Update: Interim Guidance for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection - United States, August 2016

Neuroinflammation, blood-brain barrier dysfunction, hippocampal atrophy and delayed neurodevelopment: Contributions for a rat model of congenital Zika syndrome

The congenital Zika syndrome (CZS) has been characterized as a set of several brain changes, such as reduced brain volume and subcortical calcifications, in addition to cognitive deficits. Microcephaly is one of the possible complications found in newborns exposed to Zika virus (ZIKV) during pregnancy, although it is an impacting clinical sign. This study aimed to investigate the consequences of a model of congenital ZIKV infection by evaluating the histopathology, blood-brain barrier, and neuroinflammation in pup rats 24 h after birth, and neurodevelopment of the offspring. Pregnant rats were inoculated subcutaneously with ZIKV-BR at the dose 1 × 107 plaque-forming unit (PFU mL-1) of ZIKV isolated in Brazil (ZIKV-BR) on gestational day 18 (G18). A set of pups, 24 h after birth, was euthanized. The brain was collected and later evaluated for the histopathology of brain structures through histological analysis. Additionally, analyses of the blood-brain barrier were conducted using western blotting, and neuroinflammation was assessed using ELISA. Another set of animals was evaluated on postnatal days 3, 6, 9, and 12 for neurodevelopment by observing the developmental milestones. Our results revealed hippocampal atrophy in ZIKV animals, in addition to changes in the blood-brain barrier structure and pro-inflammatory cytokines expression increase. Regarding neurodevelopment, a delay in important reflexes during the neonatal period in ZIKV animals was observed. These findings advance the understanding of the pathophysiology of CZS and contribute to enhancing the rat model of CZS.

Serological investigation of vaccine-induced antibodies for measles, rubella, and yellow fever viruses in children vertically exposed to Zika virus or with down syndrome

Background

Vaccination schedules, as well as their effectiveness and contraindications, need to be evaluated regularly, especially in specific situations. Congenital Zika Syndrome (CZS) is a severe condition that results in extensive functional and neurological impairment of fetuses and newborns due to Zika virus tropism for fetal neural progenitor cells. Down Syndrome (DS) is the leading genetic cause of intellectual disability. The immune impairment in DS has already been described, but little is known about the immune response of CZS children. Thus, CZS and DS are specific conditions that can be considered for a reassessment of the available immunizations. Here, we carried out serological analyses of attenuated vaccines-induced antibodies for measles, rubella, and yellow fever viruses in children aged 2-7, grouped into asymptomatic controls, DS children, and CZS children.

Methods

Plasma samples were taken, and vaccination records were compiled during clinical follow-up. Enzymatic immunoassays for quantifying anti-measles and anti-rubella IgG were performed to assess the response to the Measles, Mumps, and Rubella (MMR) vaccine. Plaque Reduction Neutralization Test (PRNT) was performed to investigate neutralizing antibodies in response to the Brazilian vaccine strain of yellow fever (YF-17DD).

Results

We highlight similar levels of anti-measles IgG and neutralizing antibodies for YF-17DD among CZS, DS, and asymptomatic children, although low positivity of measles data was seen in the three groups. In DS children, the 2-4-year-old group had an increased level of anti-measles IgG compared to the older group of children aged five to seven years. Lower anti-rubella IgG levels were observed in CZS and DS children compared to asymptomatic children. For anti-rubella IgG, the good performance of vaccination in asymptomatic children is due to younger ones rather than older ones.

Conclusions

There were no reports of adverse events after the use of the MMR and YF-17DD indicating that CZS and DS could continue to receive these vaccines, but our data draws attention to the necessity of monitoring the vaccination response in CZS and DS children over time and the possible need to adhere to national measles vaccination campaigns. Scientific research needs to continue to help develop appropriate CZS and DS health guidelines.

Clinical and genetic analyses in syndromic intellectual disability with primary microcephaly reveal biallelic and de novo variants in patients with parental consanguinity

BACKGROUND

Syndromic intellectual disability (ID) with accompanying primary microcephaly is a group of rare neurodevelopmental disorders exhibiting extreme genetic and clinical heterogeneity. This layered heterogeneity can partially be resolved by unbiased genetic approaches targeting the genome with next generation sequencing (NGS) technologies, including exome sequencing (ES).

OBJECTIVE

This study was performed to dissect the clinical and genetic features in five distinct IDM cases.

