Friday, September 26, 2014

Not Tonight Dear, I Had Ebola

Edit 9/28/14
I've received some very valuable feedback on this post and I agree that I should have started off with the science behind my opinion and included references. I intended to include references when I posted it, but got distracted and then forgot they weren't there. But without a rundown of what we know regarding infectious semen of surviving men, it wouldn't have been all that helpful. This is what happens when I write out of frustration and post while multi-tasking. Lesson learned.

I apologize and have edited the post to correct this. I've added references and a section with the heading "So what does science tell us about this topic" with a summary of what we know about infectious semen and transmission among survivors. I also realized I should have used the word “unprotected” in the sentence that really drives home the entire point of this post, and you will find that this sentence now has the word *unprotected* in asterisks in the text.

In addition, I added a final point regarding prostitutes (as a post script), based on a discussion on reddit. I am thrilled that this post has engendered so much discussion and I hope these changes have made it a bit clearer. I would also invite you to feel free to begin discussions here. As ever, thanks for stopping by!


Original Post:
I have fielded a lot of questions regarding Ebola virus in the semen of survivors lately and the
preponderance of people claiming this is a significant source of Ebola transmission is staggering. There is great concern and fear over this. Someone on Twitter was even genuinely concerned that these male survivors are "new highly infectious vectors" that weren't being calculated into projected disease spread. I'm a bit speechless really. Ok, maybe not that speechless.

And last night it was raging on Twitter:
Science based #Ebola horror: survivors have infectious semen for months

Maybe it's under the radar?

In large urbans after millions infected, who knows?

Counseling people on the dangers of sex post-Ebola is great but we know how people are. Who's to say they are obeying doctors orders about this?

So what does the science tell us about this topic? (added 9/28/14) Well, what we do know is from previous outbreaks and follow up with recovered patients. These are the scientific facts upon which my opinions on this are based:

  • Evidence of Ebola virus can be found in semen up to 91 days post disease onset (1, 2, 3, 4)
  • Not all surviving men have detectable virus in their semen.(2)
  • Of those who do, not all of them have it there for 91 days. Some have been found negative at 45 days.(2)
  • Men who’ve recovered are counseled by their physicians about the dangers of transmitting Ebola to sexual partners through unprotected sex. (3)
  • One study found indirect evidence that one woman may have gotten Ebola from sex, but they could not confirm that she actually had Ebola, or that she got it from sex. (1)
  • There is anecdotal evidence that one woman got Ebola from sex during this epidemic
  • Dr. Barbara Knust, an epidemiologist at the Centers of Disease Control and Prevention answered this question for NPR and said this: “Ebola is spread only by people exhibiting symptoms and through direct contact with bodily fluids. Once a person recovers from Ebola virus disease, he or she is no longer shedding virus, and thus is not contagious. In past Ebola outbreaks, follow-up studies of patients who have recovered from Ebola and their contacts found no evidence that the Ebola virus was spread from a recovered patient to their close contacts.”
    • And in response to the specific question about semen:
      • “Therefore, male survivors of Ebola are advised to avoid having sex for three months or to use condoms. Semen and breast milk are not the primary means by which Ebola is transmitted. The virus is primarily transmitted via blood, sweat, feces and vomit.”
  • Dr. William Schaffner, a professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center in Nashville, Tennessee had this to say of it. "Of all the modes of transmission, that's going to be the last," Schaffner told Live Science. "It's a little like asking me, 'If we're all going to go from New York to San Francisco, will one of us walk?' That doesn't happen too often."

Are we on the same page now?

OK. Let's think about this for a minute. No I mean really think about it. Let's think about the average male survivor in West Africa, what he's been through, who he may have lost to Ebola and how he's feeling physically after battling for his life either at home or in a terrifying Ebola ward. Are you thinking? Really thinking?

How would you feel?

