Discussion: Congenital birth defects and the Zika virus

[Dani]

In fact, the woman in the BBC article did not really even have microcephaly. What she had is called craniosynostosis. It's unfortunate that the BBC even ran that article without consulting a neurologist or neurosurgeon.

 

[Emily]

In fact, the woman in the BBC article did not really even have microcephaly. What she had is called craniosynostosis. It's unfortunate that the BBC even ran that article without consulting a neurologist or neurosurgeon.

Dani, thanks much for pointing this out. Something seemed off to me about the article, but I had to assume she had a 'mild' case of microcephaly yet I wondered about the operations. I thought maybe there were problems in addition to the microcephaly. I did give me the impression that medicine in Brazil was far advanced than here and much less expensive to boot! But there is excellent surgery here,too, for craniosynostosis. There are before/after photos:
http://www.craniosynostosis.net/

I can't find the quote now, but one researcher indicated he thought it was unhelpful for the really unusual cluster to be even called just 'microencephaly' in the media, since that can cover a lot of ground.

http://www.nytimes.com/2016/02/01/h...us-has-long-afflicted-and-mystified.html?_r=0

In Brazil, researchers say they are seeing a disproportionate number of microcephalic infants with what appear to be severe deformities, many with four striking malformations at once: a large degree of brain tissue loss; unusually smooth, wrinkleless brains; many calcium deposits; and smaller cerebellums, which play a role in motor control.

This Medscape article says the number if babies with that syndrome is very small:
http://www.medscape.com/viewarticle/858162

A report of 35 infants with microcephaly who were born during an outbreak of Zika virus infection in Brazil in 2015 described the following brain abnormalities: intracranial calcifications, ventriculomegaly, and neuronal migration disorders (lissencephaly and pachygyria). Other anomalies included congenital contractures and clubfoot. An important distinction is that neither these infants nor their mothers had laboratory-confirmed Zika virus; however, most of the mothers (~75%) reported symptoms consistent with Zika virus.

The closest virus I can find that creates some of those defects, particularly the lissencephaly, is CMV:
http://www.ncbi.nlm.nih.gov/pubmed/1646253

I would think that was ruled out right away? Also any herbal uses, even as salves on rashes?

 

[Pathfinder]

Dr. Jo?o Ricardo de Almeida says the infants born to mothers who were infected in the first trimester seem to suffer the most brain damage. And that kind of damage also appears to be different than what you would see with microcephaly caused by other types of infections.

"Regarding Zika there seems to be some particular abnormalities that we do not see in [microcephaly cases caused by] toxoplasmosis or cytomegalovirus or rubella."

A normal brain has ridges like coral. The brains of these babies look "like a smooth rock," he says.
...

https://flutrackers.com/forum/forum...n-damage-in-infants-may-be-tip-of-the-iceberg
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
What will life be like for Brazil?s generation of Zika babies?
...
?They may not be able to recognise their parents or perceive pain, and will need constant attention because they wouldn?t be able to indicate when they need food or drink,? says Geoff Woods, a clinical geneticist at the University of Cambridge, who has seen brain scans and early case reports from Brazil.
...
Based on the scans, it appears that the brain stem and the cerebellum are the regions most affected. These oversee many functions that don?t require active thought, such as swallowing, controlling body temperature and blood pressure, says Woods. Impairment of these regions means that the babies are prone to choking and fits. ?We expect it to be a disease with a very limited life expectancy,? he says.

The babies are also likely to be intellectually impaired, says Yanick Crow of the Imagine Institute in Paris, France, who has examined three brain scans sent from Brazil. Crow says these Zika-linked cases are similar to Aicardi-Goutieres syndrome, a rare condition caused by an immune over-reaction to viral DNA in the brain.

