Wednesday, November 19, 2014

Ebola can persist in the semen

Ebola in the semen

1. Ebola can be present in saliva, stool, semen, breast milk, tears, nasal blood, and a skin swab.

2. A study published in the Journal of Infectious Diseases (J Infect Dis. 1999 Feb;179 Suppl 1:S28-35) evaluated if convalescent body fluids contain Ebola virus and if secondary transmission occurs during convalescence. Twenty-nine Ebola hemorrhagic fever  convalescents and  their 152 house hold contacts were monitored for up to 21 months. Blood specimens were obtained and symptom information was collected from convalescents and their house hold contacts.  other body fluid specimens were also obtained from convalescents.  Joint and muscle pains were reported significantly more often by convalescents than house hold contacts. Evidence of Ebola virus was detected by reverse transcription-polymerase chain reaction in semen specimens up to 91 days after disease onset; however, these and all other non-blood body fluids tested negative by virus isolation.
 Among 81 initially antibody negative house hold contacts none became antibody positive.
Blood specimens of 5 house hold contacts not identified as Ebola hemorrhagic fever  patients were initially antibody positive. No direct evidence of convalescent-to- house hold contract transmission of Ebola fever was found, although the semen of convalescents may be infectious.
The existence of initially antibody-positive house hold contacts suggests that mild cases of Ebola virus infection occurred.

3. Who is a high risk Ebola Patient: Percutaneous (needle stick) or mucous membrane exposure to blood or body fluids (feces, saliva, sweat, urine, vomit, and semen) of a person with symptomatic Ebola virus disease and Exposure to the blood or body fluids (feces, saliva, sweat, urine, vomit, and semen) of a person with symptomatic Ebola virus disease without appropriate personal protective equipment (PPE). In both situations a person has to be symptomatic.

4. There is no identifiable risk when the contact is with an asymptomatic person who had contact with a person with Ebola and also contact with a person who is later diagnosed with Ebola virus disease, before the person developed symptoms.

5. Viral persistence — Virus can persist for some time in certain bodily fluids, such as semen and breast milk.

a     Follow-up studies of 40 survivors in the 1995 Kikwit, Democratic Republic of Congo outbreak showed that viral RNA sequences could be detected by RT-PCR in the semen of male patients for up to three months, and infectious virus was recovered from one individual 82 days after disease onset. [J Infect Dis. 1999;179 Suppl 1:S28.]
         In only one known instance, during the 1967 Marburg outbreak, has viral persistence in semen led to virus transmission through sexual contact. [Curr Top Microbiol Immunol. 1999;235:49, Trans R Soc Trop Med Hyg. 1969;63(3):295.]
      A study of patient samples collected during the outbreak of Ebola Sudan virus disease in Gulu, Uganda in 2000 detected virus in the breast milk of a patient, even after virus was no longer detectable in the bloodstream. Two children who were breast-fed by Ebola-infected mothers died of the disease. [J Infect Dis. 2007 Nov;196 Suppl 2:S142-7.]
         During the 2014 outbreak in West Africa, virus was cultured from a patient’s urine 12 days after the last positive culture was identified in plasma. [N Engl J Med. 2014 Oct]

6. Convalescent period of Ebola and Marburg virus disease is prolonged, and marked by weakness, fatigue, and failure to regain weight that was lost during illness. Extensive sloughing of skin and hair loss are commonly observed, possibly as a result of virus-induced necrosis of infected sweat glands and other dermal structures

7. There is no evidence that asymptomatic persons still in the incubation period are infectious to others.  But all symptomatic individuals should be assumed to have virus in the blood, and other body fluids, and appropriate safety precautions should be taken. [Arch Virol Suppl. 1996;11:141.]

8. Convalescence from Ebola Virus Disease is long and often associated with sequelae such as myelitis, recurrent hepatitis,  psychosis, or uveitis. Data on the post-recovery viraemic period are limited. As said above shedding of Ebola virus has been  reported in breast milk and semen after the virus has been cleared from blood. Viable virus has been isolated  from semen up to many weeks or months after recovery, and spermatogenic transmission of Marburg virus has been  documented. There is a paucity of data on Ebola virus in human egg cells. The risk of Ebola transmission should be considered in connection with reproductive cell donations, both for ‘partner’ and ‘other than partner’ donations.

However, the evidence that Ebola virus may persist for some time in the human body after recovery from Ebola Fever is  insufficient to define a specific deferral period for donors who have recovered from Ebola Fever. The current guidance  stipulates deferral for 12 months following recovery from a viral hemorrhagic fever and this recommendation  also applies to donors who have recovered from Ebola Fever. In addition, living or deceased donors of substances of human origin should be negative for Ebola virus by NAT testing

9. A deferral of donation for two incubation periods will provide a reasonable margin of safety for asymptomatic donors returning from Ebola affected areas. The longest incubation period for Ebola Disease has been 25 days. Thus, asymptomatic travelers or residents returning from Ebola Virus affected areas should be temporarily  deferred from donation of substance of human origin including blood for two months after leaving an area affected by Ebola virus.

10. Men who have recovered from the illness can still spread the virus to their partner through their semen for many months after recovery. For this reason, it is important for men to avoid sexual intercourse after recovery or to wear condoms if having sexual intercourse during this period after recovery.

[ Dr K K Aggarwal is Padma Shri, Dr  B C Roy National and National Science Communication Awardee, President Heart Care Foundation of India and Senior National Vice President, Indian Medical Association]

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