Let's say, worst case scenario this man lost some loved ones, family members or friends. He most likely tried to help or watched at least one of those die. Then he got sick himself and ended up in an Ebola ward. He was terrified and thought he would die. But he didn't. He survived and was released. (read about one man's Ebola survival tale that depicts this clearly.)

So is this where you think the party begins? I hardly think so. This is just the beginning of a whole new set of problems for this guy.

This man has to go back home and continue to recover. Recovery from Ebola hemorrhagic fever takes time, sometimes a lot of it. (And yes, I know we call it Ebola virus disease now, but that does little to communicate the severity of this condition, so I'm sticking with EHF - check out the diagram on the right to see what I mean).

Most likely he'll be welcomed from a distance by any family he has left. Do you really think the single ladies are lining up to give him a Hero's welcome? If they were, do you really think he'd be in the mood? You think maybe he will need some time to cope with what he's been through and with what he's lost?

What are the chances he lost his wife if he had one? Pretty good, I'd say. If both got sick, if at least 50% die and he survived. Even if he didn't lose her, do you think he's not imagining what might happen to her if he gave her Ebola through sex? Do you really think, after everything he's been through and seen, with more and more bodies, and more and more people turned away from treatment centers, that he's going to actually feel like having sex, let alone risk someone's life for it?

Let's say the man is single and has lost no one close to him. Do you think the ladies will be lining up for him either? Do you think he hasn't seen and experienced the same kind of hell? Do you really think that, in the middle of the death, loss, hopelessness and terror of the worst Ebola epidemic the world has ever seen, he doesn't care if he infects another person?

In voicing these concerns, do you have any idea how ugly the assumptions you've made about the character of Ebola survivors truly are?

Survivors are being scorned, avoided and worse. Ebola volunteers are being murdered out of fear and ignorance. Do you really think surviving men, men who are still physically and emotionally recovering, are having enough *unprotected* sex while infectious to be a significant source of transmission?

I don't. I think for the most part these men are exhausted and scared. I think they wish they were stronger so they could help more. I think they are worried about providing for themselves and their families while being isolated within cities that aren't functioning well. I think they are thinking about those they infected while they were sick, wondering who among them will die and when.

I keep saying this because it bears repeating: there's no need to look for Zebras here. The out-of-control transmission of Ebola virus in this epidemic is from the well known and documented routes of transmission, while people are sick and symptomatic, not after they've recovered. Why argue for anything else and add to the already traumatized and stigmatized survivor's burden?

We can do better than that.

We must do better than that.

Pathogen Scribe

Post Script:

This discussion continues on reddit and like I said has provided valuable feedback. I’d like to address one particular comment in response to this post:

"I think Heather underestimates the extent to which the "comfort" of a woman has become habitual to many men. A Couple of weeks after being "cured", an over-stressed man might very well revert to that familiar source of psychological balm. She assumes a setting in which potential partners know the survivor, not an urban setting. Infection of prostitutes is not out of the question.”

I would like to take this opportunity first to say thanks for reading and for commenting. And you’re right I should have addressed the idea of prostitutes. However, it would not have changed my point. In fact, if you really think this will cause transmission via semen to be a significant source of transmission (the point of the post) then these are the assumptions you’ve made:

1) A majority of men who’ve recovered from Ebola will forego doctor’s orders and risk infecting others, including prostitutes, because they want the “psychological balm” of unprotected sex more than they want to stop the spread of Ebola.
2) These men are also willing to risk any of the other sexually transmitted diseases that can be spread by unprotected sex with strangers or prostitutes.
3) The women in question, including prostitutes won’t demand the use of protection during sex with a stranger.

And you’re assuming that enough of this will happen to make the spread of Ebola through semen a significant mode of transmission.

Like I said before, we can do better.


