Time for global action on Zika virus epidemic
BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i781 (Published 08 February 2016) Cite this as: BMJ 2016;352:i781
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Although the Zika virus causes predominantly mild symptoms, this mosquito-borne disease has become the newest public health challenge.1 Indeed encephalitis, Guillain-Barré syndrome associated with deglutition disorders, and potentially microcephaly are among serious recorded complications.
The first case of Zika was diagnosed in Martinique, French West Indies, in December 2015 [World Health Organization 2016. Zikavirus. http://www.who.int/mediacentre/factsheets/zika/en/ ]. So far, the country of 400 000 inhabitants has reported over 3000 suspected cases, including 4 cases of Guillain-Barré syndrome (2 confirmed, 2 probable). Among 8 pregnant women tested positive, no cases of microcephaly have been identified. Since Aedes aegypti mosquito, which carries the virus, has a wide distribution in the Caribbean [MMWR Morb Mortal Wkly Rep. 1998 Nov 13;47(44):952-6. Dengue outbreak associated with multiple serotypes--Puerto Rico, 1998], an increase of cases can be expected in a short period of time in this region. There is an urgent need for a collaborative approach through international medical cooperation to mitigate the forthcoming Zika outbreak by providing diagnostic laboratory facilities and assistance for appropriate management of the environment.
Medical cooperation has always played a major role in the improvement of healthcare in the Caribbean, particularly through increasing collaboration and promoting cooperation among nations.2 In 1984, there was collective action to promote the health of the Caribbean people, through the formation of the Caribbean cooperation in Heath (CCH).3 There have been improvements in important health indicators such as maternal and child health, and immunization. However, previous vector-borne disease outbreaks, such as dengue fever or chikungunya, negatively impacted the region, from social, economical and health aspects, due to lack of preparedness and international support [Shepard DS. Am J Trop Med Hyg 2011]. The Zika virus outbreak provides a new opportunity for richer countries – including France - to support efficiently vulnerable Caribbean countries with fragile economies, through inter-governmental assistance or non-governmental organizations such as the Caribbean Doctors Association.
We declare no competing interests.
Dabor Resiere1,2 , Ruddy Valentino1, Gilles Guerrier2,3 , Hossein Mehdaoui1
1 La Meynard University Hospital, Fort-de-France, Martinique, France
2 The Caribbean Doctors Association
3 Hôpital Cochin, Université Paris Descartes, Paris, France
Corresponding author: Dabor.resiere@chu-fortdefrance.fr
References
1. The Lancet. Zika virus : a new global threat for 2016. Lancet 2015: 386:243-44.
2. Resiere D, Valentino R, Lucron H, et al. Inter-regional medical cooperation in the Caribbean: lessons from the ongoing cooperation between Martinique, St Lucia, and Dominica. WIMJ Open 2014; 1: 26.
3. Caribbean Cooperation in Health. http://wwwcaricom.org/jsp/community/regional_issues/health _initiative.jsp
Competing interests: No competing interests
Unless we take rigorous measures to contain the disease there will be catastrophic events with new born babies. Efforts to create a vaccine must be initiated as soon as possible Otherwise we will see a disaster soon, Since its Mosquito borne it will spread very fast as Mosquitoes dont differentiate between countries and continents.
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Using age, sex, " ethnic origin" seems fine on the face of it.
However, in countries like Brazil, where genetic homogeneity is the exception rather than the rule, " ethnicity" becomes meaningless. We do not know which chromosomes from which ancestors will join up in the baby.
As for age, presumably Yung et al believe that gestational age, determined by the mother's recollection of the last menstrual period, is reliable. I am sceptical.
Competing interests: No competing interests
Zika virus is a flavivirus, RNA virus like other RNA virus related to Yellow fever, chikengunya (an alpha virus), Dengue, West Nile, Japanese encephalitis. Zika virus originated first in the Zika forest of Uganda, Africa, and it was first discovered in 1947 in the Rhesus monkey of the Zika forest. It was subsequently identified in humans in 1952 in Uganda and in Tanzania. Sporadic Zika virus was then reported in Africa and in southern Asia. In 2007, a Zika pandemic occurred in western Pacific of America & Africa, Cape verde, West Africa, in 2013[1]. From September 2015 to February 2016 a Zika pandemic involved more than 4000 people infected in Brazil; French Polynesia documented a concomitant epidemic of 73 cases of GB syndrome and other multiple conditions in a population of approximately 2,70,000 which may represent complication of Zika[1]. Two cases were also confirmed, one in Australia and one in Ireland (a man and an elderly woman) who have recovered, and both cases had a history of travelling in Zika virus infected areas. Outbreak is likely to spread to new countries. Zika now circulates the globe.
Zika virus particles are 40 nm in diameter with an outer envelop and inner dense core.
