Ebola virus - NIAID/Flickr CC
We’re deeper into the woods with Ebola than we thought.
First, a new study shows that some men still have semen that tests positive for fragments of Ebola virus nine months after onset of symptoms, but it is not known how many of them are infectious. The Centers for Disease Control and Prevention (CDC) is conducting further tests of the samples to determine if the virus is alive and potentially infectious. This is not the scary part.
While it’s been known that Ebola (EVD) is generally transmitted through direct contact with the blood or body fluids of a person with EVD or from the body of a person who died from EVD, it was not previously known that Ebola could be transmitted months after disease. Suspicions were aroused in March, 2015, when a Liberian woman contracted Ebola; her only known exposure was through unprotected sex with a man who survived Ebola months before. Because of this case, recommendations for abstinence among survivors were extended from 3 months to 6 months, or until semen twice tested negative for Ebola virus.
As a result of these latest findings, survivors will need to be counseled on potential sexual transmission and to use a condom consistently and indefinitely, since no one knows how long the virus might persist.
It’s likely that the risk of survivors infecting others with Ebola is low, though obviously not zero. This is based on findings from areas of Sierra Leone – Kailahun and Kenema - where there are a large number of survivors following the large outbreaks, and yet there have been no new cases of Ebola there for 10 months.
Immune-privileged, “sanctuary” sites
It’s no great surprise that they have found Ebola in semen, as this was seen some time ago with the related Marburg virus and in earlier studies. The more intriguing and far more worrisome news are the findings of Ebola hiding in sanctuaries in the body like the eye. Dr. Ian Crozier’s story was shocking. A volunteer physician fighting Ebola, he almost died from the infection he contracted, with complications including respiratory and kidney failure, and neurologic damage from encephalitis. Fortunately, he made a remarkable recovery, although he has persistent symptoms. Then, two months after his apparent cure, he developed severe pain in his eye and visual loss. Fluid was withdrawn from inside his eye and was found to contain Ebola. (Because his tears and the surface of his eye did not have the virus, he was not infectious to others.)
Last week, nurse Pauline Cafferkey, who had also volunteered and had contracted Ebola last December, relapsed. Her family reports “She said, ‘I’ve a temperature, my head is splitting and I have a sore neck and photophobia.’…As a nurse, Pauline is medically aware and she thought she had meningitis. She knew it was serious. Whatever she had, she felt at that point that it was a medical emergency…” They say she was told she was suffering from a virus and sent home. Now she is critically ill in a London hospital. Unfortunately, communication about her illness has been extraordinarily poor, with the only statement being, “She is being treated for Ebola in the high level isolation unit at the Royal Free Hospital.”
At a Liberian clinic, reports the New York Times, “About 40% have eye pain, inflammation, blurred vision and blind spots in their visual fields. Some have uveitis,” (a severe eye inflammation that can cause blindness) making one wonder how many patients harbor ongoing ocular infection as Crozier did, and might later relapse as Cafferkey has.
The eye, brain (spinal fluid), and testes are the sanctuary sites thus far noted for Ebola, but much further research needs to be done. We need long-term follow-up of survivors, specifically looking for late sequelae or signs of relapse. We especially need to understand the likelihood of the virus to return to blood or become systemic. As virologist Dr. Ian Mackay, Associate Professor, University of Queensland notes regarding Nurse Cafferkey, “this may be the first documented time that the virus has re-emerged from an immune privileged site and returned to the blood, possibly causing EVD symptoms.”
Perspective:
Given the previous irrational and hysterical response to Ebola demonstrated by many, including Governors Chris Christie, Paul LePage, and Bobby Jindal, and subsequent quarantines and bans on visitors or students from affected countries, I hope that this report finding Ebola in semen will not rekindle the Ebolanoia and xenophobia.
In an accompanying editorial in the New England Journal of Medicine, Dr. Armand Sprecher, a hemorrhagic fever expert with Médecins Sans Frontières emphasizes the rarity of such late transmission, noting that there are more than 17,000 Ebola survivors, and less than 20 suspected cases that were sexually transmitted. He is also both compassionate and pragmatic, saying:
Let us not forget that survivors have already endured a painful severe illness, and many emerge from it to find that friends and family members have died. If they are then treated as pariahs and threats, we add a terrible unkindness on top of their suffering. They should be treated with all the compassion we can muster. Marking them as an ongoing threat jeopardizes this goal.
Their treatment raises a practical concern. If we want to be able to detect the next case of EVD that might emerge from late sexual transmission, we must consider that the people who may one day become the next patient will see how survivors are treated. If they find that being identified as a patient with EVD has but two outcomes — death in a frightening treatment unit or survival to return as a social outcast — they have a considerable disincentive to be identified. This prospect may drive persons with new cases of EVD into hiding and defeat the objective of the surveillance system.
A huge problem is the poor communication regarding Ebola, specifically Ms. Cafferkey’s case. As Dr. Mackay observed, “It is unclear precisely what disease is being managed. Is it EVD or a different disease that is the result of damage done by the original Ebola virus infection? Is virus present in the blood? That level of clinical detail has not been forthcoming, leaving many to simply guess at this possibly new chapter in the history of Ebola virus.” He echoes Dr. Sprecher’s concerns about stigmatization driving people underground.
With the apparent errors in Dallas and now in Glasgow, it is critical that the WHO, CDC and others improve their communications and establish a system where at-risk individuals, or those previously infected with Ebola, have a hot-line to experienced physicians who can appropriately assess their symptoms and recommend treatment. Much has been written about risk communications after last year’s response, including tips in “When the next shoe drops.”
Our response to this troublesome news about Ebola needs to be based on science and data, not inflamed fear-mongering. As Dr. Ashish Jha aptly stated last year, “I’m a believer in an abundance of caution but I'm not a believer of an abundance of idiocy." Have we learned anything since?