?The majority of children with Aicardi-Goutieres syndrome have no useful hand, locomotion or verbal function and are severely intellectually affected, and I would fear the same here,? he says.
...
https://www.newscientist.com/articl...e-like-for-brazils-generation-of-zika-babies/

 

[Pathfinder]

How Health Experts Will Definitively Link Zika to Birth Defects
Alexandra Sifferlin @acsifferlin 2:57 PM ET
...
?We continue to receive information about new microcephaly cases every day,? says Claudio Maierovitch, director of the department of communicable disease surveillance at the Brazil Ministry of Health, in an interview with TIME. ?Our laboratories are working and they are identifying the virus in tissues that have never been seen before like liver and placenta. It?s new but it?s not enough. It?s the beginning, it?s knowledge building.?

There?s some early speculation that there may be additional factors that play into whether Zika causes microcephaly. For instance, several researchers TIME spoke to say they are curious whether there are other confounding factors like a separate infection or environmental exposure that increases the odds of the disorder.

?There?s a lot of dengue circulating in the area and we know that antibodies against dengue react against Zika. So in some ways perhaps the antibodies against dengue could be facilitating the Zika virus to go across the placenta,? says Marques. However, that theory remains speculative.

http://time.com/4209537/zika-birth-defects/

 

[Laidback Al]

Various reports are suggesting that the greatest congenital threat from a Zika virus infection in a pregnant woman occurs in the first trimester.

According to the CDC,

Zika virus usually remains in the blood of an infected person for only a few days to a week. The virus will not cause infections in an infant that is conceived after the virus is cleared from the blood.

http://www.cdc.gov/zika/pregnancy/question-answers.html

If a pregnant woman is infected months earlier, and the virus has cleared out of her body, why is it still present in the amniotic fluid as reported here?

And if the woman has only recently been infected with the Zika virus and the virus has just crossed the placental barrier, how likely is it that the presence of Zika virus caused the congenital anomaly at this later stage of development?

If a pregnant woman is infected with the Zika virus and it passes into the amniotic fluid, how long will traces of the virus be present in the fluid?

Finally, could some of these pregnant women been infected twice? Once in the first trimester and later shortly before giving birth?

I hope some professionals here can answer my questions.

 

[Pathfinder]

Various reports are suggesting that the greatest congenital threat from a Zika virus infection in a pregnant woman occurs in the first trimester.

According to the CDC,
http://www.cdc.gov/zika/pregnancy/question-answers.html

If a pregnant woman is infected months earlier, and the virus has cleared out of her body, why is it still present in the amniotic fluid as reported here?

And if the woman has only recently been infected with the Zika virus and the virus has just crossed the placental barrier, how likely is it that the presence of Zika virus caused the congenital anomaly at this later stage of development?

If a pregnant woman is infected with the Zika virus and it passes into the amniotic fluid, how long will traces of the virus be present in the fluid?

Finally, could some of these pregnant women been infected twice? Once in the first trimester and later shortly before giving birth?

I hope some professionals here can answer my questions.

This article was published during the Zika outbreak in French Polynesia . It mentions the possibility of reinfection by the virus.

Source: http://www.tahiti-infos.com/Zika-un-virus-qui-peut-encore-surprendre_a92358.html

Written by Mireille Loubet on Tuesday, January 14th, 2014 in 10:32 in Tahiti Infos

Translated:
...
Another big surprise in French Polynesia the Health Surveillance Office questioned suspected recurrence. Thus patients previously affected by the virus zika would again be a few weeks later. But so far, the Zika virus was considered immunizing for the person affected as are usually all arbovirus family to which the zika belongs. "We have more and more cases of recurrence or at least related. Some patients may therefore not be fully immunized after developing a first zika affection. Although we do not have any real certainty, questions arise about the virus "continues Dr. Henri-Pierre Mallet. Little documented as not widespread in the world and mild up till now since its discovery in 1947, this virus zika brought its share of surprises since arriving in French Polynesia. Should we think that many forms of zika are possible as there are several dengue serotypes? All questions are asked. "In terms of scientific research it is difficult to interpret with our own local resources," admits Dr. Henri-Pierre Mallet.

 

[Gert van der Hoek]

Microcephaly can have many causes, everything must be examined. If Zika is a cause than a vaccine is needed. Developing a vaccine will take several years.