The vector of Zika virus is Ades mosquitoes. Most Zika spreads through Ades aegypti, which survive in cooler temperate environments, and Ades albopictus, which can also survive and hibernate at cooler temperatures. In Africa, Zika spreads by Ades Africans. These mosquitoes bite in the day or late evening hours. The vector for Chikungunya and Dengue (DNV) are also carried by Ades aegypti or in India by Ades albopictus. Ades mosquitoes breed in fresh water and household container storage water and in garbage bags.
The incubation period for Zika virus diseases is not very well known (3-12 day incubation period). So Zika virus occurs in Tropical areas with large mosquito populations and thus circulate in Africa, America, South Asian and Western pacific countries.
In 2014 December Brazil first reported Zika virus and more than 4000 people then became infected. Now a pandemic of Zika occurred throughout South America, Central Africa and the Caribbean sea [1]. The infection spread in at least 20 countries in America due to unrestricted air travel from Brazil. Asia can spread the virus. Zika is still confined to a narrow belt running across Africa to Asia [1].
The infection in 80% cases remains asymptomatic in humans as shown in old records. There may be a mild illness; fever (<38.5oC), prostration, skin rash (exanthema) arthralgia, bone pain; joint pain, headache, conjunctivitis, or symptoms almost like dengue fever or Chikengunya disease. The disease is self limiting in most cases. Severe illness may occur like GB Syndrome (so far 73 cases reported); autoimmune-like illness, neurological symptoms and in pregnancy, pregnant women giving birth to babies with microcephaly with ocular changes. However, causation between microcephaly and Zika virus is not yet established, though evidence of Zika virus has been found in the placenta, in amniotic fluid of mother and the brain of fetuses and newborn infants at autopsy. The causes of background microcephaly are not all known but various factors such as host genetics, congenital infections, drugs, alcohol and environmental exposures have also been implicated.
There are as yet no commercially available diagnostic tests in the field. Antibody to Zika virus IGM can be measured by Mac ELISA, but it may cross react with many other Flaviviruses like Dengue, Chikengunya. Quantities RT PCR test can be done. Viral culture is confirmatory. Diagnosis is mostly clinical.
Treatment of Zika virus infection is complete rest; plenty of fluids and water; avoidance of aspirin, and if GB syndrome occurs ventilators and other supportive care is required. Broad spectrum antivirals may be tried.
Prevention and awareness is the best treatment. Household storage of water is a contracting source. So control mosquito birth by biological ways-- i.e. fish that feed on mosquito larvae or genetically engineered modified sterile mosquito larvae, use of mosquito nets, strengthening public care health system to control mosquito breeding, house screening by municipality and gram panchayet for house debris, storage of fresh water, etc. Wear light color clothes that covers the maximum part of the body as much as possible.
The question remains whether Zika spreads through sexual routes, saliva or urine, or through blood with a patient’s contact who suffered from Zika virus. So far three cases recorded. A patient was infected in Dallas, Texas, is likely to have been infected by sexual contact. The patient had not travelled to infected areas but his partner had returned from Venezuela. Special attention is required for children, young adults, elderly people, travelers.The Centers for Disease Control and Prevention in the USA provided guidelines for the prevention of sexual transmission of Zika virus, 2016. Men who reside in or have travelled to an area of active Zika virus transmission and who have a pregnant partner must abstain from sexual activities or consistently and correctly use condoms during sex for the duration of pregnancy.
Indian have warned pregnant woman not to travel to countries affected by Zika virus. The two mosquito types that carry Zika virus thrive in India, and Indian patients have in the past tested positive for antibodies to Zika. But prevalance of Dengue and Chikengunya will make it hard to gauge Zika’s prevalence. Indian health ministry should start screening those who arrive on air flights from Zika affected countries like Latin America.
Reference
1] Anthony S Fauci and David M Morens “ Zika virus in the America-yet another Arbovirus threat “ Nejm January-13 ;2016 Doi 10.1056/NEJMP 1600297
Competing interests: No competing interests
A 20 fold increase in infants born with microcephaly (99.7/100,000 live births) was detected by Brazilian health authorities in November 2015 which correlated with introduction of Zika virus (ZIKV) into the country.(1) The reported background prevalence of microcephaly in new borns in Brazil prior to ZIKV introduction was 5.5/100,000 live births and 5.7/100,000 live births in 2000 and 2010 respectively.(1) More recent data from Brazil’s Ministry of Health enhanced notification protocol, have reported >3000 suspected cases of microcephaly in the second half of 2015. This would equate to a prevalence of about 200/100,000 live births.(2) Although, the steep increases are worrying, we would like to share some important epidemiological concepts on the interpretation of such signals in relation to causation and importantly, extrapolation to actual attributable risk due to ZIKV if the linked is proven.