1) Alexander K. Rowe, Jeanne Bertolli, Ali S. Khan,Rose Mukunu, J. J. Muyembe-Tamfum, David Bressler, A. J. Williams, C. J.Peters, Luis Rodriguez, Heinz Feldmann, Stuart T. Nichol, Pierre E. Rollin andThomas G. Ksiazek for the Commission de Lutte contre les Epidémies à KikwitClinical,virologic, and immunologic follow-up of convalescent Ebola hemorrhagic feverpatients and their household contacts, Kikwit, Democratic Republic of theCongo. Commission de Lutte contre les Epidemies à Kikwit. J Infect Dis 1999;179(Suppl 1):S28-35.

2) Daniel G. Bausch, Jonathan S. Towner, Scott F.Dowell, Felix Kaducu4, Matthew Lukwiya, Anthony Sanchez, Stuart T. Nichol, Thomas G. Ksiazek and Pierre E.Rollin. Assessment of the Risk of Ebola Virus Transmission from Bodily Fluidsand Fomites. J Infect Dis. (2007) 196 (Supplement 2): S142-S147.

3) R.T Emond, B Evans, ET Bowen, and G Lloyd. Br MedJ. Aug 27, 1977; 2(6086): 541-544. A case of Ebola virus infection.


  1. I accept your point that men that survive will not be a major source of transmission.

    But if you look at the behavior of the doctor in Port Harcourt, Nigeria, who continued to treat patients and even perform operations for days after he became sick after covertly treating an Ebola patient in a hotel room - he did infect and kill his wife, and let the hospital staff treat him without informing them he had Ebola, as well as letting his church congregation lay hands on him in a faith healing ritual. The difference here is that he was dying and perhaps thinking less clearly than the Ebola survivors under consideration in this article, but it still shows we can't always assume other people's behavior will be governed by our own values - even a supposed "man of science" was behaving very irrationally.

    1. Hi and thanks for stopping by! I completely agree that the Nigerian doctor was most likely motivated by fear and survival instinct, both of which are very powerful, and maybe a little denial in there too. And I imagine very different motivation than for a survivor.

      I also agree that assumptions are never a good thing and that's why I'm not assuming people will be good and not spread Ebola through sex. Instead I'm using facts about what we know people are experiencing in W. Africa during this epidemic, to imagine plausible scenarios that could help explain the transmission data that we already have.

  2. I had also been thinking about sex as a route of transmission but my concern was in the other direction. It is often stated that patients are not infectious before they are symptomatic. How does viral load build over time.
    The scenario I was considering was a prostitute who became infected, by whatever route, and continued to work up until she felt ill. Due to the very high level of mucosal contact this may involve it seem like a very favourable circumstance for transmission if vaginal secretions contain a high viral load. Poor economic circumstance may cause continued work despite early ILI symptoms and if infectious a prostitute could have many clients in a few days before becoming too ill to work. As we saw with Sawyer, and his colleague, they seemed to be able to remain at work while in the early stages and still spread despite their work not having as intimate a nature. Due to the locations and sizes of previous outbreaks I doubt this would have been a problem before but could it produce a small number of super-spreaders?

    1. Hi and thanks for stopping by. This is an excellent question. I'm not sure how much data there is on viral load in vaginal secretions before symptoms, but once symptoms start - and that means first symptoms - then it would be a source of infection. This could very well be a problem in this epidemic. As you say, some people will work while in early stages of symptom onset and a busy, infectious prostitute has the potential to become a super-spreader if she is symptomatic.

    2. Again thanks for the very prompt and considered reply. The other problem this would cause is in contact tracing, I doubt she be able to furnish a lot of names and addresses beyond them all being Johns.

    3. You're quite welcome. And that's another very good point. It illustrates just how easy it is for this kind of situation to get out of control. A few minor misses is all it takes, even with limited modes of transmission.

  3. I think it's likely that survivors are being counseled to use condoms or abstain from sex for awhile, and that most of them will follow that advice. But I don't think it's a good assumption that survivors won't feel like having sex while there might still be virus in semen. A pediatric oncology nurse once told me that it's very common, after a child dies of cancer, that the father will very much want to have sex (for comfort, to feel close) and the mother will be horrified and think he's a monster for having any sexual drive after the loss--she tried to let parents with a dying child know that different people have different grieving reactions and that it's normal to want to have sex while grieving, so that they wouldn't feel either angry at the partner or guilty for wanting to have sex.

