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Zika vaccine candidates possible by early 2017
Phase I trials to determine the safety and immunogenicity of a Zika virus vaccine could begin as soon as late summer or early fall of this year, with a candidate vaccine by early 2017.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the U.S. National Institutes of Health, made the announcement during a call with the media on March 10, stating that finding a vaccine to combat the increasingly problematic spread of the Zika virus is a top priority of federal health agencies.
Phase I trials “usually take several months – 3 or 4 months – to get an answer,” said Dr. Fauci, adding that he hopes to have “a candidate or candidates that are safe and can induce an immune response” by early 2017.
Dr. Fauci said that he hopes the vaccine could be selected for an accelerated approval schedule so that it could be manufactured and distributed as quickly as possible. That will, however, depend in large part on the state of the Zika virus outbreak in early 2017, a situation he called “impossible to predict.”
“What I can tell you is that we’ll be testing the vaccine in phase I [by] the early fall,” Dr. Fauci said.
Dr. Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, echoed Dr. Fauci’s concerns about the growing Zika virus outbreak in the Americas.
Having just returned from a trip to Puerto Rico, Dr. Frieden said he is “very concerned that, before the year is out, we could see hundreds of thousands of Zika infections in Puerto Rico, and thousands of infected pregnant women.”
Health officials, however, are making progress. The CDC and the NIH are closer than ever to understanding the links between Zika virus and the neurological conditions that have been associated with the virus, including microcephaly and Guillain-Barré syndrome.
“Never before have we had a mosquito-borne infection that could cause serious birth defects on a large scale,” Dr. Frieden said, adding that “funding from Congress is urgently needed” to adequately attack the growing threat.
Another approach being targeted to fight the Zika virus is controlling the way it is spread – through mosquitoes. To that end, Dr. Frieden outlined a four-pronged approach to reduce exposure to mosquitoes “inside the home, outside the home, at the larval stage, and at the adult mosquito stage,” including using insect repellents and wearing long-sleeve shirts and pants.
“The bottom line here is that [this] is an uphill battle,” Dr. Frieden said. “We know we won’t be able to protect 100% of women, but for every single case of Zika infection in pregnancy we prevent, we’re potentially preventing an individual, personal, and family tragedy.”
Phase I trials to determine the safety and immunogenicity of a Zika virus vaccine could begin as soon as late summer or early fall of this year, with a candidate vaccine by early 2017.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the U.S. National Institutes of Health, made the announcement during a call with the media on March 10, stating that finding a vaccine to combat the increasingly problematic spread of the Zika virus is a top priority of federal health agencies.
Phase I trials “usually take several months – 3 or 4 months – to get an answer,” said Dr. Fauci, adding that he hopes to have “a candidate or candidates that are safe and can induce an immune response” by early 2017.
Dr. Fauci said that he hopes the vaccine could be selected for an accelerated approval schedule so that it could be manufactured and distributed as quickly as possible. That will, however, depend in large part on the state of the Zika virus outbreak in early 2017, a situation he called “impossible to predict.”
“What I can tell you is that we’ll be testing the vaccine in phase I [by] the early fall,” Dr. Fauci said.
Dr. Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, echoed Dr. Fauci’s concerns about the growing Zika virus outbreak in the Americas.
Having just returned from a trip to Puerto Rico, Dr. Frieden said he is “very concerned that, before the year is out, we could see hundreds of thousands of Zika infections in Puerto Rico, and thousands of infected pregnant women.”
Health officials, however, are making progress. The CDC and the NIH are closer than ever to understanding the links between Zika virus and the neurological conditions that have been associated with the virus, including microcephaly and Guillain-Barré syndrome.
“Never before have we had a mosquito-borne infection that could cause serious birth defects on a large scale,” Dr. Frieden said, adding that “funding from Congress is urgently needed” to adequately attack the growing threat.
Another approach being targeted to fight the Zika virus is controlling the way it is spread – through mosquitoes. To that end, Dr. Frieden outlined a four-pronged approach to reduce exposure to mosquitoes “inside the home, outside the home, at the larval stage, and at the adult mosquito stage,” including using insect repellents and wearing long-sleeve shirts and pants.
“The bottom line here is that [this] is an uphill battle,” Dr. Frieden said. “We know we won’t be able to protect 100% of women, but for every single case of Zika infection in pregnancy we prevent, we’re potentially preventing an individual, personal, and family tragedy.”
Phase I trials to determine the safety and immunogenicity of a Zika virus vaccine could begin as soon as late summer or early fall of this year, with a candidate vaccine by early 2017.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the U.S. National Institutes of Health, made the announcement during a call with the media on March 10, stating that finding a vaccine to combat the increasingly problematic spread of the Zika virus is a top priority of federal health agencies.
Phase I trials “usually take several months – 3 or 4 months – to get an answer,” said Dr. Fauci, adding that he hopes to have “a candidate or candidates that are safe and can induce an immune response” by early 2017.
Dr. Fauci said that he hopes the vaccine could be selected for an accelerated approval schedule so that it could be manufactured and distributed as quickly as possible. That will, however, depend in large part on the state of the Zika virus outbreak in early 2017, a situation he called “impossible to predict.”
“What I can tell you is that we’ll be testing the vaccine in phase I [by] the early fall,” Dr. Fauci said.
Dr. Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, echoed Dr. Fauci’s concerns about the growing Zika virus outbreak in the Americas.
Having just returned from a trip to Puerto Rico, Dr. Frieden said he is “very concerned that, before the year is out, we could see hundreds of thousands of Zika infections in Puerto Rico, and thousands of infected pregnant women.”
Health officials, however, are making progress. The CDC and the NIH are closer than ever to understanding the links between Zika virus and the neurological conditions that have been associated with the virus, including microcephaly and Guillain-Barré syndrome.
“Never before have we had a mosquito-borne infection that could cause serious birth defects on a large scale,” Dr. Frieden said, adding that “funding from Congress is urgently needed” to adequately attack the growing threat.
Another approach being targeted to fight the Zika virus is controlling the way it is spread – through mosquitoes. To that end, Dr. Frieden outlined a four-pronged approach to reduce exposure to mosquitoes “inside the home, outside the home, at the larval stage, and at the adult mosquito stage,” including using insect repellents and wearing long-sleeve shirts and pants.
“The bottom line here is that [this] is an uphill battle,” Dr. Frieden said. “We know we won’t be able to protect 100% of women, but for every single case of Zika infection in pregnancy we prevent, we’re potentially preventing an individual, personal, and family tragedy.”
Ebola research update: February 2016
The struggle to defeat Ebola viral disease continues globally, although it may not always make the headlines. To catch up on what you may have missed, here are some notable news items and journal articles published over the past few weeks that are worth a look.
New research reveals that the Ebola virus is typically cleared from the blood within 16 days – meaning that the risk of infection from contact with a survivor is low. However, an exception to this is transmission via sexual intercourse due to the virus’ presence in semen for many months after a patient has otherwise recovered. Contact with the patient’s blood is also a longer-term risk.
A report in Clinical Infectious Diseases assesses two cases of Ebola viral disease (EVD) in pregnant women who survived, initially with intact pregnancies. Both patients had live second trimester fetuses in utero following cure, but each woman ultimately delivered a stillborn fetus with persistent EVD–polymerase chain reaction amniotic fluid positivity. The investigators say this highlights the need for research on possible infectivity of amniotic fluid after convalescence of the mother.
According to new research, extracts of the medicinal plant Cistus incanus attack Ebola and HIV virus particles and prevent them from multiplying in cultured cells. Since the antiviral activity of Cistus extracts differs from all clinically approved drugs, the researchers say Cistus-derived products could be an important complement to currently established drug regimens.
Investigators at the CDC used mice engrafted with human immune cells as a model for Ebola virus infection and disease progression. They demonstrated that mice devoid of their native immune response and reconstituted with a human innate and adaptive immune system are susceptible to infection and die of disease within approximately 2 weeks after inoculation with wild-type Ebola virus. Mice appear to offer a unique model for investigating the human immune response in EVD and an alternative animal model for EVD pathogenesis studies and therapeutic screening.
A study published in Scientific Reports shows the ability of a vaccine vector, based on a common herpesvirus called cytomegalovirus expressing Ebola virus glycoprotein, to provide protection against Ebola virus in the experimental rhesus macaque, non-human primate model. Investigators say the study is a step forward for the development of conventional Ebola virus vaccines for use in humans.
Researchers at the Yale School of Public Health developed computational models for disease transmission and infection progression to estimate the repercussions of the 2014-2015 West African Ebola outbreak on populations already at risk for malaria, HIV/AIDS, and tuberculosis. They estimated that a 50% reduction in access to healthcare services during the Ebola outbreak exacerbated malaria, HIV/AIDS, and tuberculosis mortality rates by additional death counts of 6,269 in Guinea; 1,535 in Liberia; and 2,819 in Sierra Leone.
A broad panel of neutralizing, anti–Ebola virus antibodies have been isolated from a survivor of the recent Zaire outbreak. Investigators said 77% of the monoclonal antibodies (mAbs) neutralize live EBOV, and several mAbs exhibit unprecedented potency. They said the results provide a framework for the design of new EBOV vaccine candidates and immunotherapies.
The Ebola epidemic in West Africa provides valuable lessons for how to respond to infectious disease epidemics generally, according to an analysis in Science. The report says rebuilding local health care infrastructures, improving capacity to respond more quickly to outbreaks, and considering multiple perspectives across disciplines during decision-making processes are the key areas for action.
A multicenter non-randomized trial of Ebola virus patients in Guinea found that favipiravir monotherapy, along with standardized care, merits further study in patients with medium to high viremia, but not in those with very high viremia. The results also confirm that viral load is a strong predictor of mortality.
According to a report in the Journal of Infectious Diseases, the support from the World Health Organization’s polio program infrastructure, particularly the coordination mechanism adopted, the availability of skilled personnel in the polio program, and lessons learned from managing the polio eradication program greatly contributed to the speedy containment of the 2014 Ebola virus disease outbreak in Nigeria.
On Twitter @richpizzi
The struggle to defeat Ebola viral disease continues globally, although it may not always make the headlines. To catch up on what you may have missed, here are some notable news items and journal articles published over the past few weeks that are worth a look.