 

[Laidback Al]

Microcephaly can have many causes, everything must be examined. If Zika is a cause than a vaccine is needed. Developing a vaccine will take several years.

There is no such thing as unlimited funds for addressing public health issues. Health officials have to decide where to invest available funds in order to obtain the best possible health return on the dollars spent. The philosophical question is: Is it more important to invest limited funds in a Zika vaccine, a vaccine for Ebola, a human MERS vaccine, or a universal influenza vaccine? Public health choices are not simple.

 

[Emily]

And don't forget CMV. I was appalled to learn about this:

http://rhrealitycheck.org/article/2...known-virus-that-may-endanger-your-pregnancy/

CMV: The Little-Known Virus That May Endanger Your Pregnancy
by Nicole Bromfield September 12, 2013 - 10:43 am


...
Unlike in the United States, CMV screening is routine for all pregnant women in eight European countries and in Israel, and is conducted as early as possible in pregnancy. If a pregnant woman is found to carry CMV antibodies, but has no active CMV infection, she has already contracted the virus at some point in her life before the pregnancy and is considered mostly ?safe? from CMV, as there is low risk that a secondary infection would affect a developing fetus.
However, if a pregnant woman does not carry CMV antibodies, she has never contracted CMV in her lifetime and is at risk for contracting a primary infection during pregnancy. In these cases, and in countries including Italy, the pregnant woman at risk for a primary CMV infection is educated about the dangers of CMV and is given guidance to avoid infection, including thorough hand washing when in contact with young children, and avoiding kisses on the mouth from any children, including her own. There is currently no vaccination for CMV.

Less than 13% of the women in the US even know about this risk!
https://www.nationalcmv.org/default.aspx

The damage can be just as severe as the worst potential Zika case. The US is totally out to lunch on this.

 

[sharon sanders]

I am irritated. Already the WHO and PAHO are arguing AND apparently the CDC has one date on their website and a different date in an email about activating their emergency response center. link


[FONT=verdana, geneva, sans-serif]Since 2010 (at least)....[/FONT]


"For example, the Pan American Health Organization considers itself to be the dean among the six regions, with a lineage going back 100 years and an independent financial base; PAHO chafes at the thought of being lumped in with WHO and pushes its moniker over the WHO’s when operating in the Americas. Most recently, PAHO announced a global health technology initiative with the U.N. Development Program, a broad mission that arguably ought to have been originated from Geneva.

With competition between branches and body, the assignments of WHO country representatives often involve extensive negotiations between the power in Geneva and the power in the region. Key appointments have many a time been blocked not by qualifications of the individuals but for political reasons."

http://foreignpolicy.com/2010/12/09/...ng-irrelevant/

 

[Emily]

http://www.thedailybeast.com/articles/2016/02/09/is-the-zika-panic-overblown.html?via=ios

[h=4]SLOW IT DOWN[/h] [h=4]02.09.16 5:01 AM ET[/h]
[h=1]Is the Zika Panic Overblown?[/h] With headlines about birth defects and cancelling the Olympics, it?s easy to see why Zika hysteria is raging. But fear about the virus is highly exaggerated.
?As an infection, Zika is generally a relatively mild?in fact?inconsequential infection,? Dr. Anthony Fauci, Director of the National Institute of Health, told reporters at the White House Monday.

...

To be sure, 270 cases of infants with microcephaly are not insignificant. According to the Cleveland Clinic, most children who are born with the neurological disorder also have some sort of mental retardation. Many suffer from severe developmental delays, while others experience extreme difficulty in movement.

But again, there is another side to the story. In 15 percent of cases, children with microcephaly have normal intelligence and live average lives. In the wake of the Zika news, parents of children with microcephaly have come forward to assuage fears about the condition. ?We love our three children, feel blessed by each unique child, and wouldn?t change one thing about our life or what we?ve been through,? a mother of two daughters with microcephaly told The Guardian.