METHODS

Singleton or trio ES approach followed by in-depth variant analysis using alternative inheritance models was performed.

RESULTS

We have identified biallelic loss of function variants in genes WDR62 and AP4M1 in three families, together with de novo missense variants in genes SOX11 and TRIO in two families. ES based haplotype analysis in two cases upon identification of an identical WDR62 variant in the homozygous state in two cases was suggestive of a small shared haplotype of 0.1 Mb. Additionally, we have shown a paternal origin for the de novo variant in TRIO via a polymorphic tag SNP, which enlightens the mutational mechanism for this variant.

CONCLUSION

In populations with high parental consanguinity, an autosomal recessive inheritance pattern for data analysis is usually the most obvious choice. Therefore, heterozygous variants may be overlooked in standard NGS analyses in consanguineous families. Our findings underlie the importance of using multiple inheritance models in NGS data analysis.

Neurological Short-Term Outcomes of a Cohort of Children Born to Zika Virus-Infected Mothers in Barcelona

Zika virus (ZIKV) is a vector-borne flavivirus with a known teratogenic effect, yet the full spectrum has not been delineated. Studies on endemic areas tried to characterize the clinical outcomes of ZIKV intrauterine exposure. We aimed to describe early neurodevelopmental outcomes on prenatally ZIKV-exposed children in a non-endemic ZIKV area. This is a prospective observational cohort study conducted from May 2016 to December 2021 at Hospital Universitari Vall d’Hebron in Barcelona, Catalonia, Spain. We monitored for up to 24 months 152 children extracted from a pregnant women cohort with suspected ZIKV infection; eleven women (11/150; 7.3%) fulfilled the criteria for a confirmed ZIKV infection. Among the 152 children included, we describe two cases of congenital ZIKV syndrome (CZS) born from women with a confirmed ZIKV infection. Additionally, we describe five cases of other potentially ZIKV-related outcomes (OPZROs), all with normal birth cranial circumference and born to women with probable ZIKV infection. The low exposed prevalence of adverse outcomes in asymptomatic children at birth in a non-endemic area suggests that close follow-up should be addressed by primary care pediatricians instead of pediatric specialists. Further studies are needed to assess the effects of ZIKV intrauterine exposure beyond two years of life.

Sleep in children with microcephaly due to Zika virus infection: a systematic review

OBJECTIVE

To review the literature on sleep changes and brain function in children with microcephaly due to Zika virus.

METHOD

Systematic review conducted in the databases MEDLINE (PubMed), Scopus, Web of Science, CINAHL, EMBASE, LILACS, and SciELO and the grey databases Google Scholar and OpenGrey.

RESULTS

Ten Brazilian primary studies with observational research design were included. These were published between 2017 and 2020 with 516 children with microcephaly due to Zika virus infection aged 4 months to 4 years. Out of these, 4 investigated qualitative aspects of sleep using the questionnaires Brief Infant Sleep Questionnaire or Infant Sleep Questionnaire and 6 investigated changes in brain activities during sleep using the Electroencephalogram or Video-Electroencephalogram exams. The children's quality of sleep was not compromised in most studies. Changes in brain activity during sleep were frequent, with epileptogenic activity being a common finding among the studies.

CONCLUSION

The quality of sleep of children with microcephaly due to Zika virus has shown to be similar to that of children with typical development and the presented behavioral changes may be related to changes in electric brain activity.

Zika virus dysregulates the expression of astrocytic genes involved in neurodevelopment

Zika virus (ZIKV) is a kind of flavivirus emerged in French Polynesia and Brazil, and has led to a worldwide public health concern since 2016. ZIKV infection causes various neurological conditions, which are associated with fetus brain development or peripheral and central nervous systems (PNS/CNS) functional problems. To date, no vaccine or any specific antiviral therapy against ZIKV infection are available. It urgently needs efforts to explore the underlying molecular mechanisms of ZIKV-induced neural pathogenesis. ZIKV favorably infects neural and glial cells specifically astrocytes, consequently dysregulating gene expression and pathways with impairment of process neural cells. In this study, we applied a model for ZIKV replication in mouse primary astrocytes (MPAs) and profiled temporal alterations in the host transcriptomes upon ZIKV infection. Among the RNA-sequencing data of 27,812 genes, we examined 710 genes were significantly differentially expressed by ZIKV, which lead to dysregulation of numerous functions including neurons development and migration, glial cells differentiation, myelinations, astrocytes projection, neurogenesis, and brain development, along with multiple pathways including Hippo signaling pathway, tight junction, PI3K-Akt signaling pathway, and focal adhesion. Furthermore, we confirmed the dysregulation of the selected genes in MPAs and human astroglioma U251 cells. We found that PTBP1, LIF, GHR, and PTBP3 were upregulated while EDNRB and MBP were downregulated upon ZIKV infection. The current study highlights the ZIKV-mediated potential genes associated with neurodevelopment or related diseases.

