negative Sample . | Assay . | Reference . |
|---|---|---|---|---|---|
| 1 | Semen | 61 | 76 | Guinea pig infective units | Edmond et al [1] |
| 2 | Vaginal | 33 | Not done | RT-PCR | Rodriguez et al [2] |
| 3 | Semen | 82 | 704 | RT-PCR | Rodriguez et al [2] |
| 4 | Semen | 101 | Not done | RT-PCR | Rodriguez et al [2] |
| 5 | Semen | 97 | 700 | RT-PCR | Rodriguez et al [2] |
| 6 | Semen | 63 | 707 | RT-PCR | Rodriguez et al [2] |
| 7 | Semen | 82 | 697 | RT-PCR | Rowe et al [3] |
| 8 | Semen | 91 | Not done | RT-PCR | Rowe et al [3] |
| 9 | Semen | 63 | 97 | RT-PCR | Rowe et al [3] |
| 10 | Semen | 63 | 701 | RT-PCR | Rowe et al [3] |
| 11 | Semen | 62 | Not done | RT-PCR | Rowe et al [3] |
| 12 | Semen | 19 | Not done | Not stated | Richards et al [4] |
| 13 | Semen | 40 | 45 | RT-PCR | Bausch et al [5] |
| 14 | Breast milk | 15 | Not done | RT-PCR | Bausch et al [5] |
Abbreviation: RT-PCR, reverse transcription polymerase chain reaction.
There are no definitive data on which to base advice on safe resumption of breastfeeding. The transmission probabilities (including viral load), duration of risk, and differences in host immune response have not been quantified. If it occurs, the population attributable fraction (PAF) for sexual transmission of Ebola during convalescence may be low, given the physical toll of illness and associated stigma. The PAF for breastfeeding, especially in settings where this is a main source of infant nutrition, may be higher.
Given the scale of the current epidemic, the increasing numbers of survivors, and the possibility that transmission may be sustained within family settings through these routes, well-designed studies on persistence of Ebola virus in semen, vaginal secretions, and breast milk are urgently needed. These will inform appropriate public health messages to interrupt transmission during the postconvalescent period and provide robust parameters for mathematical models of the transmission dynamics of Ebola for epidemic projections.
Note
Potential conflict of interest. Both authors: No reported conflicts.
Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
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