By Gary Evans, Medical Editor
In reporting another wave of tragic birth defects to babies born in the United States with Zika virus, public health officials urged healthcare providers to follow potential cases closely and reiterate prevention measures within their workplace and communities. Pregnant women are priority one.
With their backgrounds in disease transmission and staff training, infection preventionists are uniquely qualified to be a Zika resource for their facilities and communities. Although transmission of Zika within healthcare settings should be a rare event, IPs can play a key role in preventing the virus nonetheless.
“Even though it is not a hospital issue, the role of infection prevention transcends the healthcare institution—particularly in the case of IPs who work in or provide oversight for clinics and physician practices,” says Linda R. Greene, RN, MPS, CIC, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology. “Their role is crucial from that perspective [to] make sure that practices are asking the right questions, and I think most of them are.”
As with other infectious diseases, hospitals may be most likely to see Zika infections in the emergency department. In addition to asking a patient’s travel history, staff may post information about Zika in the ED.
“In terms of community education and particularly when patients come into the emergency department, I know several hospitals have put up [Zika] signage,” Greene says. “We have to be sure that no matter where someone enters the healthcare system —whether it be a hospital or a physician’s office —that people are screened for travel history. So I think there is a huge role for IPs in education.”
Similarly, staff can be apprised of risk as well, particularly those who are pregnant or trying to conceive. “It is important that not only patients or others that come into your healthcare institution —but also your healthcare workers —are educated,” she says. “Infection preventionists play a large role in getting that information out there to staff.”
The Horror
The CDC announced at a recent press conference that about 10% of pregnant women with confirmed Zika in the United States in 2016 had a baby with the horrific gamut of Zika birth defects. Zika infection—particularly in the first trimester—can lead to the well-reported outcomes of microcephaly and other serious congenital brain abnormalities, including limb defects and vision and hearing problems.
“Healthcare providers have an important role, and we encourage them to ask about possible Zika exposure when caring for both pregnant women and their babies and to follow CDC guidance for evaluation and care of infants with possible Zika infection,” says Peggy Honein, PhD, co-lead, Pregnancy and Birth Defects Task Force, CDC Zika Response.
One recommended evaluation is to do a brain scan of infants born of Zika mothers, even if there is no obvious sign of birth defects. However, only one in four babies with possible congenital Zika have received this brain imaging after birth, Honein noted at the press conference.
“Brain imaging —for example, a head ultrasound or a CT [scan]—is important to look for abnormalities, because we know that some babies have underlying brain defects that are otherwise not evident at birth,” she says. “Because we do not have brain imaging reports for most of the infants whose mothers had Zika during pregnancy, our current data might significantly underestimate the impact of Zika.”
The baseline prevalence of Zika-like birth defects before the virus emerged was three babies per 1,000 live births.
“The 10% of pregnancies with confirmed Zika that resulted in a fetus or infant with one of these Zika-associated birth defects in today’s report is more than 30 times higher than this baseline prevalence,” Honein says.
In another issue that may cloak some of the disease, CDC data show that approximately one-third of babies with possible congenital Zika infection were not tested for the virus at birth.
The CDC is urging vigilance and warning that Zika will return, though some observers think that as the disease passes through susceptible populations in epicenters like Brazil the overall outbreak may diminish. That remains to be seen, and Zika has already taken several surprising turns during this epidemic. Thus, underestimating it could be perilous.
First 2017 Cases
Florida reported 29 Zika cases for 2017 as of March 20. The CDC advises pregnant women to consider postponing travel to Miami-Dade County. The majority of the Florida cases were in travelers returning from countries where Zika is spreading, but two cases were locally acquired via mosquitoes and two were of unknown origin. The state reported Zika infections in 13 pregnant women for 2017. All Florida county health departments now offer free Zika risk assessment and testing to pregnant women.
“We’re still seeing about 30 to 40 new Zika cases in pregnant women each week in the United States,” Anne Schuchat, MD, acting director of the CDC, noted at the press conference. “With the current tally of more than 1,600 pregnant women with evidence of Zika reported nationwide, the majority of these cases involve travel to Zika-affected areas. While there is much left to learn about Zika, we do know this devastating outbreak is far from over, and the consequences of this [infection] are heartbreaking.”
In 2016 U.S. data that does not include Puerto Rico, the CDC reported that nearly 1,000 pregnant women in 44 states with lab evidence of Zika completed pregnancies during the year.
“Fifty-one, or about 5%, had Zika-related birth defects,” Schuchat says. “And these were from pregnancies with Zika virus exposure in 16 different countries or territories. Some of those pregnant women with lab evidence had confirmed Zika virus. Of this group, about 10% [had babies with birth defects], and that proportion increased to 15% for women with confirmed Zika during their first trimester.”
Though all of the 51 birth defect cases in 2016 were in women who had traveled to other countries, Schuchat warned that viruses respect no borders.
“With larger numbers of pregnant women at risk, I would anticipate birth complications in any sample of women who develop Zika during pregnancy,” she says. “It does not matter where you get Zika infection in terms of the complications of pregnancy.”
In addition to the devastating human toll, the costs for treating an infant with microcephaly is estimated at $4 million, Schuchat says. “For those who survive into adulthood, the cost could be up to $10 million.”
Take-home Points
Zika prevention measures the CDC is currently recommending include:
- Pregnant women should not travel to any areas with risk of Zika.
- Men with pregnant partners should use condoms or avoid having sex for the duration of the pregnancy if they have traveled to or live in an area with risk of Zika.
- People who must travel should talk to their healthcare provider about the risks before they go and take extra precautions like using an EPA-registered insect repellent to avoid getting bitten by mosquitoes. Pregnant women and their partners living in areas with risk of Zika should strictly follow steps to prevent mosquito bites and prevent sexual transmission by using condoms or not having sex during the pregnancy.
“Healthcare providers play a key role in these prevention efforts,” Schuchat says.
“This includes encouraging pregnant women to follow CDC’s prevention recommendations and asking their patients about possible Zika exposure when caring for pregnant women or babies. Provide testing and follow-up care to affected babies to ensure the appropriate intervention services are available to them. They can also work with parents to create a coordinated care plan and monitor the baby’s development.”
Recommendations for healthcare providers caring for babies born to mothers who had Zika during pregnancy include providing a comprehensive physical exam, brain imaging, newborn hearing screening, and Zika lab tests.
“It’s been more than a year since CDC released the first travel alert notice related to Zika virus in the Americas,” Schuchat says. “Although Zika may seem like last year’s problem or an issue confined to Brazil and parts of the Caribbean, our findings reinforce that this is not the time to be complacent. As of last count, more than 5,100 Zika virus cases have been reported in the continental U.S. and Hawaii—the majority involving travelers returning from areas with active Zika transmission. In addition, more than 1,600 pregnant women with evidence of Zika nationwide have been reported to the pregnancy registry.”
The CDC estimates some 40 million people in the U.S. travel to the Caribbean and Central and South America annually. With Aedes aegypti mosquitoes returning to many states as the weather warms, infected travelers could be a reservoir for local transmission.
“Unfortunately, every mosquito bite carries a risk,” Schuchat says. “Zika is still with us. We don’t know how much transmission there will be this year, but we can’t become complacent about the threat.”