Zika virus (ZIKV) infection causes serious neurological disorders of central and peripheral nervous system, and fetal brain development disorders including microcephaly. There are still uncovered explorations for the underlying molecular mechanism of ZIKV-infected pathogenesis. This study reveals a series of dysregulation of neuropathic genes mRNA and protein expression in mouse and human astrocytes upon ZIKV infection. As an ideal ZIKV infection model in mouse primary astrocytes (MPAs), RNA-seq was performed to profile transcriptome alteration by ZIKV infection. Bioinformatics analysis demonstrated the significant alterations of the 710 genes that were linked to glial cell differentiation and projection, neurogenesis and migration of neurons, myelination, as well as synaptic control. Among the top selected differentially expressed genes, such as PTBP1, LIF, GHR, PTBP3, EDNRB, and MBP, the mRNA and protein expressions were confirmed to identify the dysregulation of the transcriptome in MPAs upon ZIKV infection. Furthermore, ZIKV infection altered the mRNA and protein expression of these astrocytic genes involved in neurodevelopment in U251 cells following the analysis of the transcriptome. In conclusion, the alteration of astrocytic gene functions or associated-pathways suggest a novel clue of a mechanism involved in the ZIKV-induced neurodevelopment disorders.

[Meanings, risk perceptions, and prevention strategies for pregnant women since the emergence of the Zika virus in Brazil]

This study aimed to understand the meanings, risk perceptions, and strategies to prevent infection with the Zika virus developed by pregnant women with different socioeconomic conditions seen at public and private health services in the city of Salvador, Bahia State, Brazil, as well the contribution by their male partners in dealing with the risk of infection since the emergence of this virus in Brazil. A qualitative study was performed with 18 semi-structured interviews, nine each with pregnant women seen in the public and private health systems, respectively. The resulting data revealed insufficient knowledge in pregnant women concerning important aspects of Zika virus infection. The pregnant women's socioenvironmental situation was an important factor for risk perception and preventive strategies. Women interviewed in the public health system felt more vulnerable to the risk of infection than women interviewed in the private health system, with a major impact on their psychosocial well-being. According to the women, their partners placed huge demands on them to adopt preventive measures, but the male partners themselves failed to take the same precautions, e.g., ignoring the risk of sexual transmission of the Zika virus. In conclusion, three years since the outbreak reached Brazil, the Zika virus still has a major impact on the lives of pregnant women. It is crucial to strengthen health communications activities to guarantee the availability of information on the disease that responds adequately to the population's needs.

Congenital Zika syndrome: A systematic review

BACKGROUND

The signs and symptoms of Zika virus infection are usually mild and self-limited. However, the disease has been linked to neurological complications such as Guillain-Barré syndrome and peripheral nerve involvement, and also to abortion and fetal deaths due to vertical transmission, resulting in various congenital malformations in newborns, including microcephaly. This review aimed to describe the o signs and symptoms that characterize the congenital Zika syndrome.

METHODS AND FINDINGS

A systematic review was performed with a protocol and described according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search strategy yielded 2,048 studies. After the exclusion of duplicates and application of inclusion criteria, 46 studies were included. The main signs and symptoms associated with the congenital Zika syndrome were microcephaly, parenchymal or cerebellar calcifications, ventriculomegaly, central nervous system hypoplasia or atrophy, arthrogryposis, ocular findings in the posterior and anterior segments, abnormal visual function and low birthweight for gestational age.

CONCLUSIONS

Zika virus infection during pregnancy can cause a series of changes in the growth and development of children, while impacting the healthcare system due to the severity of cases. Our findings outline the disease profile in newborns and infants and may contribute to the development and updating of more specific clinical protocols.

Vaccines for Perinatal and Congenital Infections-How Close Are We?

