Research Article: Sexual transmission of Zika virus and other flaviviruses: A living systematic review

Date Published: July 24, 2018

Publisher: Public Library of Science

Author(s): Michel Jacques Counotte, Caron Rahn Kim, Jingying Wang, Kyle Bernstein, Carolyn D. Deal, Nathalie Jeanne Nicole Broutet, Nicola Low, Lorenz von Seidlein

Abstract: BackgroundHealth authorities in the United States and Europe reported an increasing number of travel-associated episodes of sexual transmission of Zika virus (ZIKV) following the 2015–2017 ZIKV outbreak. This, and other scientific evidence, suggests that ZIKV is sexually transmissible in addition to having its primary mosquito-borne route. The objective of this systematic review and evidence synthesis was to clarify the epidemiology of sexually transmitted ZIKV.Methods and findingsWe performed a living (i.e., continually updated) systematic review of evidence published up to 15 April 2018 about sexual transmission of ZIKV and other arthropod-borne flaviviruses in humans and other animals. We defined 7 key elements of ZIKV sexual transmission for which we extracted data: (1) rectal and vaginal susceptibility to infection, (2) incubation period following sexual transmission, (3) serial interval between the onset of symptoms in a primary and secondary infected individuals, (4) duration of infectiousness, (5) reproduction number, (6) probability of transmission per sex act, and (7) transmission rate. We identified 1,227 unique publications and included 128, of which 77 presented data on humans and 51 presented data on animals. Laboratory experiments confirm that rectal and vaginal mucosae are susceptible to infection with ZIKV and that the testis serves as a reservoir for the virus in animal models. Sexual transmission was reported in 36 human couples: 34/36 of these involved male-to-female sexual transmission. The median serial symptom onset interval in 15 couples was 12 days (interquartile range: 10–14.5); the maximum was 44 days. We found evidence from 2 prospective cohorts that ZIKV RNA is present in human semen with a median duration of 34 days (95% CI: 28–41 days) and 35 days (no CI given) (low certainty of evidence, according to GRADE). Aggregated data about detection of ZIKV RNA from 37 case reports and case series indicate a median duration of detection of ZIKV of 40 days (95% CI: 30–49 days) and maximum duration of 370 days in semen. In human vaginal fluid, median duration was 14 days (95% CI: 7–20 days) and maximum duration was 37 days (very low certainty). Infectious virus in human semen was detected for a median duration of 12 days (95% CI: 1–21 days) and maximum of 69 days. Modelling studies indicate that the reproduction number is below 1 (very low certainty). Evidence was lacking to estimate the incubation period or the transmission rate. Evidence on sexual transmission of other flaviviruses was scarce. The certainty of the evidence is limited because of uncontrolled residual bias.ConclusionsThe living systematic review and sexual transmission framework allowed us to assess evidence about the risk of sexual transmission of ZIKV. ZIKV is more likely transmitted from men to women than from women to men. For other flaviviruses, evidence of sexual transmissibility is still absent. Taking into account all available data about the duration of detection of ZIKV in culture and from the serial interval, our findings suggest that the infectious period for sexual transmission of ZIKV is shorter than estimates from the earliest post-outbreak studies, which were based on reverse transcription PCR alone.

Partial Text: Zika virus (ZIKV) can be transmitted between humans through sexual contact, although it is most commonly transmitted by infected Aedes spp. mosquitoes [1,2]. Sexual transmission of ZIKV has important implications for public health, for people living in endemic regions, and for sexual partners of travellers returning to non-endemic regions from endemic regions because ZIKV infection during pregnancy can cause congenital infection of the foetus and because ZIKV infection can trigger the immune-mediated neurological condition Guillain-Barré syndrome [3,4]. ZIKV is an RNA flavivirus. Flaviviruses are a genus of viruses from the Flaviviridae family, of which the majority are transmitted to vertebrates by infected mosquito or tick vectors [5].

We identified 1,227 unique citations and excluded 901 by title and abstract screening (Fig 2). Of the remaining 326 potentially eligible citations with relevant abstracts, 128 publications were eligible for inclusion. Table 2 summarises characteristics of the included studies.

This systematic review summarises published data related to sexual transmission of ZIKV and other arthropod-borne flaviviruses published on or before 15 April 2018. In animals, vaginal and rectal mucosae are susceptible to ZIKV, with the testis as a preferred site of replication. Male-to-female transmission was more frequent than female-to-male transmission in animal models and in humans. In humans, we estimated the serial interval for sexually transmitted infection to be 12 (interquartile range: 10–14.5) days. ZIKV was detectable in semen for a median of 34 (95% CI: 28–41) days by RT-PCR and 9.5 (95% CI: 1.2–20.3) days by viral culture. In mathematical modelling studies, the reproduction number for sexual transmission of ZIKV was below 1. The overall certainty of the evidence was low. We found no evidence that other arthropod-borne flaviviruses can be sexually transmitted.

This living systematic review gives an up-to-date synthesis of information about the sexual transmission of ZIKV with a structured framework. Planned regular updates will allow timely updating of relevant data from a rapidly expanding evidence base. We did not quantify the absolute risk of sexual transmission of ZIKV, but it appears small based on information about the proportion of people with symptomatic ZIKV who have ZIKV detected in genital secretions and the short median duration of detection of ZIKV in semen and vaginal fluid. Taking into account all available data about the duration of detection of ZIKV in culture and from the serial interval, our findings suggest that the infectious period for sexual transmission of ZIKV is shorter than estimates from the earliest post-outbreak studies, which were based on RT-PCR alone.



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