Up Close And Personal With The Zika Virus

The Zika Virus — an infection caused by the bite of an Aedes mosquito — is actually, on its own, a rather benign ailment, marked by a “mild fever, rash, conjunctivitis, and muscle/joint pain.” First spotted in rhesus monkeys in the Zika forest in Uganda in 1947, the virus has subsequently bobbed and weaved, cropping up in small outbreaks in Asia before infecting nearly 75% of the population in Micronesia in 2007.

The most recent outbreak sprouted in Brazil — first detected this past May — and has since sent a swath of infection into more than 20 countries in Latin America; recently Costa Rica and Jamaica joined the fray as well. And just this past Tuesday, a case in Texas was added to the list — complicating things even further by the fact that it was sexually transmitted; previously it wasn’t believed Zika could be passed along this way. The CDC says the virus can live in the blood for up to a week and they’re currently studying how long the bugger can set up shop in semen, saliva, and urine.

Cue mild hysteria.

While the fact that this disease — which is likened to dengue, but decidedly less severe — has been discovered to be sexually transmittable is troubling in and of itself, this revelation is made more poignant (read: terrifying) by the relationship between Zika and pregnant women.

The World Health Organization (WHO) describes the spreading of Zika throughout the Americas as “explosive,” and estimates nearly 4 million people could infected by the year’s end. In Colombia alone, more than 4,000 people are confirmed to have the disease, more than 2,100 of which are pregnant woman. These numbers are nothing short of devastating in light of the links found between rising cases of microcephaly and the Zika virus.

The Pan American Health Organization describes this condition:

Microcephaly is an uncommon condition whose causes can be genetic or environmental (related to toxicity, radiation, or infection). It is defined as a condition at birth in which the newborn’s head circumference is less than expected for age and sex. Microcephaly can present as an isolated condition or may be associated with other symptoms such as convulsions, developmental delays or feeding difficulties. These symptoms have varying degrees of severity and in some cases may be life-threatening.”

As of November 30 2015, 1,248 cases of microcephaly (99.7 out of 100,000 live births) have been reported in 14 states of Brazil, demonstrating a twentyfold increase in comparison to microcephaly rates in previous years; in 2010, a mere 5.7 cases out of 100,000 live births were reported.

The WHO just declared the Zika Virus a “public health emergency of international concern” and on January 21st, the deputy health minister of El Salvador, Eduardo Espinoza, urged women of “fertile age” to take steps to forgo pregnancy until 2018, as a means to counter possible brain damage in their infants. Meanwhile over in Colombia, which has the second-highest Zika infection rate after Brazil, the government is also advising women to delay pregnancy, but only for six to eight months; Ecuadorian women have received similar recommendations.

The glaring problem with all this “advice” is, of course, the fact that in just about every single one of the 25 countries where people are infected, access to reproductive health care — especially abortions — is positively draconian, leaving women with very few options. They can try to seek out bug spray (expensive), contraception (nearly impossible to access) or pursue illegal, dangerous measures to terminate their pregnancies.

Legal scholars in Brazil are likening this predicament to a 2012 ruling in Brazil that allowed abortions for fetuses suffering from anencephaly, a severe birth defect where parts of the brain or skull are missing. Complicating this precedent, however, is the fact that severe cases of microcephaly can only be detected at around 24 weeks; late-term abortions are a hard sell for the government and mothers alike.

The sliver of silver lining here is that this epidemic is forcing Brazil to examine its oppressive treatment of women and dangerously outdated notions of sex, and in the wake of this outbreak, the women of Brazil may find themselves poised in a much better place.

Women on Web has also announced that it will be offering free medical abortions — a package of pills — to those women who are less than 9 weeks pregnant and are infected with the Zika virus. Brazil will remain exempt from this aid — apparently the government intercepts all packages containing medical abortions — but other nations’ women will benefit.

The Establishment caught up with none other than my cousin, Corinne Tandy, MS, who is a fourth-year PhD candidate specializing in comparative and experimental medicine with focuses on infectious diseases and epidemiology — the study of health in human populations — to talk about the evolution of the outbreak and what to expect next.