New research reveals that the Ebola virus is typically cleared from the blood within 16 days – meaning that the risk of infection from contact with a survivor is low. However, an exception to this is transmission via sexual intercourse due to the virus’ presence in semen for many months after a patient has otherwise recovered. Contact with the patient’s blood is also a longer-term risk.
A report in Clinical Infectious Diseases assesses two cases of Ebola viral disease (EVD) in pregnant women who survived, initially with intact pregnancies. Both patients had live second trimester fetuses in utero following cure, but each woman ultimately delivered a stillborn fetus with persistent EVD–polymerase chain reaction amniotic fluid positivity. The investigators say this highlights the need for research on possible infectivity of amniotic fluid after convalescence of the mother.
According to new research, extracts of the medicinal plant Cistus incanus attack Ebola and HIV virus particles and prevent them from multiplying in cultured cells. Since the antiviral activity of Cistus extracts differs from all clinically approved drugs, the researchers say Cistus-derived products could be an important complement to currently established drug regimens.
Investigators at the CDC used mice engrafted with human immune cells as a model for Ebola virus infection and disease progression. They demonstrated that mice devoid of their native immune response and reconstituted with a human innate and adaptive immune system are susceptible to infection and die of disease within approximately 2 weeks after inoculation with wild-type Ebola virus. Mice appear to offer a unique model for investigating the human immune response in EVD and an alternative animal model for EVD pathogenesis studies and therapeutic screening.
A study published in Scientific Reports shows the ability of a vaccine vector, based on a common herpesvirus called cytomegalovirus expressing Ebola virus glycoprotein, to provide protection against Ebola virus in the experimental rhesus macaque, non-human primate model. Investigators say the study is a step forward for the development of conventional Ebola virus vaccines for use in humans.
Researchers at the Yale School of Public Health developed computational models for disease transmission and infection progression to estimate the repercussions of the 2014-2015 West African Ebola outbreak on populations already at risk for malaria, HIV/AIDS, and tuberculosis. They estimated that a 50% reduction in access to healthcare services during the Ebola outbreak exacerbated malaria, HIV/AIDS, and tuberculosis mortality rates by additional death counts of 6,269 in Guinea; 1,535 in Liberia; and 2,819 in Sierra Leone.
A broad panel of neutralizing, anti–Ebola virus antibodies have been isolated from a survivor of the recent Zaire outbreak. Investigators said 77% of the monoclonal antibodies (mAbs) neutralize live EBOV, and several mAbs exhibit unprecedented potency. They said the results provide a framework for the design of new EBOV vaccine candidates and immunotherapies.
The Ebola epidemic in West Africa provides valuable lessons for how to respond to infectious disease epidemics generally, according to an analysis in Science. The report says rebuilding local health care infrastructures, improving capacity to respond more quickly to outbreaks, and considering multiple perspectives across disciplines during decision-making processes are the key areas for action.
A multicenter non-randomized trial of Ebola virus patients in Guinea found that favipiravir monotherapy, along with standardized care, merits further study in patients with medium to high viremia, but not in those with very high viremia. The results also confirm that viral load is a strong predictor of mortality.
According to a report in the Journal of Infectious Diseases, the support from the World Health Organization’s polio program infrastructure, particularly the coordination mechanism adopted, the availability of skilled personnel in the polio program, and lessons learned from managing the polio eradication program greatly contributed to the speedy containment of the 2014 Ebola virus disease outbreak in Nigeria.
On Twitter @richpizzi
The struggle to defeat Ebola viral disease continues globally, although it may not always make the headlines. To catch up on what you may have missed, here are some notable news items and journal articles published over the past few weeks that are worth a look.
New research reveals that the Ebola virus is typically cleared from the blood within 16 days – meaning that the risk of infection from contact with a survivor is low. However, an exception to this is transmission via sexual intercourse due to the virus’ presence in semen for many months after a patient has otherwise recovered. Contact with the patient’s blood is also a longer-term risk.
A report in Clinical Infectious Diseases assesses two cases of Ebola viral disease (EVD) in pregnant women who survived, initially with intact pregnancies. Both patients had live second trimester fetuses in utero following cure, but each woman ultimately delivered a stillborn fetus with persistent EVD–polymerase chain reaction amniotic fluid positivity. The investigators say this highlights the need for research on possible infectivity of amniotic fluid after convalescence of the mother.
According to new research, extracts of the medicinal plant Cistus incanus attack Ebola and HIV virus particles and prevent them from multiplying in cultured cells. Since the antiviral activity of Cistus extracts differs from all clinically approved drugs, the researchers say Cistus-derived products could be an important complement to currently established drug regimens.
Investigators at the CDC used mice engrafted with human immune cells as a model for Ebola virus infection and disease progression. They demonstrated that mice devoid of their native immune response and reconstituted with a human innate and adaptive immune system are susceptible to infection and die of disease within approximately 2 weeks after inoculation with wild-type Ebola virus. Mice appear to offer a unique model for investigating the human immune response in EVD and an alternative animal model for EVD pathogenesis studies and therapeutic screening.
A study published in Scientific Reports shows the ability of a vaccine vector, based on a common herpesvirus called cytomegalovirus expressing Ebola virus glycoprotein, to provide protection against Ebola virus in the experimental rhesus macaque, non-human primate model. Investigators say the study is a step forward for the development of conventional Ebola virus vaccines for use in humans.
Researchers at the Yale School of Public Health developed computational models for disease transmission and infection progression to estimate the repercussions of the 2014-2015 West African Ebola outbreak on populations already at risk for malaria, HIV/AIDS, and tuberculosis. They estimated that a 50% reduction in access to healthcare services during the Ebola outbreak exacerbated malaria, HIV/AIDS, and tuberculosis mortality rates by additional death counts of 6,269 in Guinea; 1,535 in Liberia; and 2,819 in Sierra Leone.
A broad panel of neutralizing, anti–Ebola virus antibodies have been isolated from a survivor of the recent Zaire outbreak. Investigators said 77% of the monoclonal antibodies (mAbs) neutralize live EBOV, and several mAbs exhibit unprecedented potency. They said the results provide a framework for the design of new EBOV vaccine candidates and immunotherapies.
The Ebola epidemic in West Africa provides valuable lessons for how to respond to infectious disease epidemics generally, according to an analysis in Science. The report says rebuilding local health care infrastructures, improving capacity to respond more quickly to outbreaks, and considering multiple perspectives across disciplines during decision-making processes are the key areas for action.
A multicenter non-randomized trial of Ebola virus patients in Guinea found that favipiravir monotherapy, along with standardized care, merits further study in patients with medium to high viremia, but not in those with very high viremia. The results also confirm that viral load is a strong predictor of mortality.
According to a report in the Journal of Infectious Diseases, the support from the World Health Organization’s polio program infrastructure, particularly the coordination mechanism adopted, the availability of skilled personnel in the polio program, and lessons learned from managing the polio eradication program greatly contributed to the speedy containment of the 2014 Ebola virus disease outbreak in Nigeria.
On Twitter @richpizzi
EHR Report: How Zika virus reveals the fault in our EHRs
It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.
Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.
With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?
As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.
In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.
In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …
Change needs to be faster than Zika
Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.
Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.
Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.
On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.
This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.
Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”
We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!
Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …
It is time for smarter EHRs!
For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.
If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.
Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?
It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.
Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.
Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).
Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.
Few products seem to get it just right, and it’s time for this to change.
Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.
Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.
With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?
As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.
In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.
In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …
Change needs to be faster than Zika
Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.
Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.
Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.
On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.
This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.
Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”
We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!
Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …
It is time for smarter EHRs!
For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.
If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.
Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?
It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.
Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.
Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).
Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.
Few products seem to get it just right, and it’s time for this to change.
Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.
Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.
With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?
As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.
In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.
In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …
Change needs to be faster than Zika
Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.
Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.
Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.
On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.
This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.
Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”
We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!
Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …
It is time for smarter EHRs!
For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.
If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.
Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?
It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.
Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.
Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).
Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.
Few products seem to get it just right, and it’s time for this to change.
Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Brazilian study identifies fetal abnormalities linked to Zika virus
Fetal abnormalities were detected among more than a quarter of pregnant women who underwent ultrasound examinations after testing positive for Zika virus infection.
The small study, which included 88 pregnant women enrolled from September 2015 through February 2016 in Rio de Janeiro, was published online March 4 in the New England Journal of Medicine (doi: 10.1056/NEJMoa1602412).
“Our findings provide further support for a link between maternal ZIKV infection and fetal and placental abnormalities that is not unlike that of other viruses that are known to cause congenital infections characterized by intrauterine growth restriction and placental insufficiency,” investigators from Brazil and California reported.
The women in the study had developed a rash within the previous 5 days and were tested for Zika virus infection using reverse transcriptase polymerase chain reaction (RT-PCR) assays. Of the 88 women tested, 72 (82%) tested positive for Zika virus in blood, urine, or both.
Acute Zika infection was found throughout the course of pregnancy, though more than half of the women presented with acute infection during the second trimester. Along with a macular or maculopapular rash with pruritus, other distinctive clinical features of Zika virus infection included conjunctival injection, lymphadenopathy, and an absence of respiratory symptoms.
Two women who were positive for Zika virus had miscarriages during the first trimester. The investigators performed ultrasound for 42 of the remaining 70 women who had tested positive for Zika virus, as well as all women who tested negative for the virus. The other women who tested positive for Zika virus declined the imaging studies.
Fetal abnormalities were detected in 12 (29%) of the 42 women who were Zika virus positive and none of the women who had tested negative.
Among the 12 fetuses with abnormalities, there were two fetal deaths noted on ultrasound after 30 weeks of gestation. There were five fetuses with in utero growth restriction with or without microcephaly on ultrasound. Four fetuses had cerebral calcifications, and other central nervous system alterations were noted in two fetuses. Ultrasound detected abnormal arterial flow in the cerebral or umbilical arteries in four fetuses. Also, oligohydramnios and anhydramnios were seen in two fetuses.
At the time of this report, there had been six live births and two stillbirths among the study cohort and the ultrasound findings had been confirmed. The study was not supported by any research funds. The investigators reported having no financial disclosures.
On Twitter @maryellenny
Fetal abnormalities were detected among more than a quarter of pregnant women who underwent ultrasound examinations after testing positive for Zika virus infection.
The small study, which included 88 pregnant women enrolled from September 2015 through February 2016 in Rio de Janeiro, was published online March 4 in the New England Journal of Medicine (doi: 10.1056/NEJMoa1602412).
