Preventing Zika in Puerto Rico


​If you are currently pregnant or hope to be soon, you’re probably already paying attention to the growing threat of the Zika virus, because it has (4). Although I am currently not in the market for a baby (sorry, Mama!), I have been keeping up with the virus’s development in Puerto Rico, where I grew up, because the island has already been flagged as a potential Zika disaster area. Local transmission of the virus was initially reported in December, and as of this writing, the CDC estimates that as (1) in this outbreak.

Growing up on a tropical island, this isn’t my first rodeo with mosquito-transmitted diseases. When I was a kid, Puerto Rico had a dengue-fever epidemic, which is how I learned about the Aedes aegypti mosquito, which also carries Zika. Chikungunya infected almost everyone I grew up with in the past two years (thank you, Facebook, for keeping me updated).

But Zika *is* a different, potentially more frightening animal than Dengue or Chikungunya, especially for young women. Ever since it was discovered that it may cause severe birth defects in children born to infected mothers — specifically (2), which is a neurological condition where a baby is born with a smaller head and often has abnormal brain development — the stakes on prevention have gotten much higher. The virus can also be sexually transmitted, which is another reason young women may be alarmed.

What seems strangest about the situation is how much is currently unknown, and how much depends on the data gleaned from the first wave of pregnant women infected with the virus after they give birth. The CDC also just announced that the virus may be in as many as 30 U.S. states by this summer, and that it’s “scarier than we initially thought.” Very reassuring, thanks.

We talked with Dr. Dana Thomas, a medical epidemiologist who works for the CDC and the Puerto Rico Department of Health, to get facts about the disease and its effects and to learn more about prevention.

**Laia Garcia:** What is the general mood in the island right now? Are people taking it seriously? Are women more afraid than men are?

**Dana Thomas:** We’ve been conducting some focus groups, both with individual women and women in small groups, to discuss what their concerns are around Zika, and what do they feel might be effective or helpful in them preventing Zika infection. What I would say is that pregnant women are anxious. There’s a lot of concern, and there’s a sentiment that we can’t do this alone because a lot of what you have to do to prevent Zika has to do with their community behaviors. Part of our messaging is that the entire community needs to wear repellent to keep the population (3) very low. It’s not just on the pregnant woman. “You need to do this, you need to do that.” They don’t want to be told what they need to do, they want to be supported in what is going on.

We will see larger public service announcements and campaigns that will go out to the community at large. Certainly, we have a lot of folks at the ports that are trying to do education for travelers coming in and going home, but even bigger than that.

**LG:** What happens when someone is diagnosed with the virus? Is it a sit-and-wait? Are there any options, even though there’s currently no cure?

**DT:** There’s no cure. Just to back up, the interim guidelines the CDC has put forward certainly involve testing all symptomatic persons. Meaning: if you have a rash or you have an unexplained illness from another source, it could be an arbovirus . You send a blood specimen in for testing at the Puerto Rico Department of Health, and we test each specimen of an acute patient for Dengue, Chikungunya, and Zika, because the arbovirus family is so difficult to differentiate and a person could have any of the three. Certainly, physicians know to, as a priority, send in and label their specimens that are coming in from pregnant women.

Then, we think that 60, maybe 70, up to 80 percent — certainly over half — of the women that are infected are asymptomatic. There’s a second protocol that says during your pregnancy, once during your first trimester and once during your second trimester, you should be tested for antibodies against Zika. Part of what the doctors do is that they explain to women who might have concerns what the signs and symptoms of Zika would be, and then what the normal protocol will be for testing. Then, if there is a positive test, the follow-up testing involves ultrasonography to observe the baby monthly to see if there appears to be any discrepancy between length or femur length and head circumference, or just to see if there’s any other abnormality that you might pick up.

**LG:** Would this become an issue for lower-income women who may not be insured or may not be able to afford the additional tests? Are they at a bigger risk? Is there any financial help in place to help them get the necessary testing?

