Concerned about the potential for sexual transmission of Ebola, international health officials are investigating new reports of suspected cases and beginning studies to determine how often and how long the virus remains active in semen. And, for now, they are warning Ebola survivors to practice protected sex indefinitely.
A few possible cases of sexual transmission surfaced during the peak of the epidemic in West Africa, but little follow-up occurred then. Now, with new infections down to around three dozen a week across the three affected countries, medical investigators are focused on two women who died of the disease last month — one in Liberia and the other in Sierra Leone.
The women had no known risk factors, but they did have male partners who had survived Ebola last year, suggesting that the virus could be active in semen longer than researchers had previously detected, and that it could spread through sexual activity.
In recent days, American and Liberian scientists have begun finding genomic evidence in support of sexual contact being the cause of the Liberian case, researchers said. Even though such transmission has never been confirmed and is assumed to be rare, it has raised concerns because of the potential impact on declaring the epidemic over.
“You have such a huge number of cases in this outbreak,” said Dr. Daniel Bausch, an infectious disease specialist with the World Health Organization. “You start to see things that are probably not common but are happening, or may be happening. How do you deal with these outliers?”
Public health officials have faced many hurdles in fighting Ebola in West Africa — from changing burial practices to overcoming beliefs that foreign doctors in their moon suits had come to kill rather than cure patients. But perhaps no topic is as intimate and potentially incendiary as sexual transmission.
Experts have deep concerns about how to carry on research without provoking a backlash against their efforts or further stigmatizing survivors.
“There are all the issues we have seen and addressed during H.I.V. at the beginning, including confidentiality, and should the family know or not,” said Dr. Pierre Formenty, an Ebola expert at the World Health Organization. “We underestimate all the effort we’re going to have to make for this type of transmission.”
Already, that effort has stirred controversy. A recent incident in Sierra Leone involving health officials’ seeking a semen sample from a man who said he was impotent resulted in allegations that their attempts involved duress.
The W.H.O. has also been informed of a few Ebola survivors’ being detained, accused of infecting their partners in Sierra Leone. “They would have been arrested and released more as a deterrent,” said O. B. Sisay, who directs operations at the National Ebola Response Center in Freetown. He said he knew of no specific regulations criminalizing survivors’ having sex.
In India, the Health Ministry announced in November that an asymptomatic Ebola survivor who had arrived from Liberia was being held at an airport quarantine center in Delhi. Blood tests were negative, but officials found traces of the virus in the man’s semen and said he would be detained until repeat testing could not detect it.
W.H.O. guidelines strongly recommend against isolating Ebola survivors who no longer carry the virus in their blood. However, the Indian government held the man for four months, releasing him only in late March after his latest sample tested negative for Ebola, according to the Indo-Asian News Service.
One of the new cases, being examined by the United States Centers for Disease Control and Prevention and Liberian officials, involves Ruth Tugbah, a 44-year-old food seller with no known risk factors who developed Ebola in Liberia’s capital, Monrovia, and died. Before her illness, the country had detected no new infections for three weeks.
Attention focused on Ms. Tugbah’s boyfriend, an Ebola survivor. Laboratory workers detected Ebola genetic material in a semen sample he provided 175 days after he developed symptoms. That was 74 days longer than ever found in a survivor before.
Scientists from the C.D.C. are trying to determine through viral culturing whether the man’s sample contained infectious virus, not just harmless fragments of genetic material. Certain parts of the body, including the testes in men and the placenta in pregnant women, are protected from the immune system and may harbor viruses even after blood tests turn negative.
Based on the length of time that the active form of virus had been detected in semen, public health officials previously recommended protected sex practices for three months after recovery. In recent days, researchers have compared the genetic sequence of Ms. Tugbah’s virus to partial sequences obtained from the virus in her boyfriend’s semen and in blood samples taken months ago from his potential contacts with Ebola, and found they matched at several key points.
“The information we have so far is compatible with the sexual transmission,” Gustavo Palacios, a scientist at the United States Army’s Medical Research Institute of Infectious Diseases, which is supporting the Liberian Institute for Biomedical Research, where the sequencing was done, said in an interview.
More testing remains, but Ms. Tugbah’s boyfriend has since refused to cooperate with the researchers’ requests to obtain another sample, which they said would aid their analysis.
Given the significance of the early finding, a C.D.C. spokesman said the agency planned to join the W.H.O. and Liberia, which have publicly recommended that Ebola survivors — an estimated 15,000 in West Africa — consider using condoms indefinitely “for greater security” until more research is done.
But public health officials believe that vague recommendation is untenable in the long term and are urgently seeking more data. “People have sex lives,” Dr. Bausch said. Sexual activity, he said, should not be restricted beyond the point when there is unlikely to be a risk, as the virus should eventually disappear.
W.H.O. officials said in interviews that they were planning a large study with the C.D.C. and the Sierra Leone Health Ministry to determine the viability of Ebola in various body fluids of survivors, which could start as early as next week. They are also exploring the feasibility of offering all survivors individualized testing to know when their body fluids are free of the virus.
A recent case investigation highlighted the likely challenges. After a woman who was nine months pregnant and had no known risk factors died of Ebola late last month in Freetown, officials tried to establish a link to her husband, an Ebola survivor, by collecting a semen sample for the C.D.C. to analyze. An American doctor working for the W.H.O., MarkAlain Déry, said he had led the case investigation at the man’s home compound.
The husband, Ibrahim Koroma, 28, told Dr. Déry that he had been impotent since recovering from Ebola, which he contracted last November, and that he had not had sex with his wife after that, both men recalled in interviews. But Dr. Déry said he did not believe him, adding that he thought Mr. Koroma was afraid he would be implicated in his wife’s death.
Dr. Déry said he returned the next day with a letter from the government promising that Mr. Koroma would not be prosecuted. He also brought a female counselor from the United Nations agency Unaids, a Sierra Leonean whom he called “an expert in human sexuality.” She spent about two hours talking alone with Mr. Koroma before he agreed to try to produce the sample.
When he was unable to, he claimed, two other men he also thought were doctors separately tried to manually stimulate him with soap while pornographic videos played on a laptop. The female worker also undressed him and removed some of her clothing when they were alone, he said. Those efforts were unsuccessful, and embarrassing, Mr. Koroma said.
Dr. Déry acknowledged providing the videos and laptop to assist the process, but denied that any other interventions had occurred. “The idea of that happening is absolutely preposterous,” he said in an interview.
Dr. Anshu Banerjee, who was the W.H.O.’s country representative for Sierra Leone, said he had concluded that “there was no truth whatsoever in the story” after interviewing Dr. Déry and the female counselor. But he said there were lessons to be learned.
“We need to really approach this in a methodological manner to make sure we don’t run into other stories like this,” he said.