“Our findings provide further support for a link between maternal ZIKV infection and fetal and placental abnormalities that is not unlike that of other viruses that are known to cause congenital infections characterized by intrauterine growth restriction and placental insufficiency,” investigators from Brazil and California reported.
The women in the study had developed a rash within the previous 5 days and were tested for Zika virus infection using reverse transcriptase polymerase chain reaction (RT-PCR) assays. Of the 88 women tested, 72 (82%) tested positive for Zika virus in blood, urine, or both.
Acute Zika infection was found throughout the course of pregnancy, though more than half of the women presented with acute infection during the second trimester. Along with a macular or maculopapular rash with pruritus, other distinctive clinical features of Zika virus infection included conjunctival injection, lymphadenopathy, and an absence of respiratory symptoms.
Two women who were positive for Zika virus had miscarriages during the first trimester. The investigators performed ultrasound for 42 of the remaining 70 women who had tested positive for Zika virus, as well as all women who tested negative for the virus. The other women who tested positive for Zika virus declined the imaging studies.
Fetal abnormalities were detected in 12 (29%) of the 42 women who were Zika virus positive and none of the women who had tested negative.
Among the 12 fetuses with abnormalities, there were two fetal deaths noted on ultrasound after 30 weeks of gestation. There were five fetuses with in utero growth restriction with or without microcephaly on ultrasound. Four fetuses had cerebral calcifications, and other central nervous system alterations were noted in two fetuses. Ultrasound detected abnormal arterial flow in the cerebral or umbilical arteries in four fetuses. Also, oligohydramnios and anhydramnios were seen in two fetuses.
At the time of this report, there had been six live births and two stillbirths among the study cohort and the ultrasound findings had been confirmed. The study was not supported by any research funds. The investigators reported having no financial disclosures.
On Twitter @maryellenny
Fetal abnormalities were detected among more than a quarter of pregnant women who underwent ultrasound examinations after testing positive for Zika virus infection.
The small study, which included 88 pregnant women enrolled from September 2015 through February 2016 in Rio de Janeiro, was published online March 4 in the New England Journal of Medicine (doi: 10.1056/NEJMoa1602412).
“Our findings provide further support for a link between maternal ZIKV infection and fetal and placental abnormalities that is not unlike that of other viruses that are known to cause congenital infections characterized by intrauterine growth restriction and placental insufficiency,” investigators from Brazil and California reported.
The women in the study had developed a rash within the previous 5 days and were tested for Zika virus infection using reverse transcriptase polymerase chain reaction (RT-PCR) assays. Of the 88 women tested, 72 (82%) tested positive for Zika virus in blood, urine, or both.
Acute Zika infection was found throughout the course of pregnancy, though more than half of the women presented with acute infection during the second trimester. Along with a macular or maculopapular rash with pruritus, other distinctive clinical features of Zika virus infection included conjunctival injection, lymphadenopathy, and an absence of respiratory symptoms.
Two women who were positive for Zika virus had miscarriages during the first trimester. The investigators performed ultrasound for 42 of the remaining 70 women who had tested positive for Zika virus, as well as all women who tested negative for the virus. The other women who tested positive for Zika virus declined the imaging studies.
Fetal abnormalities were detected in 12 (29%) of the 42 women who were Zika virus positive and none of the women who had tested negative.
Among the 12 fetuses with abnormalities, there were two fetal deaths noted on ultrasound after 30 weeks of gestation. There were five fetuses with in utero growth restriction with or without microcephaly on ultrasound. Four fetuses had cerebral calcifications, and other central nervous system alterations were noted in two fetuses. Ultrasound detected abnormal arterial flow in the cerebral or umbilical arteries in four fetuses. Also, oligohydramnios and anhydramnios were seen in two fetuses.
At the time of this report, there had been six live births and two stillbirths among the study cohort and the ultrasound findings had been confirmed. The study was not supported by any research funds. The investigators reported having no financial disclosures.
On Twitter @maryellenny
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: Zika virus infection in pregnancy appears to be associated with in utero growth restriction, central nervous system lesions, and fetal death.
Major finding: Fetal abnormalities were detected by ultrasound in 12 of 42 pregnant women who tested positive for Zika virus infection.
Data source: A prospective study of 88 pregnant women with a rash from September 2015 through February 2016 in Rio de Janeiro.
Disclosures: The study was not supported by any research funds. The investigators reported having no financial disclosures.
WHO guidance for caring for pregnant women in Zika virus areas
The World Health Organization has released guidance for physicians and other healthcare providers on how to care for pregnant women in areas where Zika virus transmission is ongoing.
“The guidance is intended to inform the development of national and local clinical protocols and health policies that relate to pregnancy care in the context of Zika virus transmission,” according to the document, released on March 2.
The WHO does not recommend testing all pregnant women in Zika endemic areas, but suggests that physicians consider offering a first-trimester ultrasound scan to all women presenting for antenatal care to accurately date the pregnancy and perform a basic fetal morphology assessment. Women should also be counseled to present early for treatment and diagnostic work-up if they develop any signs or symptoms of Zika virus infection, including conjunctivitis, joint pain, headache, muscle pain, and fatigue.
Pregnant women who have signs of infection or a history of Zika virus disease should be tested. The following steps can be taken to diagnose the disease:
• Using reverse transcription polymerase chain reaction in maternal serum within 5 days of onset of symptoms.
• Urine analysis within 3 weeks after the onset of symptoms.
• Saliva analysis.
• Serological tests with immunoglobulin M antibodies from the fifth day following onset of symptoms.
The WHO also recommends routinely performing investigations to exclude syphilis, toxoplasmosis, cytomegalovirus, rubella, and herpes.
Later in the pregnancy, all women should be offered an 18-20 week anomaly scan to identify, monitor, or exclude fetal brain abnormalities.
Any pregnant women with possible Zika virus and fetal microcephaly and/or brain abnormalities should be referred for specialized care.
The WHO’s recommendations were produced under the agency’s emergency procedures and will remain valid until August, at which time the Department of Reproductive Health and Research at WHO Geneva will renew or update them as appropriate.
The complete guidance is available here.
The World Health Organization has released guidance for physicians and other healthcare providers on how to care for pregnant women in areas where Zika virus transmission is ongoing.
“The guidance is intended to inform the development of national and local clinical protocols and health policies that relate to pregnancy care in the context of Zika virus transmission,” according to the document, released on March 2.
The WHO does not recommend testing all pregnant women in Zika endemic areas, but suggests that physicians consider offering a first-trimester ultrasound scan to all women presenting for antenatal care to accurately date the pregnancy and perform a basic fetal morphology assessment. Women should also be counseled to present early for treatment and diagnostic work-up if they develop any signs or symptoms of Zika virus infection, including conjunctivitis, joint pain, headache, muscle pain, and fatigue.
Pregnant women who have signs of infection or a history of Zika virus disease should be tested. The following steps can be taken to diagnose the disease:
• Using reverse transcription polymerase chain reaction in maternal serum within 5 days of onset of symptoms.
• Urine analysis within 3 weeks after the onset of symptoms.
• Saliva analysis.
• Serological tests with immunoglobulin M antibodies from the fifth day following onset of symptoms.
The WHO also recommends routinely performing investigations to exclude syphilis, toxoplasmosis, cytomegalovirus, rubella, and herpes.
Later in the pregnancy, all women should be offered an 18-20 week anomaly scan to identify, monitor, or exclude fetal brain abnormalities.
Any pregnant women with possible Zika virus and fetal microcephaly and/or brain abnormalities should be referred for specialized care.
The WHO’s recommendations were produced under the agency’s emergency procedures and will remain valid until August, at which time the Department of Reproductive Health and Research at WHO Geneva will renew or update them as appropriate.
The complete guidance is available here.
The World Health Organization has released guidance for physicians and other healthcare providers on how to care for pregnant women in areas where Zika virus transmission is ongoing.
“The guidance is intended to inform the development of national and local clinical protocols and health policies that relate to pregnancy care in the context of Zika virus transmission,” according to the document, released on March 2.
The WHO does not recommend testing all pregnant women in Zika endemic areas, but suggests that physicians consider offering a first-trimester ultrasound scan to all women presenting for antenatal care to accurately date the pregnancy and perform a basic fetal morphology assessment. Women should also be counseled to present early for treatment and diagnostic work-up if they develop any signs or symptoms of Zika virus infection, including conjunctivitis, joint pain, headache, muscle pain, and fatigue.
Pregnant women who have signs of infection or a history of Zika virus disease should be tested. The following steps can be taken to diagnose the disease:
• Using reverse transcription polymerase chain reaction in maternal serum within 5 days of onset of symptoms.
• Urine analysis within 3 weeks after the onset of symptoms.
• Saliva analysis.
• Serological tests with immunoglobulin M antibodies from the fifth day following onset of symptoms.
The WHO also recommends routinely performing investigations to exclude syphilis, toxoplasmosis, cytomegalovirus, rubella, and herpes.
Later in the pregnancy, all women should be offered an 18-20 week anomaly scan to identify, monitor, or exclude fetal brain abnormalities.
Any pregnant women with possible Zika virus and fetal microcephaly and/or brain abnormalities should be referred for specialized care.
The WHO’s recommendations were produced under the agency’s emergency procedures and will remain valid until August, at which time the Department of Reproductive Health and Research at WHO Geneva will renew or update them as appropriate.
The complete guidance is available here.
WHO: Zika epidemic requires ‘research-guided’ public health interventions
The link between Zika virus infections in pregnant women and microcephaly in neonates is strong, and there is good if somewhat less robust evidence for the virus causing severe neurological sequelae, especially Guillain-Barré syndrome, world health experts say.
Zika virus outbreaks have been reported in 31 countries and territories in the Americas, totaling more than 135,000 reported cases, and about 3,000 laboratory-confirmed cases, Dr. Marcos Espinal, director of the department of communicable diseases and health analysis at the Pan American Health Organization/World Health Organization, said at a joint PAHO/WHO meeting announcing key findings from an international meeting on the global challenge from Zika virus.
“The reports of these cases do not reflect the real situation, as in 80% of the cases globally there have been no signs and symptoms of Zika disease,” Dr. Espinal said.