But even if kids with microcephaly can go on to lead normal lives, protecting pregnant moms from the birth defect that may be preventable is, of course, critical. Still, as the ?worse case scenario? in the outbreak?and seemingly, the reason for cancelling the Olympics and setting aside $1.8 billion in emergency funds?it?s a bit odd.

It?s odd not because birth defects are not worth protecting against, but because?unlike Ebola?they?re something that already permeates America. According to the CDC, birth defects affect one in every 33 babies born in the U.S. each year. Every four and a half minutes, a baby is born with a birth defect.

Some defects are not harmful; others are deadly. Only a small number can be prevented because doctors and scientists have yet to find what causes them, a process that takes a significant amount of resources and money. In the CDC?s 2015 fiscal budget, the National Center for Birth Defects and Developmental Disabilities received just $11 million of the organization?s $5 billion budget...

So the interest in birth defects was worth $11 million and now it is worth 1.8 billion? Almost 1 billion is slated to go to the CDC. They need funding since they said they had no funds to explore the Hanford neural tube defect cluster...but this would be dedicated to Zika making 1 virus a sixth of their budget. It is odd indeed.

 

[Laidback Al]

CDC Guidance

I read with interest the latest guidance from the CDC regarding Zika virus testing for pregnant women. Link

For pregnant women with a history of travel to an area with Zika virus transmission, or pregnant women residing in an area with ongoing Zika virus transmission, the update provides detailed flowcharts about the process of testing for the Zika virus. The update also notes that women who test negative for the Zika virus should undergo ultrasound testing for microcephaly, with additional tests for Zika virus later.

While this approach will eventually provide the scientific data needed to test the relationship between the Zika virus and microcephaly, the update does not provide any solace to fearful women who might have fetuses identified with microcephaly, whether caused by Zika virus or not.

Avoiding pregnancy is simply not a long-term solution to the Zika outbreak. The best that women can do now is discussed in the final section of the report reproduced and highlighted below.

Special Considerations for Women of Reproductive Age Residing in Areas of Ongoing Zika Virus Transmission

CDC recommends that health care providers discuss pregnancy intention and reproductive options with women of reproductive age. Decisions regarding the timing of pregnancies are personal and complex; reproductive life plans can assist in making these decisions (22). Patient age, fertility, reproductive and medical history, as well as the values and preferences of the woman and her partner should be considered during discussions regarding pregnancy intentions and timing. In the context of the ongoing Zika virus transmission, preconception care should include a discussion of the signs and symptoms and the potential risks associated with Zika virus infection.

Health care providers should discuss strategies to prevent unintended pregnancy with women who do not want to become pregnant; these strategies should include counseling on family planning and use of contraceptive methods. Safety, effectiveness, availability, and acceptability should be considered when selecting a contraceptive method (23). Approximately half of U.S. pregnancies each year are unintended (24); patients should be counseled to use the most effective contraceptive method that can be used correctly and consistently. For women desiring highly effective contraception, long acting reversible contraception, including contraceptive implants and intrauterine devices, might be the best choice (http:// www.cdc.gov/reproductivehealth/UnintendedPregnancy/ PDF/Contraceptive_methods_508.pdf). When choosing a contraceptive method, the risk for sexually transmitted infections should also be considered; correct and consistent use of condoms reduces the risk for sexually transmitted infections.

Strategies to prevent mosquito bites should be emphasized for women living in areas with ongoing Zika virus transmission who want to become pregnant. These strategies, including wearing pants and long-sleeved shirts, using FDA-approved insect repellents, ensuring that windows and doors have screens, and staying inside air conditioned spaces when possible, can reduce the risk for Zika virus infection and other vector-borne diseases. During preconception counseling visits, the potential risks of Zika virus infection acquired during pregnancy should be discussed.

