BMJ Open
2016, Volume 6, Issue 1
http://bmjopen.bmj.com/content/current

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Global health
Systematic review of the literature on viral persistence and sexual transmission from recovered Ebola survivors: evidence and recommendations
Anna Thorson1,2, Pierre Formenty1, Clare Lofthouse1, Nathalie Broutet1
Author Affiliations
1World Health Organization (WHO), Geneva, Switzerland
2Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
Published 7 January 2016
Abstract
Objective The main aim of this article is to present a comprehensive, systematic review on evidence of sexual transmission from Ebola survivors and persistence of Ebola virus in body fluids of relevance to sexual transmission, and additionally to review condom effectiveness against sexual transmission of Ebola.
Design We performed a systematic review of viral persistence in body fluids of relevance to sexual transmission of Ebola survivors and evidence of sexual transmission of Ebola, and carried out a targeted review of condom effectiveness.
Results We identified nine published original articles presenting results on persistence of Ebola virus in relevant body fluids, or reporting suspect sexual transmission from Ebola survivors. We also included unpublished reports from the current 2014/2015 Ebola epidemic in West Africa. We found no articles reporting on condom effectiveness, but have included a targeted review on general condom efficacy and effectiveness.
Conclusions We conclude that the risk of sexual transmission from people who have recovered from Ebola cannot be ruled out. We found the longest duration of persistent Ebola RNA in a relevant body fluid from a survivor, to be reported from a man in Sierra Leone who had reverse transcriptase PCR (RT-PCR) positive semen 284 days after symptom onset. In line with current WHO recommendations. We recommend that men are offered the possibility to test their semen regularly for presence of Ebola RNA from3 months post-symptom onset. Safe sex practices including sexual abstinence, or else condom use, are recommended by WHO until semen has tested negative twice, or in absence of testing for at least 6 months post-symptom onset. Based on evidence reviewed, we conclude that male and female latex condoms offer some protection against EBOV compared to no condom use. Survivors should be offered access to care and prevention, in order to provide them with possibilities to mitigate any risks that may occur, and efforts should be linked to destigmatising activities.

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Global health
Factors associated with declining under-five mortality rates from 2000 to 2013: an ecological analysis of 46 African countries
Aaron M Kipp1,2, Meridith Blevins1,3, Connie A Haley1,2, Kasonde Mwinga4, Phanuel Habimana4, Bryan E Shepherd1,3, Muktar H Aliyu1,5, Tigest Ketsela4, Sten H Vermund1,6
Author Affiliations
1Vanderbilt Institute for Global Health, Nashville, Tennessee, USA
2Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
3Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
4World Health Organization/Regional Office for Africa, Brazzaville, Congo
5Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
6Pediatrics Vanderbilt University School of Medicine, Nashville, Tennessee, USA
Published 8 January 2016
Abstract
Objective Inadequate overall progress has been made towards the 4th Millennium Development Goal of reducing under-five mortality rates by two-thirds between 1990 and 2015. Progress has been variable across African countries. We examined health, economic and social factors potentially associated with reductions in under-five mortality (U5M) from 2000 to 2013.
Setting Ecological analysis using publicly available data from the 46 nations within the WHO African Region.
Outcome measures We assessed the annual rate of change (ARC) of 70 different factors and their association with the annual rate of reduction (ARR) of U5M rates using robust linear regression models.
Results Most factors improved over the study period for most countries, with the largest increases seen for economic or technological development and external financing factors. The median (IQR) U5M ARR was 3.6% (2.8 to 5.1%). Only 4 of 70 factors demonstrated a strong and significant association with U5M ARRs, adjusting for potential confounders. Higher ARRs were associated with more rapidly increasing coverage of seeking treatment for acute respiratory infection (β=0.22 (ie, a 1% increase in the ARC was associated with a 0.22% increase in ARR); 90% CI 0.09 to 0.35; p=0.01), increasing health expenditure relative to gross domestic product (β=0.26; 95% CI 0.11 to 0.41; p=0.02), increasing fertility rate (β=0.54; 95% CI 0.07 to 1.02; p=0.07) and decreasing maternal mortality ratio (β=−0.47; 95% CI −0.69 to −0.24; p<0.01). The majority of factors showed no association or raised validity concerns due to missing data from a large number of countries.
Conclusions Improvements in sociodemographic, maternal health and governance and financing factors were more likely associated with U5M ARR. These underscore the essential role of contextual factors facilitating child health interventions and services. Surveillance of these factors could help monitor which countries need additional support in reducing U5M.