Although the epidemic has garnered worldwide attention, there are many more unknowns than knowns about Zika virus and its sequelae, and recent findings from the outbreak are of particular concern, noted Dr. Lyle Petersen of the Centers for Disease Control and Prevention in Atlanta.
“It’s the first vector-borne disease we’ve seen that’s caused infections in fetuses and abnormal birth outcomes, and it’s also the first vector-borne disease that is also readily spread via sexual means,” he said.
To date, cases of microcephaly in the fetuses of Zika-infected women have been reported only in Brazil and in French Polynesia. As of Feb. 23, 2016, 5,640 cases of microcephaly had been reported in Brazil. In French Polynesia, as reported in The Lancet, following an epidemic of Zika from September 2013 through March 2014 affecting an estimated 28,000 individuals (about 11.5% of the population), clinicians noted an increase in cerebral congenital abnormalities, including microcephaly, ventriculomegaly, severe abnormalities of midline structures and the cerebellum, and abnormal gyration.
In addition, an increase in the incidence of Guillain-Barré syndrome cases coinciding with Zika virus outbreaks has been reported in Brazil, Colombia, El Salvador, Suriname, and Venezuela.
Resistant mosquitoes
Dr. Paulo Buss, director of the Global Health Center at the Oswaldo Cruz Foundation in Brazil, acknowledged that his country was the epicenter of the current epidemic, but noted that Brazil’s surveillance system was quick to identify the onset of the epidemic and make connections between Zika infection and its affect on congenital malformations and neurological disease. He pointed out that the epidemic is taking an especially hard toll on Brazilians with low incomes, who often live in overcrowded, unsanitary conditions, with no running water and no window screens to protect against mosquitoes.
One of the greatest challenges to public health authorities is the hardiness and adaptability of the vector, the Aedes aegypti and Aedes albopictus mosquitoes that are also prime vectors for dengue, chikungunya, and yellow fever infections, Dr. Buss said.
That point was reinforced in a recent report in The Lancet by Brazilian researchers who said that although their government has recently intensified efforts to eliminate Aedes aegypti using insecticides to kill adult mosquitoes and larvicides to eradicate breeding pools, “the results have been very disappointing.”
Despite mosquito eradication efforts, there has been an increase in the incidence of registered dengue cases in Brazil, with 1.6 million cases and 863 deaths reported in 2015. In addition, growing resistance by the vector to pesticides has forced health authorities to try a succession of different agents, further increasing the likelihood of resistance.
Areas of need
World health authorities broadly agreed, Dr. Espinal said, on the need for improved laboratory detection of infections, particularly a rapid and accurate test for pregnant women. Research questions must focus on both clinical research into prevention and treatment of infection, but also public health issues such as more effective vector control.
“This is a unique situation,” said the CDC’s Dr. Petersen. “I’ve been studying vector-borne diseases spread by mosquitoes for more than 20 years, and I’ve never seen anything like this.”
The situation calls for a research-guided response, he said, with collaboration and support from government and nongovernment organizations, WHO, PAHO, and academic institutions. The response must also be very rapid, as thousands of new infections are occurring in the Americas daily, he added.
“I think this outbreak reminds us that we all must be prepared. Over the last decade, we have let our responsibilities for vector-borne disease deteriorate. Mosquito control programs have gone away, and we’ve not developed any new pesticides in 50 years,” Petersen said. “This is a very good reminder that new things happen, and unexpected things happen, and we must be prepared.”
He said that there is a special need for prevention efforts aimed at pregnant women, including means of protecting them from mosquito bites with the use of insect repellents, window screens, and bed nets, and also the use of condoms to protect them from the possibility of infection from sex with an infected partner.
The link between Zika virus infections in pregnant women and microcephaly in neonates is strong, and there is good if somewhat less robust evidence for the virus causing severe neurological sequelae, especially Guillain-Barré syndrome, world health experts say.
Zika virus outbreaks have been reported in 31 countries and territories in the Americas, totaling more than 135,000 reported cases, and about 3,000 laboratory-confirmed cases, Dr. Marcos Espinal, director of the department of communicable diseases and health analysis at the Pan American Health Organization/World Health Organization, said at a joint PAHO/WHO meeting announcing key findings from an international meeting on the global challenge from Zika virus.
“The reports of these cases do not reflect the real situation, as in 80% of the cases globally there have been no signs and symptoms of Zika disease,” Dr. Espinal said.
Although the epidemic has garnered worldwide attention, there are many more unknowns than knowns about Zika virus and its sequelae, and recent findings from the outbreak are of particular concern, noted Dr. Lyle Petersen of the Centers for Disease Control and Prevention in Atlanta.
“It’s the first vector-borne disease we’ve seen that’s caused infections in fetuses and abnormal birth outcomes, and it’s also the first vector-borne disease that is also readily spread via sexual means,” he said.
To date, cases of microcephaly in the fetuses of Zika-infected women have been reported only in Brazil and in French Polynesia. As of Feb. 23, 2016, 5,640 cases of microcephaly had been reported in Brazil. In French Polynesia, as reported in The Lancet, following an epidemic of Zika from September 2013 through March 2014 affecting an estimated 28,000 individuals (about 11.5% of the population), clinicians noted an increase in cerebral congenital abnormalities, including microcephaly, ventriculomegaly, severe abnormalities of midline structures and the cerebellum, and abnormal gyration.
In addition, an increase in the incidence of Guillain-Barré syndrome cases coinciding with Zika virus outbreaks has been reported in Brazil, Colombia, El Salvador, Suriname, and Venezuela.
Resistant mosquitoes
Dr. Paulo Buss, director of the Global Health Center at the Oswaldo Cruz Foundation in Brazil, acknowledged that his country was the epicenter of the current epidemic, but noted that Brazil’s surveillance system was quick to identify the onset of the epidemic and make connections between Zika infection and its affect on congenital malformations and neurological disease. He pointed out that the epidemic is taking an especially hard toll on Brazilians with low incomes, who often live in overcrowded, unsanitary conditions, with no running water and no window screens to protect against mosquitoes.
One of the greatest challenges to public health authorities is the hardiness and adaptability of the vector, the Aedes aegypti and Aedes albopictus mosquitoes that are also prime vectors for dengue, chikungunya, and yellow fever infections, Dr. Buss said.
That point was reinforced in a recent report in The Lancet by Brazilian researchers who said that although their government has recently intensified efforts to eliminate Aedes aegypti using insecticides to kill adult mosquitoes and larvicides to eradicate breeding pools, “the results have been very disappointing.”
Despite mosquito eradication efforts, there has been an increase in the incidence of registered dengue cases in Brazil, with 1.6 million cases and 863 deaths reported in 2015. In addition, growing resistance by the vector to pesticides has forced health authorities to try a succession of different agents, further increasing the likelihood of resistance.
Areas of need
World health authorities broadly agreed, Dr. Espinal said, on the need for improved laboratory detection of infections, particularly a rapid and accurate test for pregnant women. Research questions must focus on both clinical research into prevention and treatment of infection, but also public health issues such as more effective vector control.
“This is a unique situation,” said the CDC’s Dr. Petersen. “I’ve been studying vector-borne diseases spread by mosquitoes for more than 20 years, and I’ve never seen anything like this.”
The situation calls for a research-guided response, he said, with collaboration and support from government and nongovernment organizations, WHO, PAHO, and academic institutions. The response must also be very rapid, as thousands of new infections are occurring in the Americas daily, he added.
“I think this outbreak reminds us that we all must be prepared. Over the last decade, we have let our responsibilities for vector-borne disease deteriorate. Mosquito control programs have gone away, and we’ve not developed any new pesticides in 50 years,” Petersen said. “This is a very good reminder that new things happen, and unexpected things happen, and we must be prepared.”
He said that there is a special need for prevention efforts aimed at pregnant women, including means of protecting them from mosquito bites with the use of insect repellents, window screens, and bed nets, and also the use of condoms to protect them from the possibility of infection from sex with an infected partner.
The link between Zika virus infections in pregnant women and microcephaly in neonates is strong, and there is good if somewhat less robust evidence for the virus causing severe neurological sequelae, especially Guillain-Barré syndrome, world health experts say.
Zika virus outbreaks have been reported in 31 countries and territories in the Americas, totaling more than 135,000 reported cases, and about 3,000 laboratory-confirmed cases, Dr. Marcos Espinal, director of the department of communicable diseases and health analysis at the Pan American Health Organization/World Health Organization, said at a joint PAHO/WHO meeting announcing key findings from an international meeting on the global challenge from Zika virus.
“The reports of these cases do not reflect the real situation, as in 80% of the cases globally there have been no signs and symptoms of Zika disease,” Dr. Espinal said.
Although the epidemic has garnered worldwide attention, there are many more unknowns than knowns about Zika virus and its sequelae, and recent findings from the outbreak are of particular concern, noted Dr. Lyle Petersen of the Centers for Disease Control and Prevention in Atlanta.
“It’s the first vector-borne disease we’ve seen that’s caused infections in fetuses and abnormal birth outcomes, and it’s also the first vector-borne disease that is also readily spread via sexual means,” he said.
To date, cases of microcephaly in the fetuses of Zika-infected women have been reported only in Brazil and in French Polynesia. As of Feb. 23, 2016, 5,640 cases of microcephaly had been reported in Brazil. In French Polynesia, as reported in The Lancet, following an epidemic of Zika from September 2013 through March 2014 affecting an estimated 28,000 individuals (about 11.5% of the population), clinicians noted an increase in cerebral congenital abnormalities, including microcephaly, ventriculomegaly, severe abnormalities of midline structures and the cerebellum, and abnormal gyration.
In addition, an increase in the incidence of Guillain-Barré syndrome cases coinciding with Zika virus outbreaks has been reported in Brazil, Colombia, El Salvador, Suriname, and Venezuela.
Resistant mosquitoes
Dr. Paulo Buss, director of the Global Health Center at the Oswaldo Cruz Foundation in Brazil, acknowledged that his country was the epicenter of the current epidemic, but noted that Brazil’s surveillance system was quick to identify the onset of the epidemic and make connections between Zika infection and its affect on congenital malformations and neurological disease. He pointed out that the epidemic is taking an especially hard toll on Brazilians with low incomes, who often live in overcrowded, unsanitary conditions, with no running water and no window screens to protect against mosquitoes.