Women of reproductive age with current or previous laboratory-confirmed Zika virus infection should be counseled that there is no evidence that prior Zika virus infection poses a risk for birth defects in future pregnancies (7). This is because the viremia is expected to last approximately 1 week in patients with clinical illness (2,25). There is no current evidence to suggest that a fetus conceived after maternal viremia has resolved would be at risk for fetal infection (7)

 

[Dani]

Laidback Al, I agree that the CDC recommendations for evaluation of women exposed to CDC is more to attain knowledge for future use than it is to help affected women. As a clinician, I always ask "What is the end result of all of this testing? How will it change the clinical course?" In this case, it doesn't change a thing. The right side of the flow chart is basically normal prenatal care that most women in developed countries will get. The left part does little to diminish the worries of the mother and does nothing to alter the outcome of the baby.

In fact, it is among the most clinically useless diagnostic cascades I've ever seen. There is no prenatal treatment, and microcephaly usually can't be detected until late enough that termination is likely not an option even where second trimester abortion is legal. Further, the false-positive rate of microcephaly diagnosis by ultrasound is around 25%. And of those with actual clinical microcephaly at birth, around 15% will have normal cognition. So one in three babies diagnosed with microcephaly by ultrasound will be cognitively normal. Now I would expect that number to fall due to the higher pre-test probability in women with Zika. But it will never be zero. To a mother, her family and her clinicians, how helpful is any of this?

This is not the CDC's fault. It is just a reflection of the state of our knowledge and clinical abilities at this time. But it will lead to a great deal (a very great deal) of testing, expense and anxiety with very little clinical impact. I've seen this happen before, of course. When you sit down with pregnant women and really explain to them the pathway and options for testing for such things as Down's syndrome and other genetic disorders, a significant percentage will just pass on the tests altogether. If it doesn't help the baby, they don't want to know.

 

[Laidback Al]

Dani, thanks for providing some clarity to my uneasiness about this CDC guidance.

 

[Dani]

I've been dealing with the Pandora's box of prenatal testing for decades. It's amazing how many women (and their clinicians) will advocate for testing "Just to make sure everything's all right." Well, what if it isn't? People need to spend more time pondering that question. The answers are not the same for every woman, nor for every condition. The one thing I do know, you don't want to start down these pathways lightly. For one thing, there is risk to amniocentesis. Normal babies will be lost to amniocentesis under this protocol. Who makes that risk/benefit calculation? Will we lose more normal babies than are diagnosed with Zika? Are those things equivalent? I don't know. If I were the pregnant mom exposed to Zika, I doubt very much I'd even get tested.

 

[Dani]

I don't mean to go on a rampage about all of this, it's just frustrating from a doctor's point of view.

And, I'm glad to be able to contribute something, so thanks for your words of appreciation, Laidback Al.

 

[sharon sanders]

Hi Dani. You are not making a rampage. It is really great to see what someone thinks who is directly affected by this situation.

I am also affected but in a different way. My recently married daughter would like to start a family late this year. Since we live in Florida she is closely watching the developments.

 

[Laidback Al]

Today, ProMED published a response from Dr. Ronald St. John, who was a former Director General for Centre for Emergency Preparedness and Response, Public Health Agency of Canada.

It is reprinted with bolding added below. Dr. St. John is posing some of the same questions about issues we are discussing here.

Date: Mon 8 Feb 2016
From: Ronald St. John


It is self-evident that we live in an age of instant communication thanks to the Internet. But instant communication through web sites, Facebook, Twitter, etc. can be a double-edged sword, and the media frenzy over Zika is a case in point.

Today (6 Feb 2016), we counted 89 Zika postings on HealthMap, many of which report some "facts" but no context, i.e. any estimate of the risk. The current media frenzy to be the 1st to publish the latest incidental finding about the Zika virus has both positive and negative effects. On the positive side, the monitoring of a fast-moving event is a benefit for researchers and policy makers. On the negative side, the reported events are often lacking in context.

For example, is it really surprising to find virus in saliva and urine, but what is the risk of transmission by this route? How many people are likely to have broken skin in contact with the saliva or urine of an infected person? Is virus in saliva a risk for kissing?

Since so many infected people are asymptomatic and unaware of their infection, is it surprising to document transmission by blood transfusion?