Congenital and perinatal infections are transmitted from mother to infant during pregnancy across the placenta or during delivery. These infections not only cause pregnancy complications and still birth, but also result in an array of pediatric morbidities caused by physical deformities, neurodevelopmental delays, and impaired vision, mobility and hearing. Due to the burden of these conditions, congenital and perinatal infections may result in lifelong disability and profoundly impact an individual's ability to live to their fullest capacity. While there are vaccines to prevent congenital and perinatal rubella, varicella, and hepatitis B infections, many more are currently in development at various stages of progress. The spectrum of our efforts to understand and address these infections includes observational studies of natural history of disease, epidemiological evaluation of risk factors, immunogen design, preclinical research of protective immunity in animal models, and evaluation of promising candidates in vaccine trials. In this review we summarize this progress in vaccine development research for Cytomegalovirus, Group B Streptococcus, Herpes simplex virus, Human Immunodeficiency Virus, Toxoplasma, Syphilis, and Zika virus congenital and perinatal infections. We then synthesize this evidence to examine how close we are to developing a vaccine for these infections, and highlight areas where research is still needed.

Electrical status epilepticus during sleep in patients with congenital Zika virus syndrome: An unprecedented clinical finding

BACKGROUND

Brazil experienced a disproportionately higher rate of microcephaly cases in November 2015 with evidence of a causal link with Zika virus (ZIKV) infections during pregnancy. Epilepsy is a major neurological feature seen as part of congenital Zika virus syndrome (CZVS). Different seizure types and electroencephalographic (EEG) abnormalities have been described in association with this syndrome. However, clinical and neurophysiological features of epilepsy seen in children with CZVS are not fully understood.

METHODS

We evaluated children with CZVS showing an EEG pattern of electrical status epilepticus during slow-wave sleep (ESES). Information on gender, age of onset of seizures, head circumference at birth, gross motor function at the time of diagnosis, of clinical and EEG aspects of seizures, EEG features and response to drug treatment was assessed.

RESULTS

Our case series included four patients. They were diagnosed with epilepsy between one month to 18 months of age and showed an ESES pattern at the age of three. They presented with a wide range of epileptic symptoms, but all experienced tonic seizures. Multiple drug treatment was the management approach for three patients; however, they showed poor response to treatment with conventional drugs used in the treatment of ESES.

CONCLUSIONS

Children with CZVS may develop an EEG pattern of ESES. Clinicians and neurologists should be aware of this neurological presentation to improve the management of these patients.

Enhanced surveillance and response approaches for pilgrims and local Saudi populations against emerging Nipah, Zika and Ebola viral diseases outbreaks threats

Increasing emergence and spread of Nipah, ZIKV and Ebola case and potential outbreaks threats have been reported in several regions around the globe. Yet, emerging Nipah, Ebola and Zika viral diseases outbreaks have been indirectly linked to substantially globalization of trade and travel, climate change and intense urbanization impact, healthcare and socioeconomic inequities as well in affected community settings. Although no case has been documented in Saudi Arabia, there is a great risk of sudden emergence of any of these viruses and others via introducing among pilgrims coming from endemic regions during ritual ceremonies of mass gatherings. Consequently, promoting and investing on new and sensitive proven effective and innovative surveillance and monitoring approaches, including enhanced risk communication, improved integrated vectors surveillance in addition to improved sustainable highly pathogens surveillance control programs to human motility and environmental sanitation strategies all represent 'One Health' approach implementation strategic core. Initiation, development and implementation leaded by Saudi government and international stakeholders' of new partnership, coordinated response leadership and resource mobilization for multidisciplinary and intersectorial advocacy on emerging viral disease outbreaks, accompanied with R&D roadmap and taskforce is crucial. More efforts in epidemiological and laboratory early screening and surveillance of highly pathogenic germs/microbes, and confirmation of asymptomatic and syndromic cases amongst suspected Hajj and Umrah pilgrims, local vulnerable populations and expatriate workers is vital in generating reliable data and data sharing platform for timely risk communication and tourist information update, appropriate immunization campaigns or safe and efficacious care delivery implementation. Moreover, increase Hajj/Umrah mass gathering emergency outbreak preparedness, pilgrims health education and engagement outreach, pre-, during and post programs coverage and effectiveness is needed through One Health approach integration in attaining pilgrims and local population health safety and security, in advancing Saudi sustainable health development goals.

