How to talk to your patients about Zika

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The hype around Zika virus seems to be settling down. The Summer Olympics in Rio appeared to occur without incident (at least associated to the virus spread), and the number of reported cases has plateaued. Media interest, while not gone, is definitely waning from where it was in February, when the World Health Organization declared Zika a Public Health Emergency of International Concern.

Yet for those working on the frontlines or in global organizations trying to define and understand the outbreak, it is clear this is a false period of calm.

This past July, as I walked the halls of a hospital in Brazil, I witnessed the impact of the disease firsthand. Tired and despairing mothers carried their infants with abnormally small heads, trying futilely to soothe their shrill cries as they waited for medical care. They carried them close and explained to our visiting group of public health officials that the stigma of having a child with Zika virus has started to pervade society, with people simultaneously fascinated and frightened by their children.

For these mothers, taking care of their children has become their full-time job. Providers and families in the affected regions remain afraid and worried about the long-term care that these children will require. And this wave of fear and uncertainty is moving to the U.S.

While the media reports have dwindled, every month the World Health Organization’s situation report continues to report new regions affected by the outbreak. The numbers are sobering: up to 72 countries and territories have been affected, with more than 20 areas reporting children afflicted with signs and symptoms of congenital infection.

Questions and fear extend beyond patients. Plenty of physicians are also asking questions. How afraid for our patients should we be? Who should we screen? What are the risks? How bad is the disease, and what are the cases really like? Answers to some of these questions are emerging.

Those affected with the congenital syndrome associated with Zika virus, including the severe microcephaly that has become symbolic of the outbreak, will have lifelong disabilities. These effects are not only devastating on an individual level, but present challenges to a health care system that must allocate resources to accommodate these new needs.

What clinicians really want to know about Zika

Dispelling myths is difficult because research has been primarily relegated to a series of small case reports and a few larger descriptive studies. But with detailed review, a clearer picture can be found.

  • Primary Zika virus infection is asymptomatic — in up to 80 percent of older children and adults afflicted, no symptoms are noted. A recent study of younger children with Zika also showed no serious harm. In those who do show symptoms, a 3- to 7-day course of mild flu-like symptoms (namely fever, rash, conjunctivitis, myalgias, malaise and headaches) may be noted. In rarer instances, post-infectious sequelae, such as Guillain-Barre, have been reported.
  • Close Up Of Pregnant Woman Having 4D Ultrasound ScanFor the pediatrician, a clearer picture of Zika’s connection with congenital neurological problems has also been emerging. While Zika was initially identified by a rise in cases of microcephaly, it is now known that the presence of microcephaly is only the tip of the iceberg. A recent study of pregnant women in Brazil demonstrated that if a rash appeared in the first trimester, it was highly likely the child was afflicted. Unfortunately, some pregnant women never develop a rash and therefore don’t even know they are infected. In utero, an ultrasound may reveal pronounced microcephaly and intracranial abnormalities including ventriculomegaly, hypoplasia of the corpus callosum, cerebellar hypoplasia and/or enlarged cisterna magna.
  • Gyral abnormalities may be identified at this early stage or in early infancy. These are most commonly described as pachygyria, polymicrogyria, and/or lissencephaly. These findings may be easier to find on a newborn, who exhibits clinical signs of microcephaly, craniofacial disproportion, redundant scalp skin and marked spasticity.
  • Arthrogryposis has also been reported in infants. As the infant grows, development remains delayed; marked irritability is noted (this often fades by the fifth or sixth month of life); and refractory seizures are often observed. (These have been described as infantile spasms, but data regarding this is still emerging.) Difficulty swallowing has also been described, and hearing impairment was recently reported as well. Visual abnormalities, including retinopathy, pigmentary changes and optic nerve malformations have also been described.
  • Even in milder cases, where pronounced microcephaly is not appreciated early on but exposure is verified, many of the less obvious neurodevelopmental issues emerge as the infant develops. This demonstrates the pervasive nature of the virus into the central nervous system.

What can we do?A healthy perspective

The virus is here.

Prevention is key until a reliable vaccine is developed.

Counseling for women of childbearing age is crucial. Travel to any region of risk should be carefully considered — the epidemic is real.

In the congenital syndrome, as with all syndromes of this kind, early detection remains key. Identifying at-risk children will help secure services as soon as possible and maximize neurodevelopmental outcomes.

Perhaps the Zika virus outbreak really is slowing down. But the effects will still be felt for years, and we need to be prepared to continue to advocate for the children affected. We can learn from this outbreak to be prepared for similar situations in the future.

Download the guide: 5 things to know about microcephaly.

patel_archana2About the blogger: Archana Patel, MD, MPH

Clinical care is the main focus of Dr. Archana Patel’s career, in both general child neurology and the subspecialty of pediatric epilepsy. Dr. Patel is also dedicated to global health child neurology, with both direct research interests in the development of methods to deliver care in low-resource regions, as well as interests in broader public health measures of working in policy and advocacy directed toward access to care, stigma and education.