Katie: When is something declared a health emergency? From what I understand it’s rare for Zika to kill you. Is this about the speed at which it makes someone sick? The ease with which it is spread?

Corinne: The World Health Organization has a specific set of criteria regarding this. What the director-general has declared, specifically, is a public health emergency of international concern. What this really boils down to is that the situation with Zika virus is unusual, unexpected, and requires an international response. (For a full description of when/why a PHEIC is made, check this out.)

Zika is a mild illness, especially compared to its relative dengue, which occurs in the same parts of the world. I think that in this situation, the expert panel that spoke with the director-general stressed the potential link between Zika infection in pregnancy and microcephaly. The greatest concern here is that there is a potentially causal relationship between an easily acquired virus with no treatment or vaccine and a chronic, debilitating condition with no cure. The seriousness of this potential relationship is certainly worth deploying an international effort to find out exactly what is going on.

Katie: This may sound utterly daft, but how does a disease “disappear” for so long and suddenly crop up again? Is it literally because the mosquito carrying it hadn’t bitten anyone?!

Corinne: I think the idea that the disease ever “disappeared” in the first place is not quite right. Though diseases, particularly ones passed from animals to humans and those passed by insects or other vectors, can sort of play “hide-and-seek” like Ebola has for decades, the slow creep out of the jungle and eventual retreat back to its unknown animal reservoir is so insidious as to be something out of a post-apocalyptic horror movie. But I’m not sure that’s the case with Zika.

I think Zika “disappeared” because it wasn’t worth worrying about and, as a whole, people weren’t paying attention. And understandably so. This is a disease that gives you a rash and some joint pain. Frankly, who cares? And in the areas where it has been seen before — Africa, Asia and the Pacific — there are more severe diseases to worry about like malaria, polio, and dengue. I also think that it isn’t newsworthy to mention it; it isn’t “sexy.” This is all on top of the disease not being “reportable,” that is, no doctor has to tell the government, which was appropriate until recently. It would have been like making doctors report to the government every time someone got a cold. The medical and public health literature shows case reports and research about Zika over the past decades so there are some people that have been paying attention.

Ultimately, people have been getting Zika and no one really minded. We’ve only seen one outbreak prior to this one that caused anything remotely like what we’re seeing now — a 2013 outbreak in French Polynesia saw an increase in Guillain-Barre Syndrome, a neurological disorder.

Katie: Is this Brazil’s “fault” as it were? Should their government/health organizations had protocol in place that they didn’t? Is this similar to the “arrogance” we talked about re: the Ebola virus last year and American attitudes (in particular) that “these kinds of things” — like enormous plagues — just don’t happen anymore?

Corinne: Absolutely not. In fact, Brazil already has enormous protocols and infrastructure in place to reduce transmission of dengue fever, which is carried by the exact same type of mosquitoes. I’m not sure what they could have done differently as a preventive measure to keep Zika out. Especially since we had no idea that Zika could do something like this.

I think that there is a fundamental difference between Zika-as-we-knew-it and the recent Ebola pandemic and that’s the “we” could have seen it coming if it weren’t for “our” arrogance factor. With Zika, there was no chance for “Ohoho, that doesn’t happen here in the civilized world” because there was no that to happen! I know I keep saying this over and over, but we had no idea that this virus could cause the health problems it is causing — and we couldn’t have predicted it might since none of its sister species cause anything like this.

Katie: The WHO recently announced that Zika is sexually transmittable: Why is this unusual? Isn’t bodily fluid a common place for disease to thrive and be transferred?

Corinne: It is unusual in the case of this genus of viruses (Flavivirus); they are mostly arboviruses, meaning they are transmitted by arthropods like mosquitoes and ticks. Humans are normally dead-end hosts for arboviruses, meaning that we can’t pass it on. Non-arboviral transmission is not the norm and sexual transmission between humans has not been documented. Well, except for Zika apparently. There are several cases of potential sexual transmission proposed in the literature.