    1. Hi and thank you for checking out the blog! I hear what you're saying and I agree that sex offers great comfort and love in hard times.

      But I'd like to point out that I actually didn't make the assumption that surviving men wouldn't feel like having sex. Instead, I was calling into question the assumption that the majority of them would, and would do so unprotected. And I used facts about what we know people are experiencing in W. Africa during this epidemic, to imagine plausible scenarios that could help explain the transmission data that we already have.

      As for the man in your scenario, I wonder if he would feel like, or push for unprotected sex, if he knew that doing so could endanger the life of his wife (again, I'm not assuming he wouldn't, I'm questioning the assumption that he would).

  4. Hi Heather, we're all imposing our own personal opinions and biases when we project "what an Ebola survivor with infected semen would do" during the window of time that his semen contains the virus. Rather than speculating about the "what-if's" of human behavior, it would be more valuable as a woman to understand exactly what the risks are of having unprotected sex with a male who has " recovered" from Ebola. As we all know, condoms aren't a guarantee against either pregnancy or HIV. So, they should not be considered a guarantee to women that they will not become infected with Ebola.

    1. Hi, and thanks for stopping by. No one is guaranteeing that condoms will be 100% protective, but you can be sure they are 100% ineffective if not used. The risks and precautions for survivors with potentially infectious semen, would be the same as for any sexually transmitted disease, during the time he might be infectious. The only way to be 100% sure that you won't get infected with a sexually transmitted disease is to not have sex.

  5. Yes, Heather, I'm "really thinking," and I'm thinking that your assumptions about the accountability and integrity of human behavior are somewhat naive when it comes to this topic. It's well -documented that humans (male and female) have acted irresponsibly when it comes to the prospect of infecting a partner with a venereal disease. Why is Ebola any different? If semen containing the Ebola virus can infect others, it's a certainty that others will become infected via that transmission route. THAT'S the real point of discussion, not your assumptions about how men who have recovered from Ebola will (or should) behave with their sexual partners.

    1. Hi and thanks for taking the time to read the post and leave a comment.

      "If semen containing the Ebola virus can infect others, it's a certainty that others will become infected via that transmission route."

      The transmission data we have show us clearly that this is not a significant source of transmission. See references above.

  6. I looked at that data, and as a woman, I wouldn't risk my health by having sex (protected or not) within the timeframe in which my partner's semen might contain the virus. But thank you for your perspective.

    1. Thanks for reading and for leaving a comment! I'm with you! Neither would I.

  7. Heather,
    I am a fulminant meningococcemia survivor who developed DIC and some other complications. I think, possibly, the biggest misjudgement being made by people is about the physical capacity of someone who is recovering from an illness so severe. Sure, I can understand the assumption that one could find psychological comfort of some sort out of a sexual relationship after the devaatation of their family, country, and surviving something like Ebola. I cannot understand, though, unless one is particularly superhuman, the physical desire or capacity for most people during their recovery to even think of sex. I am not excluding the possibility because I am sure it may and has happened but I find it highly unlikely.

    Also, when they do the initial contact tracing (which I had to go through as well- and in the US so likely in a more sensitive fashion), a person with a reportable infectious disease is horrified that they are lying in the hospital, dying, and may have passed the disease along unknowingly. I speak from experience when I say that process alone will generally scare anyone enough from themselves that they would not risk the life of anyone else- not even a prostitute.

    1. Hi Abby, Thank you so much for stopping by to read and for taking the time to comment! I sincerely appreciate having your view brought into this discussion. First of all, I'm really glad you made it through with such a serious illness, and you are right, convalescence from a horrible disease is quite difficult and prolonged. And I am so glad that you also brought up the effects of going through the process of contact tracing. It provides an even stronger argument for the idea that the willingness to infect and risk the life of another person is not a common thread for infectious disease survivors. Thank you!!!!