One of the greatest challenges to public health authorities is the hardiness and adaptability of the vector, the Aedes aegypti and Aedes albopictus mosquitoes that are also prime vectors for dengue, chikungunya, and yellow fever infections, Dr. Buss said.
That point was reinforced in a recent report in The Lancet by Brazilian researchers who said that although their government has recently intensified efforts to eliminate Aedes aegypti using insecticides to kill adult mosquitoes and larvicides to eradicate breeding pools, “the results have been very disappointing.”
Despite mosquito eradication efforts, there has been an increase in the incidence of registered dengue cases in Brazil, with 1.6 million cases and 863 deaths reported in 2015. In addition, growing resistance by the vector to pesticides has forced health authorities to try a succession of different agents, further increasing the likelihood of resistance.
Areas of need
World health authorities broadly agreed, Dr. Espinal said, on the need for improved laboratory detection of infections, particularly a rapid and accurate test for pregnant women. Research questions must focus on both clinical research into prevention and treatment of infection, but also public health issues such as more effective vector control.
“This is a unique situation,” said the CDC’s Dr. Petersen. “I’ve been studying vector-borne diseases spread by mosquitoes for more than 20 years, and I’ve never seen anything like this.”
The situation calls for a research-guided response, he said, with collaboration and support from government and nongovernment organizations, WHO, PAHO, and academic institutions. The response must also be very rapid, as thousands of new infections are occurring in the Americas daily, he added.
“I think this outbreak reminds us that we all must be prepared. Over the last decade, we have let our responsibilities for vector-borne disease deteriorate. Mosquito control programs have gone away, and we’ve not developed any new pesticides in 50 years,” Petersen said. “This is a very good reminder that new things happen, and unexpected things happen, and we must be prepared.”
He said that there is a special need for prevention efforts aimed at pregnant women, including means of protecting them from mosquito bites with the use of insect repellents, window screens, and bed nets, and also the use of condoms to protect them from the possibility of infection from sex with an infected partner.
FROM A JOINT PAHO/WHO MEETING
Ebola continues to impact survivors as epidemic wanes
Ebola virus disease (EVD) survivors often complained of headache, musculoskeletal pain, and ocular symptoms during the weeks after they tested negative for the virus, according to an analysis of patients cared for at an Ebola treatment unit in Freetown, Sierra Leone.
The study participants included 44 EVD patients who were discharged from the treatment unit during December 2014 to March 2015 after testing negative for Ebola virus on separate days, in two consecutive negative polymerase chain reaction assessments. All 44 patients had attended at least two follow-up appointments at the treatment unit within 2 weeks of discharge, when the researchers conducted their analysis.
All survivors made at least one complaint about their health after discharge, with the median number of health issues and maximum number of health issues reported having been two and five, respectively. Of the 117 complaints reported by the patients, 31 were for musculoskeletal pain, 21 were for headaches, and 6 were for ocular problems, including eye pain, clear discharge, red eyes, and blurred vision.
While there were no significant differences in viral load at admission to the Ebola treatment unit between those patients who had ocular problems or musculoskeletal pain and those who did not, patients who reported headache had a significantly higher viral load at admission than those who did not report a headache.
Of the 44 EVD patients who had been discharged from the unit, one had died as of March 8, 2015. That patient’s death occurred 1 month after his recovery from acute EVD and was preceded by deteriorating respiratory symptoms and left-sided pleural effusion.
Dr. Janet T. Scott, a clinical lecturer in pharmacology and infectious disease at the Institute of Translational Medicine at the University of Liverpool (England), and her colleagues recommended future studies of Ebola survivors follow patients for a longer period of time than the first 2 weeks after discharge from an Ebola treatment center.
“Because some complications occur weeks or months after acute onset of EVD, some symptoms might be underestimated in this cohort,” the researchers said.
Read the study in Emerging Infectious Diseases (doi: 10.3201/eid2204.151302).
Ebola virus disease (EVD) survivors often complained of headache, musculoskeletal pain, and ocular symptoms during the weeks after they tested negative for the virus, according to an analysis of patients cared for at an Ebola treatment unit in Freetown, Sierra Leone.
The study participants included 44 EVD patients who were discharged from the treatment unit during December 2014 to March 2015 after testing negative for Ebola virus on separate days, in two consecutive negative polymerase chain reaction assessments. All 44 patients had attended at least two follow-up appointments at the treatment unit within 2 weeks of discharge, when the researchers conducted their analysis.
All survivors made at least one complaint about their health after discharge, with the median number of health issues and maximum number of health issues reported having been two and five, respectively. Of the 117 complaints reported by the patients, 31 were for musculoskeletal pain, 21 were for headaches, and 6 were for ocular problems, including eye pain, clear discharge, red eyes, and blurred vision.
While there were no significant differences in viral load at admission to the Ebola treatment unit between those patients who had ocular problems or musculoskeletal pain and those who did not, patients who reported headache had a significantly higher viral load at admission than those who did not report a headache.
Of the 44 EVD patients who had been discharged from the unit, one had died as of March 8, 2015. That patient’s death occurred 1 month after his recovery from acute EVD and was preceded by deteriorating respiratory symptoms and left-sided pleural effusion.
Dr. Janet T. Scott, a clinical lecturer in pharmacology and infectious disease at the Institute of Translational Medicine at the University of Liverpool (England), and her colleagues recommended future studies of Ebola survivors follow patients for a longer period of time than the first 2 weeks after discharge from an Ebola treatment center.
“Because some complications occur weeks or months after acute onset of EVD, some symptoms might be underestimated in this cohort,” the researchers said.
Read the study in Emerging Infectious Diseases (doi: 10.3201/eid2204.151302).
Ebola virus disease (EVD) survivors often complained of headache, musculoskeletal pain, and ocular symptoms during the weeks after they tested negative for the virus, according to an analysis of patients cared for at an Ebola treatment unit in Freetown, Sierra Leone.
The study participants included 44 EVD patients who were discharged from the treatment unit during December 2014 to March 2015 after testing negative for Ebola virus on separate days, in two consecutive negative polymerase chain reaction assessments. All 44 patients had attended at least two follow-up appointments at the treatment unit within 2 weeks of discharge, when the researchers conducted their analysis.
All survivors made at least one complaint about their health after discharge, with the median number of health issues and maximum number of health issues reported having been two and five, respectively. Of the 117 complaints reported by the patients, 31 were for musculoskeletal pain, 21 were for headaches, and 6 were for ocular problems, including eye pain, clear discharge, red eyes, and blurred vision.
While there were no significant differences in viral load at admission to the Ebola treatment unit between those patients who had ocular problems or musculoskeletal pain and those who did not, patients who reported headache had a significantly higher viral load at admission than those who did not report a headache.
Of the 44 EVD patients who had been discharged from the unit, one had died as of March 8, 2015. That patient’s death occurred 1 month after his recovery from acute EVD and was preceded by deteriorating respiratory symptoms and left-sided pleural effusion.
Dr. Janet T. Scott, a clinical lecturer in pharmacology and infectious disease at the Institute of Translational Medicine at the University of Liverpool (England), and her colleagues recommended future studies of Ebola survivors follow patients for a longer period of time than the first 2 weeks after discharge from an Ebola treatment center.
“Because some complications occur weeks or months after acute onset of EVD, some symptoms might be underestimated in this cohort,” the researchers said.
Read the study in Emerging Infectious Diseases (doi: 10.3201/eid2204.151302).
FROM EMERGING INFECTIOUS DISEASES
WHO’s psychosocial guidelines for Zika are a useful tool
As the Zika virus spreads across 31 countries in the Americas, bringing with it the threat of microcephaly seen in Brazil, local and international public health experts are scrambling to assess the extent of the threat. Systems for epidemiologic surveillance are emerging, as are guidelines for pregnant women and those of childbearing age.
Amid all of this is the World Health Organization’s recently released guidelines, “Psychosocial Support for Pregnant Women and for Families With Microcephaly and Other Neurological Complications in the Context of Zika Virus” (http://who.int/csr/resources/publications/zika/psychosocial-support/en). These guidelines, an adaptation of previous interventions used in disasters, are a helpful resource for physicians.
The guidelines emphasize eight areas: having accurate information, what information is conveyed, how that information is conveyed, understanding common distress reactions, providing basic support, strengthening social support, teaching stress reduction, and educating mothers about parenting children with microcephaly. Readers familiar with psychological first aid (PFA), used in disaster response to provide basic psychological support, will recognize these elements as distillations of PFA specifically for Zika.
PFA focuses on addressing peoples’ basic physiologic, safety, and social needs as a means of addressing their overall psychological needs. It has been promulgated as a best practice by the National Institute of Mental Health since the Sept. 11, 2001, terrorist attacks.
Another useful aspect of the guidelines is that they are aimed at health professionals in general, rather than mental health professionals in particular. This approach makes sense, because women concerned about potential infection with Zika, of course, are not going to go to a mental health professional to address their anxiety but to an internist, family physician, ob.gyn., or possibly a pediatrician. They are understandably focused on the distressing problem rather than on the distress itself.
Health care professionals now on the frontlines of the Zika public health response may naturally be following many of the principles in the psychosocial guidelines. Nevertheless, they probably would benefit from reviewing them in order to lend some more structure to the psychosocial soundness of their practice. In addition, becoming aware of the guidelines might help those health professionals deal with their own risk for burnout.
In discussing common distress reactions, the guidelines note that severely distressed individuals should be referred for “specialized care,” which means a mental health professional when psychosocial care is discussed in low-resource settings around the world. The overwhelming majority of countries in the Americas where Zika transmission has been reported are low- and middle-income countries, according to the World Bank’s ranking system. As such, they are surely the places where governments are most likely to devote the least amount of their health care budgets to mental health services.
And, even in high-income countries among the list of Zika-affected countries, it is not clear from consulting the World Health Organization’s 2014 Mental Health Atlas that even those countries fund anything more than inpatient psychiatric care (for example, information from Barbados lists only inpatient psychiatric resources). My point? The ranks of mental health professionals in Zika-affected countries who might benefit from the WHO’s Zika guidelines probably are few. Those who are there probably are overwhelmed tending to the preexisting (mostly inpatient) psychiatric needs of their countries.