There have been a few [3] documented instances of sexual transmission of this virus, but what is the risk? It is our understanding that viral loads in semen are too low to be infectious, but we have not seen this mentioned in any sensational news article about this "new" sexually transmitted infection.

And then there is microcephaly. Evidence for a causal association is growing, but solid epidemiological studies have not yet nailed it down. Experts in Brazil have begun a critical review of reported cases. All babies with a head circumference of less than 32 cm are flagged as a suspected case, regardless of the potential cause. Of the 1313 cases the government has investigated so far, only around a 3rd, or 404, were confirmed to have microcephaly. The diagnosis was rejected in the remaining cases.

Although Brazilian experts are addressing the issue of over-diagnosis, the increases in this condition still require explanation. Still, the question of why [only in] Brazil persists. In Colombia, where there are at least 20 000 known cases -- and at least 80 000 more [infections] -- since 80 percent of infected people have no symptoms, why are there no reports of microcephaly? Is/are some other factor(s) present that may be present in Brazil absent elsewhere? Defining the real risk for this condition will depend on solid epidemiological study design and good science. This takes time.

However, time appears to be a luxury in our instant communication world. There is a rush to be the 1st to report the latest finding. Although Zika was being transmitted in Brazil for some time (late 2014, early 2015?), the media frenzy began in earnest with the microcephaly issue. The downside is the challenge faced by policy makers who have to respond to incomplete information with lack of solid scientific evidence. Media pressure forces bad policy that is not science-based. The knee-jerk reaction (e.g., El Salvador asks women to postpone pregnancy for 2 years, really?), and the spillover of fear to travelers will adversely affect income in countries depending on tourism.

And, as more and more countries start to test for Zika, they will find it is already there. For the media, it would seem to be a startling finding. But, if this virus is already widespread globally, wherever the mosquito vector occurs, can it really be a Public Health Event of International Concern (PHEIC)? Early genomic analyses of the Americas virus point to an origin from the Pacific region. If it has mutated in ways to increase its virulence, then it would be another matter and properly considered as a PHEIC.

Precautionary advice when the science is incomplete is a must (e.g., CDC's recommendations for pregnant women), but another precaution to be emphasized in the media is not to jump too soon to conclusions without facts.

On a more positive note, in the course of time, and with widespread asymptomatic infections, a country's population will build up sufficient herd immunity to block further spread in it. This likely outcome is not mentioned in any media report. Herd immunity may be little help for pregnant women today, but there is hope for the future that the risk to pregnancy could decline in less than 2 years.

--
Ronald St. John, MD, MPH
Former Director General
Centre for Emergency Preparedness and Response
Public Health Agency of Canada

http://www.promedmail.org/post/4007411

 

[sharon sanders]

Notes from the Field: Evidence of Zika Virus Infection in Brain and Placental Tissues from Two Congenitally Infected Newborns and Two Fetal Losses ? Brazil, 2015 - February 10, 2016

 

[Pathfinder]

Notes from the Field: Evidence of Zika Virus Infection in Brain and Placental Tissues from Two Congenitally Infected Newborns and Two Fetal Losses — Brazil, 2015 - February 10, 2016

CDC confirms link between Zika, microcephaly in Brazilian babies who died

Erin Kelly, USA TODAY 2:57 p.m. EST February 10, 2016

WASHINGTON ? The Centers for Disease Control has identified the Zika virus in the tissue of two babies who died in Brazil from microcephaly ? the strongest link yet between the virus and the birth defect that has stricken developing fetuses, the CDC director told a House panel Wednesday.

"Zika is new, and new diseases can be scary, particularly when they can affect the most vulnerable among us," CDC Director Tom Frieden told members of the House Foreign Affairs Committee.

The CDC is warning pregnant women to protect their babies by avoiding travel to South America, Central America and the Caribbean, where the virus is spreading the fastest. Women who are already in those countries should take precautions to protect themselves from mosquitoes, which are the main way that the disease is transmitted, Frieden said.
...
http://www.usatoday.com/story/news/...rocephaly-brazilian-babies-who-died/80179898/