Generally speaking, though, bodily fluids are a fantastic place for viruses to thrive and move along to the next host. However, certain bodily fluids are more common than others and, for flaviviruses, semen isn’t typically on the list. A better answer about tissue tropism and what requirements different kinds of viruses need from host cells and why will come from a virologist. All I know is what we typically see and that it is important to keep an open mind because viruses are tricky little buggers.

Katie: How did they discover this link between the Zika virus and microcephaly? Is this a common phenomenon for there to be a connection between pregnancy and passing along a separate disorder/disease/condition?

Corinne: In October 2015, an unexpected increase in microcephaly cases was reported in Northeastern Brazil. An area that maybe saw 10 cases a year had seen nearly 150 by mid-November. The Brazil Ministry of Health noticed this was happening in other states around the nation as well and they declared a national emergency.

Immediately, health authorities began reviewing all the clinical, laboratory, and ultrasound data they had on the registered cases to look for what could link all these cases together. The Flavivirus Lab at the Osvaldo Cruz Institute isolated the Zika virus genome from the amniotic fluid of two women whose fetuses had been diagnosed with microcephaly in mid-November.

By the end of November, 1,248 cases of microcephaly [99.7 out of 100,000 live births] had been identified — Brazil had seen about five [out of 100,000 live birth] in both 2000 and in 2010. This jump in incidence is extraordinary — a twentyfold increase.

French Polynesia reported seeing an increase in nervous system malformations at the same time as a Zika virus outbreak at the end of November 2015. A few days after this, the Brazil Ministry of Health established the connection between Zika and microcephaly by detecting Zika genome in the tissue and blood of a microcephalic infant.

The second part of your question is a bit complex. So, first, what’s happening here is that women are getting an infectious disease while pregnant and the infectious organism is crossing the placenta and exposing the fetus. The list of infectious agents that can do this is quite short, thankfully, and those that do often have different outcomes in the fetus than in the mother. It’s a very different thing for a grownup, all bits and pieces in the right places, to be exposed to something than it is for a developing organism to. Development is a sensitive process — so much has to go exactly as planned or it goes wrong — and is easily disrupted. Depending on the exposure, things can go mildly wrong or terribly wrong.

When I was trying to find a way to answer this question, I was racking my brain for a good comparison for Zika. There isn’t one perfect example. Other mosquito-borne illnesses, like malaria, can cause health problems for mother and child but that’s not the same thing. The best example that comes to mind is rubella, a vaccine-preventable viral disease that in adults causes rash and joint pain. Sound familiar? You know what it also does? Causes microcephaly in fetuses.

At the end of the day, I think it can be reasonably expected that how a disease manifests in mothers will be different in how it will affect the fetus, since the disease impacts development. It’s quite a different “inheritance” process than we are used to thinking about.

Katie: The deputy health minister of El Salvador, has formally urged women of “fertile age” to take steps to plan their pregnancies until 2018 . . .

Corinne: Oh, yikes. Yeah this is kind of an intense recommendation. So we have no idea what we are in for with those 96 pregnant women in El Salvador. We don’t know if the cases will increase or decrease depending on when the mother got infected. We don’t know a whole lot at all! We know we need to advise against getting Zika while pregnant or trying to become pregnant if you have Zika, out of an abundance of caution. Of course, that’s easier said than done. It is nearly impossible to stop a mosquito from biting you, despite our best efforts. If this weren’t an issue we would have waaaay fewer public health problems. So, some authorities have recommended we approach this situation a little differently — don’t get pregnant until we know what is going on! Please.

It is easier to not get bitten by a mosquito than it is to access basic reproductive preventive needs such as birth control or basic reproductive rights, like abortion. I’m of the general opinion that if nations would like to recommend that their populations discontinue reproducing, then they should supply their populations with some means to control this.

It’s also basic human rights, but that’s a different conversation. One nice thing is that Brazil is considering (thanks, condescending patriarchy) allowing abortions for women with microcephalic fetuses.

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