Pediatric Practice Readiness for Disaster Response

OBJECTIVES

The American Academy of Pediatrics (AAP) calls for the inclusion of office-based pediatricians in disaster preparedness and response efforts. However, there is little research about disaster preparedness and response on the part of pediatric practices. This study describes the readiness of pediatric practices to respond to disaster and delineates factors associated with increased preparedness.

METHODS

An AAP survey was distributed to members to assess the state of pediatric offices in readiness for disaster. Potential predictor variables used in chi-square analysis included community setting, primary employment setting, area of practice, and previous disaster experience.

RESULTS

Three-quarters (74%) of respondents reported some degree of disaster preparedness (measured by 6 indicators including written plans and maintaining stocks of supplies), and approximately half (54%) reported response experience (measured by 3 indicators, including volunteering to serve in disaster areas). Respondents who reported disaster preparation efforts were more likely to have signed up for disaster response efforts, and vice versa.

CONCLUSIONS

These results contribute information about the state of pediatric physician offices and can aid in developing strategies for augmenting the inclusion of office-based pediatricians in community preparedness and response efforts.

Management of Patients in the Context of Zika Virus: ACOG COMMITTEE OPINION, Number 784

Zika virus is a flavivirus with the potential to cause serious adverse pregnancy and infant outcomes. Although rates of Zika virus infection have decreased in the United States, obstetrician-gynecologists and other health care providers should continue to assess their patients for potential exposure based on travel or sexual history and test symptomatic patients with possible exposure and pregnant women with ongoing exposure regardless of symptoms in accordance with the Centers for Disease Control and Prevention recommendations. Pregnant women and those planning a pregnancy should talk to their health care providers about potential risks before traveling to an area where current or past Zika virus transmission has occurred. Testing recommendations for pregnant women with possible Zika virus exposure differ based on the presence or absence of symptoms of Zika virus infection and the circumstances of possible exposure. If obstetrician-gynecologists or other health care providers identify a patient who has possibly been exposed to the Zika virus and may require testing, they should contact their local or state health department for assistance. Consultation with a maternal-fetal medicine specialist or an infectious disease specialist with expertise in the management of infectious diseases in pregnancy may be useful for pregnant women with possible maternal Zika virus infection or concerning fetal findings. Zika virus identification and follow-up care of infants born to women with possible exposure to Zika virus during pregnancy are critical and can ensure that appropriate intervention services are available to affected infants. Obstetrician-gynecologists and other obstetric care providers should have a system to ensure relevant information regarding a woman's Zika infection status is communicated to pediatric care providers.

Neurodevelopmental Abnormalities in Children With In Utero Zika Virus Exposure Without Congenital Zika Syndrome

IMPORTANCE

The number of children who were born to mothers with Zika virus (ZIKV) infection during pregnancy but who did not have apparent disability at birth is large, warranting the study of the risk for neurodevelopmental impairment in this population without congenital Zika syndrome (CZS).

OBJECTIVE

To investigate whether infants without CZS but who were exposed to ZIKV in utero have normal neurodevelopmental outcomes until 18 months of age.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study prospectively enrolled a group of pregnant women with ZIKV in Atlántico Department, Colombia, and in Washington, DC. With this cohort, we performed a longitudinal study of infant neurodevelopment. Infants born between August 1, 2016, and November 30, 2017, were included if they were live born, had normal fetal brain findings on magnetic resonance imaging and ultrasonography, were normocephalic at birth, and had normal examination results without clinical evidence of CZS. Seventy-seven infants born in Colombia, but 0 infants born in the United States, met the inclusion criteria.

EXPOSURES

Prenatal ZIKV exposure.

MAIN OUTCOMES AND MEASURES

Infant development was assessed by the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) and the Alberta Infant Motor Scale (AIMS) at 1 or 2 time points between 4 and 18 months of age. The WIDEA and AIMS scores were converted to z scores compared with normative samples. Longitudinal mixed-effects regression models based on bootstrap resampling methods estimated scores over time, accounting for gestational age at maternal ZIKV infection and infant age at assessment. Results were presented as slope coefficients with 2-tailed P values based on z statistics that tested whether the coefficient differed from 0 (no change).