Microcephaly can be defined as a head circumference of less than two or three standard deviation (SD) below the mean for sex, age and ethnic origin.1 Definitions can also vary between clinicians and regions. The European Surveillance of Congenital Anomalies network (EUROCAT)) uses less than three SD.(3) Brazil currently defines microcephaly as being less than two SD although prior to November 2015, a broader definition was actually in use.(2,4) Anthropometric measurements including head circumference charts used for neonates, infants and children are frequently developed around the normal distribution although some may include a small amount of skew.(5,6) According to the normal distribution, less than two SD and less than three SD would equate to about 2.275% and 0.135% respectively of a cohort.(Figure 1) Therefore, if we assume 100% ascertainment in a reporting system, an increase in the number of new borns with microcephaly up to 2275/100,000 live births (< 2SD) or 135/100,000 live births (< 3SD) would still be within the expected range in a population. There were no reported changes to Brazil’s Live Births Information prior to the signal detection which could lead to increased ascertainment. However, only a slight 4% (5/2275 to 100/2275) or 8% (5/2275 to 200/2275) increase in case ascertainment if a case definition of < 2SD was used, could trigger a 20 fold or 40 fold increase respectively. Factoring this, if ZIKV is confirmed to be a causative agent for microcephaly, the true risk may be much lower.
The causes of background microcephaly are not all known but various factors such as host genetics, congenital infections, drugs, alcohol and environmental exposures have been implicated. Therefore, attributable or excess risk data are critical in guiding clinical management and informing the appropriate level of public health response to ZIKV as a possible new risk factor for microcephaly. There is an urgent need for shoe leather epidemiology in terms of well-designed studies with appropriate controls using robust definitions to meet a major gap in confirming, and subsequently quantifying the link between ZIKV and microcephaly.
References
1) Pan American Health Organization. Epidemiological Alert - Neurological syndrome, congenital malformations, and Zika virus infection. Implications for public health in the Americas [Internet]. WHO; 2015 [cited 2016 Jan 16]. Available from: http://www.paho.org/hq/index.php?option=com_topics&view=readall&cid=7880... (accessed 29th January 2016)
2) Lavinia Schuler-Faccini, Erlane M. Ribeiro, Ian M.L. Feitosa, et al and Brazilian Medical Genetics Society–Zika Embryopathy Task Force. Possible Association Between Zika Virus Infection and Microcephaly —Brazil, 2015. Early Release / Vol. 65 January 22, 2016.
Available from: http://www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6503e2er.pdf (accessed 29th January 2016)
3) EUROCAT European Surveillance of Congenital Anomalies. Data Collection.
Available at: http://www.eurocat-network.eu/aboutus/datacollection/guidelinesforregist... (accessed 29th January 2016)
4) Nota sobre medida do perímetro cefálico para diagnóstico de microcefalia (Google translate: Note on measuring head circumference for diagnosis of microcephaly) 07/12/2015
Available at: http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/secreta... (accessed 29th January 2016)
5) Villar J, Ismail LC, Victora CG, et al: International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21 . Lancet 2014; 384: pp. 857-868
6) Borghi E, de Onis M, Garza C, et al. Construction of the World Health Organization child growth standards: selection of methods for attained growth curves. Stat Med 2006; 25: 247–65.
Figure 1: The normal distribution and standard deviations
("Empirical Rule" by Dan Kernler - Own work. Licensed under CC BY-SA 4.0 via Commons - https://commons.wikimedia.org/wiki/File:Empirical_Rule.PNG#/media/File:E...)
