OB/GYNs Reflect on the Year of Zika
In early February, not long after Zika virus became international news, the Society for Maternal-Fetal Medicine (SMFM) annual meeting held a special session to answer questions about Zika and treating patients who may have been exposed. Here we review the developments that have occurred since.
If 2016 was the year of Zika virus, no specialty was more affected in their every day practice than ob/gyns.
In January, the CDC issued guidelines for ob/gyns taking care of patients who had been potentially exposed to Zika virus, as the virus appeared to pose the risk of microcephaly in the infant. On February 1, the World Health Organization declared the link between Zika virus and microcephaly a public health emergency of international concern — and only recently lifted that warning.
During the February SMFM session, Laura Riley, MD, then the society's president, summed up the main issue at the time for ob/gyns trying to answer patient questions about Zika:
“At the end of the day, the patient doesn't want to know is my baby infected, but is my baby affected?” she said in February. “Even if you stick a needle in there and get back a virus, you don't know.”
Almost a year later, Riley, who also chairs the American College of Obstetricians and Gynecologists' immunization expert working group, reflected on how little information that researchers, and ob/gyn providers, actually had about Zika virus.
“We didn't know anything,” she told MedPage Today. “Everything we were thinking about, we were extrapolating from other viral infections, such as cytomegalovirus, which we knew was a teratogen that we knew a fair amount about.”
At the end of the month, the CDC reported the first U.S. case of microcephaly from a pregnant traveler. A few days later, researchers said they found the “smoking gun” that linked pregnant women with Zika virus to neurological complications in their unborn babies. The causal link between microcephaly and Zika was confirmed in April.
Jeanne Sheffield, MD, of Johns Hopkins University, told MedPage Today that Zika has made ob/gyns much more cognizant of travel and travel-related diseases, which she characterized as “eye-opening” for providers.
“Now every single prenatal visit, you go 'OK, where have you traveled?' and that's not something we ever asked before,” she said. “But our world is globalized now, and I think making ob/gyns more aware of asking about travel and knowing what diseases are present in certain areas is more and more important in today's society and today's world.”
Current SMFM president Mary Norton, MD, commented to MedPage Today about the time involved in the Zika screening process.
“The Zika crisis added an entirely new concern that took significant time and effort to manage,” she said. “The additional screening took substantial resources, especially as recommendations continued to change as we learned more about the virus.”
Riley also commented on the steep learning curve, with ob/gyns consistently having to keep up with numerous CDC advisories, practice advisories, and travel bulletins. In addition, providers had to educate themselves on complex protocols for infectious disease testing — which she said was “an educational experience for most obstetricians.”
“It's not something you necessarily would've been familiar with, and the testing is more complex than what we're used to,” said Riley.
“Testing for antibodies — you don't know how long they last or when they become positive, and then there's the cross-reactivity for other viruses, and the average obstetrician in Iowa probably didn't know anything about those things.”
Indeed, the guidelines for ob/gyn providers changed again in July, when the window of time for testing to detect Zika RNA was expanded, due to new research.
Recent studies in the last month suggest that Zika RNA can be detected months after a pregnant woman is infected, and it may be due to infection in the fetus.
In the latter part of the year, much of the research and guidance shifted from pregnant women to how to test, treat, and care for infants born with Zika virus.
Sheffield said that the idea that an infant can be “normal-appearing” at birth, and then later develop issues after birth, is one of the scariest things for ob/gyns.
“Initially we were 'OK, we can diagnose this on ultrasound or at the time of delivery and we can counsel them and we can get them the appropriate follow-up and services.' Now it's looking those infants who appear normal at birth, we need to follow long-term because some of them are having issues at 2, 3, 4 months of life,” she said.
SMFM specialists in February expressed concern that Zika may become endemic to certain areas of the U.S. This proved prescient when local transmission of the virus was reported in a Miami neighborhood in July, leading to the continental U.S.' first Zika-related travel warning.
Riley said that travel will remain a key issue for providers. One of the main gaps in diagnostic testing, she said, is that no IgG test — which can detect antibodies months after infection — exists for Zika, making it impossible for women who live in or travel to endemic areas to know if they have already been infected prior to getting pregnant.
“There's going to be this whole population of people who are going to say 'I was just in the West Indies, have I already had it, can I go back there?',” she said. “So, being able to tell people you already had it and it's not a risk in your next pregnancy is going to be important information.”
But prevention continues to be the main deterrent, with Zika vaccine trials now in their earliest stages. Sheffield said that while pregnant women will ly never be vaccinated, there may be the potential for “herd immunity” by immunizing everyone around the pregnant woman. The ultimate goal would be to vaccinate women as teenagers, prior to childbearing.
As research on Zika continues, Riley praised the relationship between public health authorities and providers, saying that “for the first time in my almost 30 year career, I felt there was really good collaboration” between the two. She said that because of this, providers didn't have to wait a year until medical literature came out to advise their patients.
“I think it's been kind of an interesting exercise, but it should become a very important model for future threats, because it's nice to have that interface with public health. This public-private partnership is critical, especially when something is totally new,” Riley noted.