A pregnant woman there got a diagnosis that the fetus she was carrying had developed a severe case of the birth defect. The fetus’ head was too small and the brain showed signs of calcification: clusters of dead neural cells throughout. Whether the mother had a miscarriage or chose an abortion, Puerto Rico’s secretary of health, Ana Rius Armendariz, would not say. But the pregnancy wasn’t carried to term. The secretary would not give further details on the case, but the woman did not contract the disease through travel.
“We know that we were waiting for this news at some point,” said Rius Armendariz in a statement. “Having a robust surveillance system allowed us to detect this case early.”
It was all a disturbing reminder of Zika's ability to cause birth defects, but it also raised the question of whether women in the contiguous states should be worried about summer pregnancies. Obstetricians and other physicians around Georgia are fielding that question as mosquito season arrives.
Some governments, such as El Salvador, have suggested the extreme, which is not to get pregnant this year or next. The Centers for Disease Control and Prevention has not issued such dire advice, even for women in Puerto Rico.
But even though Zika isn’t in the continental states yet, health agencies such as the CDC, the Georgia Department of Public Health and individual doctors across Georgia are advising a growing number of concerned mothers and want-to-be mothers about the disease. The message is reassuring but edged with caution: While there’s no need for panic, protect against mosquito bites as much as possible this summer.
“You don’t want to create mass alarm, so you have to strike a delicate balance,” said Dr. Bedri Yusuf, chief physician executive for Gwinnett Medical Group/Gwinnett Medical Center. “We’re better off educating the public to prevent catastrophe should Zika arrive here.”
It’s a question some doctors have dealt with in their own families.
“If you live in the Gulf States, there’s a likelihood we’re going to see some cases here,” said Dr. Stephen A. Thacker, director of pediatric infectious disease at Children’s Hospital in Savannah. “My wife just had a baby, our third boy, and my wife said, ‘Oh my goodness, what if Zika makes it here before I deliver?’”
Skeptics and threats
So far, the continental U.S. has dodged the threat, unlike Puerto Rico, where local and CDC health officials expect up to 20 percent of the island’s population of 3.5 million will contract Zika this year. The virus is already ensconced in Mexico.
The CDC has said based on travel patterns it's likely the virus will show up first in Texas, Florida or New York, most likely with infected people bringing the virus home, then being bitten by mosquitoes here, which can go on to spread it. That's why the CDC has recommended that people who've traveled to outbreak regions wear bug repellent for up to three weeks after their return home.
Between January and April there have been 13 travel-related cases of Zika in Georgia and through May there have been 503 cases in the U.S. Forty-eight cases have involved pregnant women.
Still, some people have expressed doubt that the U.S. will see a massive outbreak.
“I hope the skeptics are right and that Zika doesn’t start circulating here,” said Dr. Denise Jamieson of the Pregnancy and Birth Defects Team with the CDC Zika Virus Response Team. Even so, the agency has “plans in place of what we’ll do after the first case of local transmission” in the contiguous U.S.
Zika travels mainly through two types of mosquitoes, the Aedes aegypti and Aedes albopictus. The virus, however, can be transmitted through sexual contact and persists in blood and semen for weeks longer that researchers initially thought. That is why the CDC has offered strict guidelines regarding sexual activity to anyone who has traveled to the ever-growing regions where Zika is prevalent.
Insect repellent and long sleeves
In the past week, a flurry of new studies from Missouri to China have documented how the Zika virus attacks the fetus in utero. For example, using mice, researchers at the University of Washington not only showed how the virus attacks the placenta, but also how the placenta amplifies the presence of the virus, causing severe cell death in fetal brains.
The research suggested the earlier a mother is infected, the higher the probability that her baby will be affected by the virus, or that the virus will cause her to miscarry.
The specter of birth defects from the bite of the ubiquitous summer insect has put some patients on edge, said Dr. Jane Ellis, medical director of Emory University’s Regional Perinatal Center at Grady Memorial Hospital. Ellis specializes in high-risk pregnancies. She said she and her colleagues are seeing patients whose concerns are rising, especially if they have travel plans to Latin America.
“They say, ‘I’m going to the Dominican Republic on my honeymoon and what if I get pregnant,” Ellis said. “… We’ll have a talk about good common sense precaution.”
Patients have asked Ellis questions about the virus while she is performing their ultrasounds. They’ve also asked about insect repellents and have expressed concerns about the toxicity of some repellents, especially DEET, which the CDC recommends along with other precautions, such as wearing long-sleeved clothes and making sure all home windows have screens.
“Patients are aware DEET kills bugs, but they worry about it and wonder if it will seep through their skin and hurt their baby,” she said. “I tell them for all we know right now, the evidence suggests if used properly it should pose minimal to no risk to you or the baby.”
Thacker of Savannah has also advised patients about using repellent this summer, though he tells patients not to use anything above 50 percent DEET on an adult. He advises less than 30 percent DEET on children, and no DEET at all on infants younger than 2 months.
‘There is no treatment’
While there haven’t been local transmission cases in Georgia, there have been concerns. The state health department has tested at least 78 pregnant women for Zika exposure. All were negative for the virus.
Dr. Ellis has also had pregnant patients who’ve been in Zika outbreak regions refuse to take blood tests to rule out infection. In each case the women asked about treatment for the virus. There is no treatment, Ellis told them, at least not yet.
“Each of those patients declined (blood tests) and said, ‘If you can’t treat me, what’s the point?’” she said. “A lot of my patients say, ‘I’m putting my faith in God.’”
For those patients, Ellis ramped up the number of ultrasounds they got from just a few during pregnancy to one every two weeks. While ultrasounds have detected fetal abnormalities because of Zika, some problems such as hearing or vision loss can manifest themselves months after birth.
So far all of Ellis’ patients have delivered apparently healthy babies.
Dr. Yusuf with Gwinnett Medical said increasingly patients who’ve visited affected countries are asking for Zika tests. In the last month alone a husband who had recently returned from Colombia sought a test through Gwinnett Medical because his wife was pregnant. A pregnant woman who’d recently traveled to South America also came in for testing, Yusuf said. Both were negative.
So, should Georgia women who want to get pregnant this summer do so, even with the possibility of a local outbreak, however remote?
“Yes,” said Yusuf, “of course. There’s no reason to plan otherwise. You have to enjoy life.”
But they shouldn’t forget to wear bug spray either, he said.