RESULTS

Of the 77 Colombian infants included in this cohort study, 70 (91%) had no CZS and underwent neurodevelopmental assessments. Forty infants (57%) were evaluated between 4 and 8 months of age at a median (interquartile range [IQR]) age of 5.9 (5.3-6.5) months, and 60 (86%) underwent assessment between 9 and 18 months of age at a median (IQR) age of 13.0 (11.2-16.4) months. The WIDEA total score (coefficients: age = -0.227 vs age2 = 0.006; P < .003) and self-care domain score (coefficients: age = -0.238 vs age2 = 0.01; P < .008) showed curvilinear associations with age. Other domain scores showed linear declines with increasing age based on coefficients for communication (-0.036; P = .001), social cognition (-0.10; P < .001), and mobility (-0.14; P < .001). The AIMS scores were similar to the normative sample over time (95% CI, -0.107 to 0.037; P = .34). Nineteen of 57 infants (33%) who underwent postnatal cranial ultrasonography had a nonspecific, mild finding. No difference was found in the decline of WIDEA z scores between infants with and those without cranial ultrasonography findings except for a complex interactive relationship involving the social cognition domain (P < .049). The AIMS z scores were lower in infants with nonspecific cranial ultrasonography findings (-0.49; P = .07).

CONCLUSIONS AND RELEVANCE

This study found that infants with in utero ZIKV exposure without CZS appeared at risk for abnormal neurodevelopmental outcomes in the first 18 months of life. Long-term neurodevelopmental surveillance of all newborns with ZIKV exposure is recommended.

Detecting Emerging Infectious Diseases: An Overview of the Laboratory Response Network for Biological Threats

The Laboratory Response Network (LRN) was established in 1999 to ensure an effective laboratory response to high-priority public health threats. The LRN for biological threats (LRN-B) provides a laboratory infrastructure to respond to emerging infectious diseases. Since 2012, the LRN-B has been involved in 3 emerging infectious disease outbreak responses. We evaluated the LRN-B role in these responses and identified areas for improvement. LRN-B laboratories tested 1097 specimens during the 2014 Middle East Respiratory Syndrome Coronavirus outbreak, 180 specimens during the 2014-2015 Ebola outbreak, and 92 686 specimens during the 2016-2017 Zika virus outbreak. During the 2014-2015 Ebola outbreak, the LRN-B uncovered important gaps in biosafety and biosecurity practices. During the 2016-2017 Zika outbreak, the LRN-B identified the data entry bottleneck as a hindrance to timely reporting of results. Addressing areas for improvement may help LRN-B reference laboratories improve the response to future public health emergencies.

Anxiety and depression among caregivers of young children with Congenital Zika Syndrome in Brazil

PURPOSE

To examine the psychological well-being of primary caregivers of infants and toddlers with Congenital Zika Syndrome (CZS), and the roles of family resources, parenting stress, and coping strategies in caregivers' adaptation.

MATERIALS AND METHODS

Family caregivers (N = 50) of children with CZS who were receiving treatment at a rehabilitation hospital in Recife, Brazil participated a cross-sectional survey study. Caregivers completed measures of anxiety and depression, coping strategies, family resources, and parenting stress.

RESULTS

Mild to severe symptoms of depression were identified in 40% of caregivers and were a more prominent concern than symptoms of anxiety. Fewer family resources and high levels of parenting stress were significantly associated with both anxiety and depression. The association between parenting stress and depression was moderated by coping, such that parenting stress was associated with higher caregiver depression at low but not high levels of coping strategy use.

CONCLUSIONS

Practitioners in Brazil should consider the role of family coping and resources as important resilience promoting factors in the development of new programs designed to promote psychological adaptation in caregivers to children with CZS. It is recommended that caregiver mental health support services be integrated into existing early intervention programs targeting children with CZS.Implications for RehabilitationParents and other primary caregivers are encouraged to take an active role in the care and developmental monitoring of children born with CZS, but their ability to provide care may be compromised by difficulties in psychological adaptation.Moderate and severe symptoms of depression were more prominent in caregivers than moderate and severe symptoms of anxiety (20% versus 6%, respectively).Practitioners should include assessment of coping strategies, parenting stress and family resources conjointly with evaluation of symptoms of depression and anxiety as part of routine CZS family evaluations.A useful approach for caregivers in Brazil may be to more fully integrate caregiver mental health support services into existing early intervention programs for children with CZS.