**DT:** We have worked really closely with the Puerto Rico chapter of the American College of Obstetrics and Gynecology. I don’t think there are any pregnant women who are uninsured in Puerto Rico. Even if they have Medicaid, they are insured. Then, the question, like you said, becomes, as we see increased demand for testing, will it be met, and will there be any discrepancy as to who gets tests? I don’t think we’re at that point yet. We have a couple hundred, 250 cases of Zika, and roughly ten percent are among pregnant women. We’re talking about 25 women that we’re following right now.

**LG:** Twenty-five?

**DT:** Right. In the ballpark of 25. Ten percent of all positives that we found. Remember, those women are tested at a higher rate; they’re overrepresented amongst those who get tested.

There is also a concern amongst pregnant women, who we’ve worked most closely with, that their partner, who may be asymptomatic, could be viremic and could have virus in his sperm. For weeks to even months, the virus has been seen in sperm after an infection. We’ve provided guidance on using condoms during pregnancy, really just as another mechanism to prevent infection of the mom.

**LG:** Are people being receptive to that?

**DT:** No. I can’t say that it’s the most popular idea that we’ve ever shopped. There’s resistance in some ways on both partners. Women don’t necessarily like latex or condoms any more than men do, so it’s trying to educate them, and saying, “You just realize these are the risks that you choose to take.” It’s like a woman that says, well, I’m going to have a glass of wine with dinner tonight. I know I’m pregnant. People will choose their own threshold for what’s the level of risk they feel they can tolerate.

**LG:** Is there a specific time during the pregnancy where, if you’re exposed to the virus, there’s a higher risk of fetal complications?

**DT:** We hope that our work in Puerto Rico will answer that question more definitively. Is it at the eight-week point or is at the 20-week point that you have to still be concerned? We definitely believe first-and second-trimester infections are more likely to have adverse outcomes in terms of fetal development, because there’s so much neurological development going on, early brain development. We have about a half a dozen women who will be some of our first to give birth, and most of them were infected late second trimester or in their third trimester. They’ll be the first ones we know about.

**LG:** It sounds like the research is in its early stages.

**DT:** We identified our first case in Puerto Rico, we reported it on the 31st of December. Really, when I say there’s 250 cases, it’s not that we haven’t been looking. We’ve tested probably 4,000 specimens to find those 250 cases. That’s probably the strongest suit that Puerto Rico has. We have excellent surveillance protocols in place, island-wide. We’re receiving specimens from all kinds of clinics all over the island.

**LG:** Are there any procedures in place for babies if they are born with microcephaly?

**DT:** Absolutely. Our director for children born with special needs or birth defects has helped establish a protocol that we use to collect data from all women that are pregnant and extract Zika and extract their medical records at least three times early in their pregnancy, then at the time of birth, and then also post delivery, which includes information on the infant too. Right now, he is the person that will make final determination on the validity of the measurements, to figure out whether they were done correctly and if they meet our criteria for microcephaly. Because microcephaly has a lot of causes, but what we’re looking for is microcephaly that’s a pure microcephaly, that’s not associated with any other birth defect like spina bifida.

**LG:** One last question: What is the best mechanism for the population at large? Is it really just to wear insect repellent and clean out stagnant water, or is there anything more?

**DT:** We’re hoping to use a very multipronged approach. Like you said, it’s repellent, it’s education on why you need to do that, why it’s not solely the pregnant woman’s area of concern. We’re talking about protecting the next generation of Puerto Ricans. This is a community responsibility. I think that women will be offered, pregnant women in particular, insecticide, potentially spraying around their home to try to reduce the risk of mosquitoes in those neighborhoods and those areas. That’s another vector control measure.

Again, what we’re trying to do is figure out what’s the earliest point that we can get messaging to our population that maybe doesn’t intend to get pregnant this year. We can potentially facilitate long-acting contraception amongst women who would prefer not to have a baby right now. We know that over half of the children born in the United States were unintended, so this is another aspect of virus contraction we’re working on.

*This interview has been condensed and edited.*

*Laia Garcia is the deputy editor of Lenny.*

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