Fortunately, the WHO’s Mental Health Atlas shows Brazil to be an exception with a comparatively robust outpatient as well as inpatient public mental health system. This is fortuitous given that Brazil for the moment is the center of the surge in microcephaly. Hopefully, the Northeastern region of Brazil, where that surge is highest, has a proportionate share of Brazil’s mental health resources. For mental health professionals there and potentially elsewhere in Zika-affected countries, the guidelines for psychosocial support can prove to be an essential tool.
To the extent that mental health professionals can and should provide support to their Zika-affected communities, these guidelines will help them to “stand down” from a traditional psychiatric model of care to a more normalizing one, where diagnoses and treatment are not the focus of attention. This was certainly the case in the comparable setting of post-Ebola Liberia, where mental health clinicians trained by the Carter Center found PFA central to what they could offer their devastated communities and to gaining unprecedented acceptance from those communities (unpublished observations).
As of this writing, the Zika virus has not spared the continental United States. Florida has been hit the hardest, followed by Texas, according to data from the Centers for Disease Control and Prevention. Those of us looking to help patients deal with the possibility of coming in contact with the Zika virus should remember the WHO psychosocial guidelines. They can help health professionals integrate mental health into their practices, and help mental health professionals transfer their skills and knowledge to their communities.
Dr. Katz is associate clinical professor of psychiatry and medical education, and director of the program in global mental health, at the Icahn School of Medicine at Mount Sinai, New York.
As the Zika virus spreads across 31 countries in the Americas, bringing with it the threat of microcephaly seen in Brazil, local and international public health experts are scrambling to assess the extent of the threat. Systems for epidemiologic surveillance are emerging, as are guidelines for pregnant women and those of childbearing age.
Amid all of this is the World Health Organization’s recently released guidelines, “Psychosocial Support for Pregnant Women and for Families With Microcephaly and Other Neurological Complications in the Context of Zika Virus” (http://who.int/csr/resources/publications/zika/psychosocial-support/en). These guidelines, an adaptation of previous interventions used in disasters, are a helpful resource for physicians.
The guidelines emphasize eight areas: having accurate information, what information is conveyed, how that information is conveyed, understanding common distress reactions, providing basic support, strengthening social support, teaching stress reduction, and educating mothers about parenting children with microcephaly. Readers familiar with psychological first aid (PFA), used in disaster response to provide basic psychological support, will recognize these elements as distillations of PFA specifically for Zika.
PFA focuses on addressing peoples’ basic physiologic, safety, and social needs as a means of addressing their overall psychological needs. It has been promulgated as a best practice by the National Institute of Mental Health since the Sept. 11, 2001, terrorist attacks.
Another useful aspect of the guidelines is that they are aimed at health professionals in general, rather than mental health professionals in particular. This approach makes sense, because women concerned about potential infection with Zika, of course, are not going to go to a mental health professional to address their anxiety but to an internist, family physician, ob.gyn., or possibly a pediatrician. They are understandably focused on the distressing problem rather than on the distress itself.
Health care professionals now on the frontlines of the Zika public health response may naturally be following many of the principles in the psychosocial guidelines. Nevertheless, they probably would benefit from reviewing them in order to lend some more structure to the psychosocial soundness of their practice. In addition, becoming aware of the guidelines might help those health professionals deal with their own risk for burnout.
In discussing common distress reactions, the guidelines note that severely distressed individuals should be referred for “specialized care,” which means a mental health professional when psychosocial care is discussed in low-resource settings around the world. The overwhelming majority of countries in the Americas where Zika transmission has been reported are low- and middle-income countries, according to the World Bank’s ranking system. As such, they are surely the places where governments are most likely to devote the least amount of their health care budgets to mental health services.
And, even in high-income countries among the list of Zika-affected countries, it is not clear from consulting the World Health Organization’s 2014 Mental Health Atlas that even those countries fund anything more than inpatient psychiatric care (for example, information from Barbados lists only inpatient psychiatric resources). My point? The ranks of mental health professionals in Zika-affected countries who might benefit from the WHO’s Zika guidelines probably are few. Those who are there probably are overwhelmed tending to the preexisting (mostly inpatient) psychiatric needs of their countries.
Fortunately, the WHO’s Mental Health Atlas shows Brazil to be an exception with a comparatively robust outpatient as well as inpatient public mental health system. This is fortuitous given that Brazil for the moment is the center of the surge in microcephaly. Hopefully, the Northeastern region of Brazil, where that surge is highest, has a proportionate share of Brazil’s mental health resources. For mental health professionals there and potentially elsewhere in Zika-affected countries, the guidelines for psychosocial support can prove to be an essential tool.
To the extent that mental health professionals can and should provide support to their Zika-affected communities, these guidelines will help them to “stand down” from a traditional psychiatric model of care to a more normalizing one, where diagnoses and treatment are not the focus of attention. This was certainly the case in the comparable setting of post-Ebola Liberia, where mental health clinicians trained by the Carter Center found PFA central to what they could offer their devastated communities and to gaining unprecedented acceptance from those communities (unpublished observations).
As of this writing, the Zika virus has not spared the continental United States. Florida has been hit the hardest, followed by Texas, according to data from the Centers for Disease Control and Prevention. Those of us looking to help patients deal with the possibility of coming in contact with the Zika virus should remember the WHO psychosocial guidelines. They can help health professionals integrate mental health into their practices, and help mental health professionals transfer their skills and knowledge to their communities.
Dr. Katz is associate clinical professor of psychiatry and medical education, and director of the program in global mental health, at the Icahn School of Medicine at Mount Sinai, New York.
As the Zika virus spreads across 31 countries in the Americas, bringing with it the threat of microcephaly seen in Brazil, local and international public health experts are scrambling to assess the extent of the threat. Systems for epidemiologic surveillance are emerging, as are guidelines for pregnant women and those of childbearing age.
Amid all of this is the World Health Organization’s recently released guidelines, “Psychosocial Support for Pregnant Women and for Families With Microcephaly and Other Neurological Complications in the Context of Zika Virus” (http://who.int/csr/resources/publications/zika/psychosocial-support/en). These guidelines, an adaptation of previous interventions used in disasters, are a helpful resource for physicians.
The guidelines emphasize eight areas: having accurate information, what information is conveyed, how that information is conveyed, understanding common distress reactions, providing basic support, strengthening social support, teaching stress reduction, and educating mothers about parenting children with microcephaly. Readers familiar with psychological first aid (PFA), used in disaster response to provide basic psychological support, will recognize these elements as distillations of PFA specifically for Zika.
PFA focuses on addressing peoples’ basic physiologic, safety, and social needs as a means of addressing their overall psychological needs. It has been promulgated as a best practice by the National Institute of Mental Health since the Sept. 11, 2001, terrorist attacks.
Another useful aspect of the guidelines is that they are aimed at health professionals in general, rather than mental health professionals in particular. This approach makes sense, because women concerned about potential infection with Zika, of course, are not going to go to a mental health professional to address their anxiety but to an internist, family physician, ob.gyn., or possibly a pediatrician. They are understandably focused on the distressing problem rather than on the distress itself.
Health care professionals now on the frontlines of the Zika public health response may naturally be following many of the principles in the psychosocial guidelines. Nevertheless, they probably would benefit from reviewing them in order to lend some more structure to the psychosocial soundness of their practice. In addition, becoming aware of the guidelines might help those health professionals deal with their own risk for burnout.
In discussing common distress reactions, the guidelines note that severely distressed individuals should be referred for “specialized care,” which means a mental health professional when psychosocial care is discussed in low-resource settings around the world. The overwhelming majority of countries in the Americas where Zika transmission has been reported are low- and middle-income countries, according to the World Bank’s ranking system. As such, they are surely the places where governments are most likely to devote the least amount of their health care budgets to mental health services.
And, even in high-income countries among the list of Zika-affected countries, it is not clear from consulting the World Health Organization’s 2014 Mental Health Atlas that even those countries fund anything more than inpatient psychiatric care (for example, information from Barbados lists only inpatient psychiatric resources). My point? The ranks of mental health professionals in Zika-affected countries who might benefit from the WHO’s Zika guidelines probably are few. Those who are there probably are overwhelmed tending to the preexisting (mostly inpatient) psychiatric needs of their countries.
Fortunately, the WHO’s Mental Health Atlas shows Brazil to be an exception with a comparatively robust outpatient as well as inpatient public mental health system. This is fortuitous given that Brazil for the moment is the center of the surge in microcephaly. Hopefully, the Northeastern region of Brazil, where that surge is highest, has a proportionate share of Brazil’s mental health resources. For mental health professionals there and potentially elsewhere in Zika-affected countries, the guidelines for psychosocial support can prove to be an essential tool.
To the extent that mental health professionals can and should provide support to their Zika-affected communities, these guidelines will help them to “stand down” from a traditional psychiatric model of care to a more normalizing one, where diagnoses and treatment are not the focus of attention. This was certainly the case in the comparable setting of post-Ebola Liberia, where mental health clinicians trained by the Carter Center found PFA central to what they could offer their devastated communities and to gaining unprecedented acceptance from those communities (unpublished observations).
As of this writing, the Zika virus has not spared the continental United States. Florida has been hit the hardest, followed by Texas, according to data from the Centers for Disease Control and Prevention. Those of us looking to help patients deal with the possibility of coming in contact with the Zika virus should remember the WHO psychosocial guidelines. They can help health professionals integrate mental health into their practices, and help mental health professionals transfer their skills and knowledge to their communities.
Dr. Katz is associate clinical professor of psychiatry and medical education, and director of the program in global mental health, at the Icahn School of Medicine at Mount Sinai, New York.
Zika more complex public health challenge than Ebola
The vector-borne and often asymptomatic nature of Zika virus infection makes it a more complex public health challenge than Ebola, researchers say.
The Zika virus was first isolated from a macaque in Uganda in 1947, and has historically been restricted to Africa and Asia. However since its introduction to Brazil in 2014 or early 2015, possibly via Polynesia, it has spread rapidly and estimates now point to between 440,000 and 1,300,000 cases of Zika virus infection in Brazil during 2015.
In the past, Zika virus infection in adults has presented with non-life-threatening symptoms including mild fever, maculopapular rash, arthralgia, myalgia, headache, retro-orbital pain and vomiting.
Writing in the March 1 online edition of PLoS Neglected Tropical Diseases, researchers say the viral variant currently associated with the outbreak in Brazil is presenting a new and more challenging public health problem.
