Zika Infection Still Poses Concern for Pregnant Women

Zika has not gone away. Nor will it any time soon.

Experts Oluwatosin Goje, MD, head of the Ob/Gyn & Women’s Health Institute Gynecologic Infection Diseases Program, and Steven Gordon, MD, Chair, Department of Infectious Disease, shed light on new thinking for assessment, testing and prevention of Zika and how to manage women who are pregnant or who may become pregnant.

(This is an edited excerpt of a video conversation made possible in part by a grant from the Ohio Department of Health (ODH). The ODH awarded Dr. Goje $50,000 to travel the State of Ohio educating healthcare providers about Zika virus infection, especially in pregnancy.)

Zika knowledge has grown

Dr. Goje: Our knowledge about Zika has grown in the past two years, but there’s still a lot to do. Weʼre researching, we have trials, and providers need education.

Dr. Gordon: Zika is on our radar screens now, especially for pregnant women. The burden of infection for the unborn baby and congenital birth defects are of major concern.

Goje: How did Zika get to the United States?

Gordon: It is primarily a mosquito-borne disease, but Zika also can be transmitted sexually, through infected semen from a male who harbors the virus but is asymptomatic.

Viral RNA has been detected in semen up to six months after exposure. So couples need to practice safe sex for about six months after a partner may have been exposed.

That’s generally how a pregnant woman in say Cleveland, Ohio, who’s never traveled outside the United States, is still potentially at risk for acquisition of Zika.

Goje: The photos of babies with microcephaly in Brazil break our hearts. We know that congenital Zika syndrome includes microcephaly, brain calcifications, hearing loss and/or ophthalmic abnormalities.

Gordon: A number of studies show that Zika infection during pregnancy is clearly a risk factor for microcephaly. As we study children born to mothers with Zika, we are finding the other birth defects as well. This does not prove Zika is the cause, but the numbers are statistically important and fulfill Koch’s postulates.

Goje: What are signs and symptoms of Zika virus infection?

Gordon: Most patients are asymptomatic, and that is why the Centers for Disease Control and Prevention (CDC) recommends “opting in,” meaning any pregnant woman or woman who is thinking about becoming pregnant should be assessed based on history for risk of Zika infection.

It’s not just where you’ve been, but also where your partner has been. Practitioners need to take a risk history for exposure for the pregnant woman and for her partner. As of July 2017, the World Health Organization (WHO) identified about 95 countries where there is ongoing transmission of Zika.

Screening differs from testing

Goje: How is a Zika diagnosis confirmed?

Gordon: Patients don’t come in with the diagnosis flashing on their forehead. The history and physical are important as is staying up to date. Diagnosis can be difficult because, unlike HIV or hepatitis C, the virus remains in tissue for a relatively short time and women are not necessarily tested then, which can make diagnosis problematic.

Goje: Screening is different than testing. Who should be tested?

Gordon: The testing algorithm from the CDC and WHO continues to evolve. Today, the symptomatic pregnant woman with exposure will always be tested. But the asymptomatic pregnant woman who may have been exposed but is not in an area of ongoing exposure doesn’t necessarily have to be tested.

Nucleic amplification testing (NAT) allows us to test for Zika virus in blood or urine up to 12 weeks after pregnancy or exposure.

Help pregnant women avoid test anxiety

Goje: Some women and their providers will be apprehensive about not being tested.

They want to protect their baby and be sure they are infection-free. This is when education comes in because testing actually could create more anxiety.

We had a patient fly here from Florida for a second opinion because she was about to terminate a pregnancy. We reached out to the CDC to help clarify what testing would mean for her.

Gordon: You’ve taught me how important it is to avoid test anxiety in a pregnant woman. And that’s not just for Zika, but also for screening for congenital toxoplasmosis or other congenital infections.

Goje: Correct. We don’t want to create more anxiety, but we don’t want miss something important. Again, I tell providers to reach out to the CDC.

What about prevention?

Gordon: For travelers going from a nonendemic area to one where there’s risk, as an obstetrician, you can certainly tell your patient not to go. Having said that, there may be some reasons why someone needs to go – a funeral or another occasion that is extremely urgent. If a woman who is pregnant or potentially pregnant must go, then we talk about nonpharmacologic interventions, or mosquito avoidance. Avoiding times of the day when mosquitos bite frequently, wearing long sleeves and covering up, using an FDA-approved mosquito repellent and netting. Staying in shelters with screens and air conditioning is good. These are not foolproof measures, of course.

Goje: So it is about mitigating risk.

Gordon: Yes. One thing you taught me is that about 1 percent of the world’s population is pregnant at any time. We don’t like to waste a crisis, but it reminds us that society really does adore this vulnerable population and should protect and cocoon them. It’s all about putting our patients first no matter where they are.

Is natural immunity possible?

Goje: Patients have asked me if they may be immune if they have been exposed to Zika. I had a patient jokingly ask if she should expose herself to Zika then get married and have babies!

Gordon: Donʼt do that! We are not at the point when we can say go get a natural infection. I do believe basic science will bring us primary vaccine prevention, an antiviral, as well as a vaccine for women and men who are in areas with ongoing transmission. So stay tuned.

Goje: Thank you, Dr. Gordon. If physician readers have questions, please reach out to the CDC, Ohio Department of Health or the Infectious Disease Department at Cleveland Clinic.