With Zika, U.S. Hospitals Head Into the Unknown


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In a packed auditorium at Children’s National Medical Center in the District of Columbia Monday, doctors, nurses and residents gathered for an educational session on the Zika virus, which has infected at least three people in the city and 49 others throughout the country who are visiting the U.S. or returning after traveling in Latin America.

Dr. Roberta DeBiasi, chief of the hospital’s division of pediatric infectious diseases, took the stage, explaining at the session that the virus is transmitted through the same mosquitoes that carry the Dengue and chikungunya viruses.

“If you’re thinking of those two, you need to be thinking of Zika,” she said about patients who present with certain travel histories.

The session is an example of how hospitals are planning for Zika, which has spread explosively in Latin America, leading the World Health Organization to declare a rare public health emergency. In Brazil, Zika has infected 1.5 million people, and is projected to infect 4 million worldwide during the coming year. To get ahead of potential transmission in the U.S., hospitals are reminding their staffs to ask patients whether they have traveled recently, and they are working with public health officials to track where and how Zika is spreading. Mistakes of past epidemics are part of the conversation, and officials stress the importance of following protocols.   

“When you talk about lessons hospitals take from recent experiences, being able to work collaboratively with the public health system is probably the most important part of that,” says Dr. Jeff Duchin, professor of medicine at the University of Washington School of Medicine and a member of the Infectious Disease Society of America.

The session at Children’s National illustrates how much is still unknown about Zika, and the extent to which hospitals rely on information from scientists and public health officials to track and prevent disease.

For most people, the virus shows no symptoms or is otherwise mild, causing fever, rash and joint pain. But officials say evidence strongly suggests the effects of the virus are far worse for a developing fetus, leading them to concentrate most of their health guidance on pregnant women or women who are of childbearing age. In Brazil, the virus is believed to be linked to more than 4,000 cases of babies born with microcephaly, a condition of having unusually small heads and sometimes underdeveloped brains. In Colombia, health officials have not seen a surge in microcephaly, but have noticed that the virus appears to be tied to a neurological illness called Guillain-Barre syndrome, which can lead to paralysis and has caused three deaths in the country.

“As much as we know and as much as is coming out each day, there are still hundreds of questions we don’t know,” DeBiasi said to the audience. It isn’t known whether an infected person who doesn’t have symptoms can still spread Zika, or whether spit and tears are infectious, she cites as examples.

After the presentation, doctors and nurses asked questions about whether the virus can be spread through breast milk, and whether people who get the virus then become immune against it – more that scientists still don’t know.

Though the U.S. hasn’t had the kind of outbreak seen in other parts of the world, the virus appears to be moving quickly. At least 25 countries and territories have had local transmission of Zika, and the virus has been confirmed in travelers visiting or returning to at least 16 states and the District of Columbia, with one case in Dallas transmitted sexually.

This reality leads to multi-layered guidelines about prevention. In the absence of a vaccine or treatment, officials stress the best approach is to avoid mosquito bites by using repellent and wearing long sleeves when traveling to infected areas. At Children’s National, DeBiasi tells staff that they should advise pregnant women to cancel travel plans to affected areas. The Centers for Disease Control and Prevention has advised women not to have sex with their partners unless they do so with a condom.

“You have to work with the unknown,” says Dr. Arnold Monto, professor of epidemiology at the University of Michigan School of Public Health. “That’s where we are with Zika. … The situation here is so fluid that we just have to be on the alert.”

Given the way the virus is primarily spread, Monto says the U.S. is unlikely to see high numbers of direct transmission overall, though he adds that it could see some cases of transmission in the southern part of the U.S., where the climate is warmer and mosquitoes tend to thrive. Still, he points out that hospitals have not followed certain protocol in the past that caused cases to be missed, such as the Ebola patient that entered a Dallas hospital, transmitting the disease to health care workers, and the transmission of SARS in Toronto that killed 44 people in 2003.

“Even with protocols in place, there will be error and omission,” he says.

Duchin says that Zika is another reminder of how important it is for medical staff to ask about travel history. “The infectious disease outbreak is really highlighting what we also saw with measles, Ebola, MERS, SARS and H1N1,” he says. “There is an increasing appreciation of [travel history queries] in the medical community in general.”

Other than infection control and tracking, hospitals are preparing to potentially manage cases of babies born with microcephaly. When women are infected while pregnant, U.S. hospitals are likely to conduct more sonograms, though it’s difficult for doctors to tell until well into the second trimester whether a fetus is developing microcephaly.

Each case would be evaluated and treated according to its needs, says Debra Bingham, vice president of nursing research, education and practice at the Association of Women’s Health, Obstetric & Neonatal Nurses. If necessary, a woman who is pregnant and whose fetus shows signs of microcephaly could be assigned to a hospital that specializes in handling more difficult cases – as is typically already done in neonatal practice.

“There won’t be any need to redo that process,” Bingham says. “That has been identified and set up. The whole country is organized in that way.”

Neonatal nurses are trained in caring for infants with microcephaly, which has several other causes, resulting in 2,500 babies diagnosed with the condition in the U.S. each year. Care after birth would vary, Bingham says, as newborns can struggle with keeping their temperature up and problems with feeding. In particular, hospitals will need to continue to track incidences and see whether they have a surge of cases in a particular area.

So far, no babies have been born in the U.S. with microcephaly that has been linked to Zika.

More data will become available as hospitals report incidences in states. Hospitals and state public health systems are dependent on each other for treatment and surveillance, explains Vicki Allen, a spokeswoman for the Association for Professionals in Infection Control and Epidemiology, and infection prevention director at CaroMont Health in Gastonia, North Carolina. They are not only watching out for Zika, but tracking incidences of diseases such as tuberculosis and chickenpox, and then looping in the CDC to detect outbreaks.

The problem with tracking Zika, she points out, is that the majority of people don’t have symptoms, so they would be unlikely to go to the hospital even if they are infected.  

But even in cases that are found, the lack of sustained investment in public health can lead to slow surveillance and hinder officials’ ability to get ahead of an outbreak, says Richard Hamburg, interim president and CEO at Trust for America’s Health, an organization that advocates prevention measures.

Each year the organization highlights how states differ in prevention efforts, revealing significant gaps in funding depending on where Americans live. Hamburg says while the White House has proposed $1.8 billion in federal funding to combat the virus, the influx – as seen with Ebola – highlights the country’s lack of overall focus on prevention and mitigating outbreaks.  

“The tendency is to focus on the newest, most alarming threat,” Hamburg says. “How many times do we need to be burned before we change the way we operate?” 


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