“What makes this outbreak a high priority global public health concern is the association with incidence of birth defects involving the central nervous system and the apparent increased incidence of Guillain-Barré syndrome,” wrote Dr. Robert W. Malone, from RW Malone MD, and his coauthors (PLoS Negl Trop Dis. 2016 Mar 1. doi: 10.1371/journal.pntd.0004530).
They cited one retrospective study in French Polynesia that suggested there was a ratio of one case of Zika-associated Guillain-Barré syndrome for every 208 suspected cases of Zika virus infection.
The outbreak has also been linked to an unusually high incidence of the otherwise rare microcephaly, with Brazil recording a 20-fold increase in incidence during 2015. The connection with Zika virus is supported by a case study in which large numbers of viral particles were found in the central nervous system tissue of a microcephalic Zika-infected fetus.
Based on estimates of the overall incidence of Zika virus infection, researchers have calculated that Brazilian mothers infected with the virus are 3,700-11,000 times more likely to deliver infants with primary microcephaly, compared with those who are not infected.
There are still some key uncertainties around the transmission of Zika virus, the authors said.
“The degree to which humans, nonhuman primates, or other animals can amplify and transmit the virus to insect vectors is poorly understood,” they wrote. “The typical range and types of insect vectors observed in the past may not be predictive for the virus now circulating in the Americas [and] infectivity of the circulating strain, viremia levels, duration, and risk of occult persistence are not yet understood.”
The virus is transmitted primarily by mosquito vectors such as Aedes aegypti and Aedes albopictus, with primates – including humans – the best documented animal reservoir.
“Recent reports indicate the potential for both human blood-borne and sexual transmission of Zika virus, including prolonged presence of virus in semen,” the authors wrote.
The virus has also been found in the saliva of infected individuals, and viral sequences have been identified in breast milk.Commenting on possible medical countermeasures to combat the spread and impact of the Zika virus, the paper’s authors noted that due to the absence of an existing vaccine and long potential development times for candidate vaccines, other prophylactics and therapeutics need to be explored.
In particular, they called for development and deployment of Zika diagnostics to regional clinical health laboratories, discussions between obstetricians and patients about the risks to ongoing or planned pregnancies, and resources for neurologists dealing with “unprecedented” Guillain-Barré syndrome outbreaks.
“Perhaps the biggest challenge with Zika will be to recognize it for what it is: a new disease which does not fit the epidemiology or response paradigm of Ebola or dengue and which will demand effort, resources, unparalleled collaboration, and above all, open mindedness in formulating responses.”
Two authors declared employment with and equity holdings in RW Malone MD, and two authors declared employment with – and one of these also declared equity holdings in – Nanotherapeutics.
The vector-borne and often asymptomatic nature of Zika virus infection makes it a more complex public health challenge than Ebola, researchers say.
The Zika virus was first isolated from a macaque in Uganda in 1947, and has historically been restricted to Africa and Asia. However since its introduction to Brazil in 2014 or early 2015, possibly via Polynesia, it has spread rapidly and estimates now point to between 440,000 and 1,300,000 cases of Zika virus infection in Brazil during 2015.
In the past, Zika virus infection in adults has presented with non-life-threatening symptoms including mild fever, maculopapular rash, arthralgia, myalgia, headache, retro-orbital pain and vomiting.
Writing in the March 1 online edition of PLoS Neglected Tropical Diseases, researchers say the viral variant currently associated with the outbreak in Brazil is presenting a new and more challenging public health problem.
“What makes this outbreak a high priority global public health concern is the association with incidence of birth defects involving the central nervous system and the apparent increased incidence of Guillain-Barré syndrome,” wrote Dr. Robert W. Malone, from RW Malone MD, and his coauthors (PLoS Negl Trop Dis. 2016 Mar 1. doi: 10.1371/journal.pntd.0004530).
They cited one retrospective study in French Polynesia that suggested there was a ratio of one case of Zika-associated Guillain-Barré syndrome for every 208 suspected cases of Zika virus infection.
The outbreak has also been linked to an unusually high incidence of the otherwise rare microcephaly, with Brazil recording a 20-fold increase in incidence during 2015. The connection with Zika virus is supported by a case study in which large numbers of viral particles were found in the central nervous system tissue of a microcephalic Zika-infected fetus.
Based on estimates of the overall incidence of Zika virus infection, researchers have calculated that Brazilian mothers infected with the virus are 3,700-11,000 times more likely to deliver infants with primary microcephaly, compared with those who are not infected.
There are still some key uncertainties around the transmission of Zika virus, the authors said.
“The degree to which humans, nonhuman primates, or other animals can amplify and transmit the virus to insect vectors is poorly understood,” they wrote. “The typical range and types of insect vectors observed in the past may not be predictive for the virus now circulating in the Americas [and] infectivity of the circulating strain, viremia levels, duration, and risk of occult persistence are not yet understood.”
The virus is transmitted primarily by mosquito vectors such as Aedes aegypti and Aedes albopictus, with primates – including humans – the best documented animal reservoir.
“Recent reports indicate the potential for both human blood-borne and sexual transmission of Zika virus, including prolonged presence of virus in semen,” the authors wrote.
The virus has also been found in the saliva of infected individuals, and viral sequences have been identified in breast milk.Commenting on possible medical countermeasures to combat the spread and impact of the Zika virus, the paper’s authors noted that due to the absence of an existing vaccine and long potential development times for candidate vaccines, other prophylactics and therapeutics need to be explored.
In particular, they called for development and deployment of Zika diagnostics to regional clinical health laboratories, discussions between obstetricians and patients about the risks to ongoing or planned pregnancies, and resources for neurologists dealing with “unprecedented” Guillain-Barré syndrome outbreaks.
“Perhaps the biggest challenge with Zika will be to recognize it for what it is: a new disease which does not fit the epidemiology or response paradigm of Ebola or dengue and which will demand effort, resources, unparalleled collaboration, and above all, open mindedness in formulating responses.”
Two authors declared employment with and equity holdings in RW Malone MD, and two authors declared employment with – and one of these also declared equity holdings in – Nanotherapeutics.
The vector-borne and often asymptomatic nature of Zika virus infection makes it a more complex public health challenge than Ebola, researchers say.
The Zika virus was first isolated from a macaque in Uganda in 1947, and has historically been restricted to Africa and Asia. However since its introduction to Brazil in 2014 or early 2015, possibly via Polynesia, it has spread rapidly and estimates now point to between 440,000 and 1,300,000 cases of Zika virus infection in Brazil during 2015.
In the past, Zika virus infection in adults has presented with non-life-threatening symptoms including mild fever, maculopapular rash, arthralgia, myalgia, headache, retro-orbital pain and vomiting.
Writing in the March 1 online edition of PLoS Neglected Tropical Diseases, researchers say the viral variant currently associated with the outbreak in Brazil is presenting a new and more challenging public health problem.
“What makes this outbreak a high priority global public health concern is the association with incidence of birth defects involving the central nervous system and the apparent increased incidence of Guillain-Barré syndrome,” wrote Dr. Robert W. Malone, from RW Malone MD, and his coauthors (PLoS Negl Trop Dis. 2016 Mar 1. doi: 10.1371/journal.pntd.0004530).
They cited one retrospective study in French Polynesia that suggested there was a ratio of one case of Zika-associated Guillain-Barré syndrome for every 208 suspected cases of Zika virus infection.
The outbreak has also been linked to an unusually high incidence of the otherwise rare microcephaly, with Brazil recording a 20-fold increase in incidence during 2015. The connection with Zika virus is supported by a case study in which large numbers of viral particles were found in the central nervous system tissue of a microcephalic Zika-infected fetus.
Based on estimates of the overall incidence of Zika virus infection, researchers have calculated that Brazilian mothers infected with the virus are 3,700-11,000 times more likely to deliver infants with primary microcephaly, compared with those who are not infected.
There are still some key uncertainties around the transmission of Zika virus, the authors said.
“The degree to which humans, nonhuman primates, or other animals can amplify and transmit the virus to insect vectors is poorly understood,” they wrote. “The typical range and types of insect vectors observed in the past may not be predictive for the virus now circulating in the Americas [and] infectivity of the circulating strain, viremia levels, duration, and risk of occult persistence are not yet understood.”
The virus is transmitted primarily by mosquito vectors such as Aedes aegypti and Aedes albopictus, with primates – including humans – the best documented animal reservoir.
“Recent reports indicate the potential for both human blood-borne and sexual transmission of Zika virus, including prolonged presence of virus in semen,” the authors wrote.
The virus has also been found in the saliva of infected individuals, and viral sequences have been identified in breast milk.Commenting on possible medical countermeasures to combat the spread and impact of the Zika virus, the paper’s authors noted that due to the absence of an existing vaccine and long potential development times for candidate vaccines, other prophylactics and therapeutics need to be explored.
In particular, they called for development and deployment of Zika diagnostics to regional clinical health laboratories, discussions between obstetricians and patients about the risks to ongoing or planned pregnancies, and resources for neurologists dealing with “unprecedented” Guillain-Barré syndrome outbreaks.
“Perhaps the biggest challenge with Zika will be to recognize it for what it is: a new disease which does not fit the epidemiology or response paradigm of Ebola or dengue and which will demand effort, resources, unparalleled collaboration, and above all, open mindedness in formulating responses.”
Two authors declared employment with and equity holdings in RW Malone MD, and two authors declared employment with – and one of these also declared equity holdings in – Nanotherapeutics.
FROM PLOS NEGLECTED TROPICAL DISEASES
Stronger evidence links Zika to Guillain-Barré syndrome
Serological evidence from French Polynesia links an outbreak of Zika virus to a spike in cases of Guillain-Barré syndrome seen there in 2013-2014.
The research, published online Feb. 29 in The Lancet, is the first to use a case-control design to demonstrate that Zika, a mosquito-borne flavivirus, is associated with Guillain-Barré syndrome (Lancet. 2016 Feb 29. doi: 10.1016/S0140-6736(16)00562-6).
Guillain-Barré syndrome (GBS) is an immune-mediated flaccid paralysis that can follow viral or bacterial infections. Most patients with GBS recover with intensive care in hospitals, although the syndrome can be permanently debilitating or, in rare cases, fatal.