  8. SO , Can you explain this then?
    Best is to put chastity belt on the male survivors. No other choice , for 180 days.

    1. Hi and thank you so much for stopping by! I am not surprised that it happened, but the point of my post is that it's not a significant mode of transmission. This man's personal choice, to disregard the doctors advice, if true, was selfish and disgusting and is clearly not the norm or we'd see this mode of transmission on a much bigger scale.

  9. Dear Heather,
    I cannot help but feel that this whole discussion about Ebola as an STD is just ridiculous. It just highlights how fear and perception around this disease are totally out of control.

    If you live in the US, the disease that we should legitimately be afraid of is heart disease, so please put down the hamburger and go run around the block a few times.

    I'm not an expert on prostitution in Sierra Leone or Liberia, but I've seen enough prostitution in sub-saharan Africa to make some educated guesses.

    I'm not going to make assumptions, but based on my experiences in Mozambique and other countries I'd guess that most prostitutes in Liberia, Sierra Leone, and Guinea are young teenage girls (13ish) who have already contracted a whole host of diseases including HIV, Hepatitis, etc. and have little to no knowledge of anything medical or even basic hygiene. I would also guess that their Johns have gotten them high on some kind of really addictive drug and that they are primarily living in the worst areas of the country with no basic amenities. Most of them probably do not know what AIDS is or how you can protect yourself from it, or that it cannot be cured by antibiotics or god. In much of sub-saharan Africa, sex with one of these women costs about US $1.50, and there was no way that they were going to spend $.25 on a condom if they even knew what that was.

    I'm going to guess that this girl would be WAY more likely to get Ebola from general clients and the unhygienic environment in which she lives than from some depressed scared Ebola survivor seeking comfort!! She's probably most likely to transmit it to someone else when someone attempts to drag her body out of the street or clean her room. I'm so glad that you weren't worried about this girl 13 years ago in Liberia when she was born in substandard conditions, but now you're worried about her because she might be a *vector* for Ebola?!?

    I don't think it's a safe assumption that this male Ebola survivor with potentially infectious sperm has received some kind of extensive counseling from an overwhelmed clinic with 200 sick people waiting at the door other than "oh by the way, don't have sex and have a nice life" but most of his potential sexual partners probably are sick, dying, or gone, and he's going to have a heck of a time coming up with the $1.50 for a prostitute even if he did feel well enough which he probably doesn't.

    I think this whole Ebola epidemic is just a big wake up call for the developed world to tell us that we should have been caring about general health care and education in Africa decades ago, and that it's never too late to start that.

    Sorry for the rant.

    1. Hi and thanks for taking the time to comment! No apologies needed, you bring up excellent points! You're right. Global health is something that shouldn't be ignored. If we had collectively bolstered W. Africa's health infrastructure long ago, this wouldn't have spiraled out of control. Thank you for stopping by!

  10. Great reading Heather!
    I was just thinking along the lines of JJackson's comment. Not only with prostitutes but with couples or sexually active people in general, I would think, the close contact involved in sexual activity at first onset of symptoms would be a more likely culprit than post virus sexual activity. From what I understand the first notable symptom seems to be a low grade fever, something people may or may not notice at first, or feel they have the luxury to notice, as the case may be. I would think the vast majority of West Africans at this point are probably as proactive as possible when it comes to self monitoring and cutting out as much contact as possible. I couldn't imagine, however, that these "sexually related" factors at onset haven't played a part. People are people after all (fortunately and unfortunately).
    Thanks for all the info!

    1. Hi and thank you so much for taking the time to read and comment! I genuinely appreciate your kind words. I also really appreciate your input in this discussion! I completely agree that intimacy at first stages of illness are far more likely and play a greater role in transmission, especially for sex workers. Your phrase, "...feel they have the luxury to notice..." is especially important I think in this regard. Thanks again for reading!