Evaluation of Patients for Zika Virus Infection in a Travel Clinic in the Southeast United States, 2016

OBJECTIVES

Zika virus is an emerging infection that has posed vexing challenges to the US public health system. Improved characterization of patients with possible and confirmed infection is needed to better understand risks for infection in US travelers and to inform evolving evaluation guidelines.

METHODS

We performed a retrospective electronic health record review of patients evaluated for Zika virus infection at an academic travel clinic in Atlanta, Georgia, from January 1 through August 31, 2016. We evaluated 46 patients who presented to the clinic during this period for evaluation of possible Zika virus infection, including patients with Zika virus symptoms, asymptomatic patients with possible exposure to Zika virus, and referral visits for Zika virus testing.

RESULTS

Among the 46 patients evaluated, 30 (65.2%) were tested for Zika virus, 8 of whom (17.4%) had laboratory evidence of infection (7 confirmed, 1 probable). Cases, including confirmed and probable infections, most commonly had fever, rash, conjunctivitis, headache, and myalgia, although differences compared with noncases were not statistically significant. Many patients evaluated were not tested because of stringent testing criteria.

CONCLUSIONS

Our findings may help inform improvements in timely clinical decision making for Zika virus testing. This may assist clinicians and public health agencies. Wider access to accurate screening modalities will help providers evaluate and advise patients.

Zika virus infection from a newborn point of view. TORCH or TORZiCH?

Zika virus (ZIKV) belongs to the group of viruses called arboviruses. Congenital Zika syndrome is a new disease with infectious teratogenic aetiology. The clinical symptoms are divided into morphological and functional. Most severe complication is the foetal brain disruption sequence that includes severe microcephaly, anomalies of the eyes and congenital contractions of joints. The aim of this paper was to review available facts about Zika virus infection from a newborn point of view in a form of the summary of all important information. Zika virus infection is a problem of past, present and future. Epidemics may occur because of global climate changes, also in countries where natural conditions for life of mosquitos are not present. This clearly indicates the need to continue developing of vaccines and specific antiviral drugs. Until this happens, we must adhere individual preventive measures. Zika virus has proven to us how it can affect the health of adults and neonates but also thinking of healthy people. Newborns with microcephaly on the front pages of the media caused in 2015 panic and fear around the world – for this reason education of people is necessary. Due to serious congenital disorders associated with ZIKV infection and global impact of virus we suggest modifying old acronym TORCH for new TORZiCH to accent the position of Zika virus.

Auditory findings associated with Zika virus infection: an integrative review

Introduction

Possible associations between Zika virus infection and hearing loss were observed during the epidemic in the Americas.

Objective

To describe the auditory alterations, pathogenesis and recommendations for follow-up in individuals with prenatal or acquired Zika virus infection.

Methods

Bibliographic research conducted in March/2018–April/2019 at the main available databases. Article selection, data extraction and quality evaluation were carried out by two independent reviewers. Studies containing auditory evaluation of patients with congenital or acquired Zika virus infection; and/or hypotheses or evidences on the pathophysiology of auditory impairment associated with Zika virus; and/or recommendations on screening and follow-up of patients with auditory impairment by Zika virus were included.

Results

A total of 27 articles were selected. Sensorineural and transient hearing loss were reported in six adults with acquired Zika virus infection. Of the 962 studied children, 482 had microcephaly and 145 had diagnostic confirmation of Zika virus; 515 of the 624 children with auditory evaluation performed only screening tests with otoacoustic emissions testing and/or automated click-stimuli auditory brainstem response testing. Studies in prenatally exposed children were very heterogeneous and great variations in the frequency of altered otoacoustic emissions and automated click-stimuli auditory brainstem response occurred across the studies. Altered otoacoustic emissions varied from 0% to 75%, while altered automated click-stimuli auditory brainstem response varied from 0% to 29.2%. Sensorineural, retrocochlear or central origin impairment could not be ruled out. One study with infected mice found no microscopic damage to cochlear hair cells. Studies on the pathogenesis of auditory changes in humans are limited to hypotheses and recommendations still include points of controversy.

Conclusion

The available data are still insufficient to understand the full spectrum of the involvement of the auditory organs by Zika virus, the pathogenesis of this involvement or even to confirm the causal association between auditory involvement and virus infection. The screening and follow-up recommendations still present points of controversy.