As a large outbreak of Zika continues in Central and South America, hospitals should be prepared for excess GBS cases, the authors of the study say, and assure adequate intensive-care capacity to treat them. Based on the 66% attack rate of Zika during the French Polynesia outbreak, investigators estimated the incidence of GBS at 0.24 per 1,000 Zika infections, but noted that it could be different in the current outbreak.
Dr. Van-Mai Cao-Lormeau of the Unit of Emerging Infectious Diseases at Institut Louis Malardé in Papeete, French Polynesia, alongside colleagues in France and French Polynesia, used a case-control design to compare serological samples from 42 patients (74% male) diagnosed at a Tahiti hospital with GBS with samples from age-and sex-matched patients who presented at the same hospital, also during the time of the outbreak, with a nonfebrile illness (n = 98) or with acute Zika disease without neurological symptoms (n = 70).
The investigators found that all but one patient with GBS had Zika virus antibodies, and all of them had neutralizing antibodies to Zika virus. By comparison, only 56% (n = 54) of the control group admitted with nonfebrile illness had neutralizing antibodies (P less than .0001).
Also, 93% of the GBS patients had Zika virus immunoglobulin M (IgM) and 88% reported symptoms consistent with Zika infection a mean of 6 days before onset of neurological symptoms. Acute Zika infection is usually characterized by rash, fever, and conjunctivitis.
Past dengue virus infection, which had been considered a possible risk factor for Zika-mediated GBS, did not differ significantly between patients in the control groups and those with GBS.
The investigators were also able to subtype the clinical characteristics of the GBS cases as consistent with acute motor axonal neuropathy, or AMAN, phenotype. However, the antibodies typically seen associated with AMAN were not seen in these patients, leading investigators to suspect that a different biological pathway was responsible.
More than a third of the GBS patients in the study required intensive care, most of these also with respiratory support, though none died.
The government of France, the European Union, and the Wellcome Trust funded the study. The researchers declared that they had no competing interests.
Zika virus can be added to our list of viruses that can cause Guillain-Barré syndrome, and investigation of these cases should include tests for Zika when there is a possibility of infection by that virus. Whether Zika will be proven to pose a greater threat in causing Guillain-Barré syndrome than its various flavivirus cousins remains to be determined. A little caution should be taken because the data are still scarce and we do not know whether the current Zika virus is identical to that in previous outbreaks, whether it will behave exactly the same in a different population with a different genetic and immunity background, or whether a cofactor or co-infection is responsible. Reassuringly, the investigators did not find any evidence that previous dengue infection enhanced the severity of the disease, which could substantially have increased the threat in areas of regular activity.
Dr. David W. Smith is a clinical professor of pathology and laboratory medicine at the University of Western Australia in Perth. John Mackenzie, Ph.D., is a professor of tropical and infectious diseases at Curtin University in Bentley, Australia. They had no competing interests to disclose.
Zika virus can be added to our list of viruses that can cause Guillain-Barré syndrome, and investigation of these cases should include tests for Zika when there is a possibility of infection by that virus. Whether Zika will be proven to pose a greater threat in causing Guillain-Barré syndrome than its various flavivirus cousins remains to be determined. A little caution should be taken because the data are still scarce and we do not know whether the current Zika virus is identical to that in previous outbreaks, whether it will behave exactly the same in a different population with a different genetic and immunity background, or whether a cofactor or co-infection is responsible. Reassuringly, the investigators did not find any evidence that previous dengue infection enhanced the severity of the disease, which could substantially have increased the threat in areas of regular activity.
Dr. David W. Smith is a clinical professor of pathology and laboratory medicine at the University of Western Australia in Perth. John Mackenzie, Ph.D., is a professor of tropical and infectious diseases at Curtin University in Bentley, Australia. They had no competing interests to disclose.
Zika virus can be added to our list of viruses that can cause Guillain-Barré syndrome, and investigation of these cases should include tests for Zika when there is a possibility of infection by that virus. Whether Zika will be proven to pose a greater threat in causing Guillain-Barré syndrome than its various flavivirus cousins remains to be determined. A little caution should be taken because the data are still scarce and we do not know whether the current Zika virus is identical to that in previous outbreaks, whether it will behave exactly the same in a different population with a different genetic and immunity background, or whether a cofactor or co-infection is responsible. Reassuringly, the investigators did not find any evidence that previous dengue infection enhanced the severity of the disease, which could substantially have increased the threat in areas of regular activity.
Dr. David W. Smith is a clinical professor of pathology and laboratory medicine at the University of Western Australia in Perth. John Mackenzie, Ph.D., is a professor of tropical and infectious diseases at Curtin University in Bentley, Australia. They had no competing interests to disclose.
Serological evidence from French Polynesia links an outbreak of Zika virus to a spike in cases of Guillain-Barré syndrome seen there in 2013-2014.
The research, published online Feb. 29 in The Lancet, is the first to use a case-control design to demonstrate that Zika, a mosquito-borne flavivirus, is associated with Guillain-Barré syndrome (Lancet. 2016 Feb 29. doi: 10.1016/S0140-6736(16)00562-6).
Guillain-Barré syndrome (GBS) is an immune-mediated flaccid paralysis that can follow viral or bacterial infections. Most patients with GBS recover with intensive care in hospitals, although the syndrome can be permanently debilitating or, in rare cases, fatal.
As a large outbreak of Zika continues in Central and South America, hospitals should be prepared for excess GBS cases, the authors of the study say, and assure adequate intensive-care capacity to treat them. Based on the 66% attack rate of Zika during the French Polynesia outbreak, investigators estimated the incidence of GBS at 0.24 per 1,000 Zika infections, but noted that it could be different in the current outbreak.
Dr. Van-Mai Cao-Lormeau of the Unit of Emerging Infectious Diseases at Institut Louis Malardé in Papeete, French Polynesia, alongside colleagues in France and French Polynesia, used a case-control design to compare serological samples from 42 patients (74% male) diagnosed at a Tahiti hospital with GBS with samples from age-and sex-matched patients who presented at the same hospital, also during the time of the outbreak, with a nonfebrile illness (n = 98) or with acute Zika disease without neurological symptoms (n = 70).
The investigators found that all but one patient with GBS had Zika virus antibodies, and all of them had neutralizing antibodies to Zika virus. By comparison, only 56% (n = 54) of the control group admitted with nonfebrile illness had neutralizing antibodies (P less than .0001).
Also, 93% of the GBS patients had Zika virus immunoglobulin M (IgM) and 88% reported symptoms consistent with Zika infection a mean of 6 days before onset of neurological symptoms. Acute Zika infection is usually characterized by rash, fever, and conjunctivitis.
Past dengue virus infection, which had been considered a possible risk factor for Zika-mediated GBS, did not differ significantly between patients in the control groups and those with GBS.
The investigators were also able to subtype the clinical characteristics of the GBS cases as consistent with acute motor axonal neuropathy, or AMAN, phenotype. However, the antibodies typically seen associated with AMAN were not seen in these patients, leading investigators to suspect that a different biological pathway was responsible.
More than a third of the GBS patients in the study required intensive care, most of these also with respiratory support, though none died.
The government of France, the European Union, and the Wellcome Trust funded the study. The researchers declared that they had no competing interests.
Serological evidence from French Polynesia links an outbreak of Zika virus to a spike in cases of Guillain-Barré syndrome seen there in 2013-2014.
The research, published online Feb. 29 in The Lancet, is the first to use a case-control design to demonstrate that Zika, a mosquito-borne flavivirus, is associated with Guillain-Barré syndrome (Lancet. 2016 Feb 29. doi: 10.1016/S0140-6736(16)00562-6).
Guillain-Barré syndrome (GBS) is an immune-mediated flaccid paralysis that can follow viral or bacterial infections. Most patients with GBS recover with intensive care in hospitals, although the syndrome can be permanently debilitating or, in rare cases, fatal.
As a large outbreak of Zika continues in Central and South America, hospitals should be prepared for excess GBS cases, the authors of the study say, and assure adequate intensive-care capacity to treat them. Based on the 66% attack rate of Zika during the French Polynesia outbreak, investigators estimated the incidence of GBS at 0.24 per 1,000 Zika infections, but noted that it could be different in the current outbreak.
Dr. Van-Mai Cao-Lormeau of the Unit of Emerging Infectious Diseases at Institut Louis Malardé in Papeete, French Polynesia, alongside colleagues in France and French Polynesia, used a case-control design to compare serological samples from 42 patients (74% male) diagnosed at a Tahiti hospital with GBS with samples from age-and sex-matched patients who presented at the same hospital, also during the time of the outbreak, with a nonfebrile illness (n = 98) or with acute Zika disease without neurological symptoms (n = 70).
The investigators found that all but one patient with GBS had Zika virus antibodies, and all of them had neutralizing antibodies to Zika virus. By comparison, only 56% (n = 54) of the control group admitted with nonfebrile illness had neutralizing antibodies (P less than .0001).
Also, 93% of the GBS patients had Zika virus immunoglobulin M (IgM) and 88% reported symptoms consistent with Zika infection a mean of 6 days before onset of neurological symptoms. Acute Zika infection is usually characterized by rash, fever, and conjunctivitis.
Past dengue virus infection, which had been considered a possible risk factor for Zika-mediated GBS, did not differ significantly between patients in the control groups and those with GBS.
The investigators were also able to subtype the clinical characteristics of the GBS cases as consistent with acute motor axonal neuropathy, or AMAN, phenotype. However, the antibodies typically seen associated with AMAN were not seen in these patients, leading investigators to suspect that a different biological pathway was responsible.
More than a third of the GBS patients in the study required intensive care, most of these also with respiratory support, though none died.
The government of France, the European Union, and the Wellcome Trust funded the study. The researchers declared that they had no competing interests.
FROM THE LANCET
Key clinical point: Acute infection with Zika virus in French Polynesia was associated with Guillain-Barré syndrome.
Major finding: Among GBS patients admitted to hospitals during an 2013-2014 outbreak of Zika virus, nearly all had antibodies or neutralizing antibodies to Zika, vs. 56% of age and sex-matched controls (P less than .0001).
Data source: A case-cohort study comparing blood results from 42 GBS cases and two cohorts of controls, one with acute Zika infection without GBS (n = 70) and another admitted during the outbreak for other illnesses (n = 98).
Disclosures: The French government, the European Union, and the Wellcome Trust sponsored the study. Investigators disclosed no conflicts of interest.