Competing interests: No competing interests
Zika Eye disease ...CPD integrating specialities and global cooperation at World Congress of Ophthalmology,Mexico
Zika and other diseases like Dengue increasingly blur the margins between specialities in modern medicine. We already have a gamut of manifestations of dengue in the eye called as dengue eye disease . Now faced with conjunctivitis in returning travellers , even ophthalmologists have to be aware of the possibility of conjunctivitis being the initial presentation of a Zika infection. Traditionally a conjunctivitis with pre auricular lymph node enlargement was invariably considered as adenovirus infection . But now we are reading of Zika virus infection presenting with post auricular lymphadenopathy (1) What makes it interesting further is the fact that what one may conclude to be dengue eye disease may well be Zika conjunctivitis since false positive Dengue NS 1 has been reported in patients suffering from Zika virus infection (2) Zika has been known to be implicated in uveitis as well (3) with symptoms appearing one week after the systemic manifestations in the form of "bilateral ocular discomfort for near tasks, blurry vision, and mild redness" . But what was notable was "an intraocular pressure of 40 and 28 mmHg in right and left eye " which is something we have noted in some cases of Guillian Barre syndrome and glaucoma due to secondary immune iridocyclitis. Secondary to "unknown viral fever" . Another Brazilain study found patients with microcephalic syndrome to have lesions like focal pigment mottling, chorioretinal atrophy in the posterior pole of the eye, more so the macular area and optic nerve involvement, in form of optic nerve hypoplasia with double ring sign and severe optic disc cupping and pallor , lens subluxation, and bilateral iris coloboma (4) (5) All this only means that information needs to be shared rapidly and in an open access manner ,not only between specialists but also across specialities . The recently concluded World Congress of Ophthalmology at Mexico (6) had a late breaking session where all these were discussed in terms of Zika eye disease and I realised that I found it better to be forewarned . The international community needs to understand the importance of collaboration across specialities and address the Zika infection in a modular fashion involving doctors from all specialities so that a holistic approach can be followed for the care of the patient as a whole because there have been reports of co infection with dengue , Zika and Chikungunya. ( 7) Zika has been found to be persistent in semen for a longer time and found to be spread by sexual contact and we also have to be careful about blood transfusion (8) Zika RNA has also been detected in saliva (9) Even urine has been evaluated as a potential testing sample to be used for detection of Zika (10)
Since it can pass through blood brain barrier and ocular barrier and may be found persistently in aqueous , this fact may need to be considered during ophthalmic procedures as well and while examining patients with conjunctivitis returning from Zika prone areas it may be prudent to wear gloves and discard them carefully
Considering the varying symptomatology , the diverse human body systems involved, the possibility of co infections and the persistence of the virus in some body fluids ; the need for education and CPD for doctors of every speciality cannot be neglected and this will need doctors of all specialities to get together and discuss this not only at world congresses but also after the conferences in email communications with each other and scientific communications will need to be less time consuming and open access so that information is spread faster than the disease .In this regard I have found Facebook communications from doctors useful but the medicolegal aspects and privacy concerns need to be looked into. Hence it is upto journals like the BMJ to rapidly disseminate knowledge in this regard and I congratulate the editors and staff for doing an amazing job so far.
References :-
1) Weitzel T, Cortes CP. Zika Virus Infection Presenting with Postauricular
Lymphadenopathy. Am J Trop Med Hyg. 2016 Feb 16. pii: 16-0096.
2) Gyurech D, Schilling J, Schmidt-Chanasit J, Cassinotti P, Kaeppeli F, Dobec M.
False positive dengue NS1 antigen test in a traveller with an acute Zika virus
infection imported into Switzerland. Swiss Med Wkly. 2016 Feb 9;146:w14296. doi:
10.4414/smw.2016.14296.
3) Fontes BM. Zika virus-related hypertensive iridocyclitis. Arq Bras Oftalmol.
2016 Feb;79(1):63. doi: 10.5935/0004-2749.20160020.
4) De Paula Freitas B, de Oliveira Dias JR, Prazeres J, et al. Ocular findings in infants with microcephaly associated with presumed Zika virus congenital infection in Salvador, Brazil. JAMA Ophthalmol2016; published online 9 Feb, doi:10.1001/jamaophthalmol.2016.0267.
5) Ventura CV, Maia M, Ventura BV, Linden VV, Araújo EB, Ramos RC, Rocha MA,
Carvalho MD, Belfort R Jr, Ventura LO. Ophthalmological findings in infants with
microcephaly and presumable intra-uterus Zika virus infection. Arq Bras Oftalmol.
2016 Feb;79(1):1-3. doi: 10.5935/0004-2749.20160002.
6) http://www.wocabstracts.org/index.cfm?do=ev.viewEv&ev=4721
7) Villamil-Gómez WE, González-Camargo O, Rodriguez-Ayubi J, Zapata-Serpa D,
Rodriguez-Morales AJ. Dengue, chikungunya and Zika co-infection in a patient from
Colombia. J Infect Public Health. 2016 Jan 2. pii: S1876-0341(15)00221-X. doi:
10.1016/j.jiph.2015.12.002. [Epub ahead of print] PubMed PMID: 26754201.
8) Franchini M, Velati C. Blood safety and zoonotic emerging pathogens: now it's
the turn of Zika virus! Blood Transfus. 2015 Nov 5:1. doi: 10.2450/2015.0187-15.
9) Musso D, Roche C, Nhan TX, Robin E, Teissier A, Cao-Lormeau VM. Detection of
Zika virus in saliva. J Clin Virol. 2015 Jul;68:53-5. doi:10.1016/j.jcv.2015.04.021.
10) Gourinat AC, O'Connor O, Calvez E, Goarant C, Dupont-Rouzeyrol M. Detection of Zika virus in urine. Emerg Infect Dis. 2015 Jan;21(1):84-6. doi:10.3201/eid2101.140894.
Competing interests: No competing interests