Provider and Public Health Adaptation to Changing Centers for Disease Control and Prevention Guidance for Zika Virus, 2015-2017

In 2015, Harris County (Texas) Public Health responded to the Zika virus (ZIKV) threat by investigating every report of potential ZIKV infection, including those with negative laboratory results, through December 2017. Before investigations, 40.6% of patients who were indicated for testing received it in accordance with Centers for Disease Control and Prevention guidelines. By investigating reports with negative ZIKV results, we increased the number of patients receiving correct and complete laboratory testing to 54.5%, and improved dissemination of evolving guidelines to partners across the health care spectrum.

Diagnosis of Zika Virus Infections: Challenges and Opportunities

Accurate diagnosis of Zika virus (ZIKV) infections has become a pressing need for the effective prevention and control of the epidemic. The findings that ZIKV infections are associated with birth defects and neurologic disease, and that the virus can be sexually transmitted, accentuate the need for accurate diagnostic testing for different applications new to the arbovirus field. Antibody response to related flaviviruses has long been known to be cross-reactive, and antibody detection of ZIKV is nonspecific in populations previously exposed to any of the four dengue viruses or West Nile virus, or vaccinated against yellow fever virus. Therefore, the diagnosis of ZIKV infections has increasingly depended on detection by nucleic acid tests. During the recent epidemic, tests authorized for emergency use have been utilized by public health laboratories and the commercial sector, but a more dependable and responsive diagnostic testing has yet to be developed.

Unilateral Phrenic Nerve Palsy in Infants with Congenital Zika Syndrome

This case series of right unilateral diaphragmatic paralysis suggests peripheral nervous system involvement.

Since the first identification of neonatal microcephaly cases associated with congenital Zika virus infection in Brazil in 2015, a distinctive constellation of clinical features of congenital Zika syndrome has been described. Fetal brain disruption sequence is hypothesized to underlie the devastating effects of the virus on the central nervous system. However, little is known about the effects of congenital Zika virus infection on the peripheral nervous system. We describe a series of 4 cases of right unilateral diaphragmatic paralysis in infants with congenital Zika syndrome suggesting peripheral nervous system involvement and Zika virus as a unique congenital infectious cause of this finding. All the patients described also had arthrogryposis (including talipes equinovarus) and died from complications related to progressive respiratory failure.

Ocular Manifestations and Visual Outcome in Children With Congenital Zika Syndrome

The recent Zika virus (ZIKV) outbreak and the link to birth defects in newborns exposed in utero, caught international attention. Due to its rapid spread throughout the Americas, authorities declared ZIKV a Public Health Emergency of International Concern that lasted from February to November 2016."Congenital Zika Syndrome" (CZS) is a new entity that reflects a broad spectrum of symptoms and signs observed in newborns infected by the ZIKV in utero. A recent review concluded that CZS differs from other congenital infections for its five distinct features: "(1) severe microcephaly with partially collapsed skull; (2) thin cerebral cortices with subcortical calcifications; (3) macular scarring and focal pigmentary retinal mottling; (4) congenital contractures; and (5) marked early hypertonia and symptoms of extrapyramidal involvement."Diagnosing and managing CZS has become a challenge for health professionals including ophthalmologists. The ocular manifestations of CZS are unique and have important consequences on vision. This article reviews the ocular manifestations of the CZS, addresses the visual outcomes of affected infants, and elucidates the early intervention protocols for visual improvement.

Zika Virus Infection in Children

Zika virus is a mosquito-borne Flavivirus responsible for symptomatic and asymptomatic infections in humans. Zika was first identified in Africa as a cause of sporadic febrile illness. Beginning in 2015, Zika virus infection was identified in Brazil and linked with several symptomatic infections. Notably, congenital infections were observed with marked neurologic abnormalities. Diagnosis relies on detection of Zika virus by real-time polymerase chain reaction or by the presence of anti-Zika antibodies. Treatment of this viral illness remains supportive; however, proactive screening and interventions are indicated in the treatment of infants with symptomatic congenital infection.

Zika Virus-Associated Guillain-Barré Syndrome in a Returning US Traveler

Zika virus (ZIKV) infection has been associated with Guillain-Barré Syndrome (GBS). Roughly 60% of people in countries such as the U.S. live in areas at risk for seasonal spread of ZIKV. ZIKV belongs to a class of diseases that is not typically seen in hospital settings across the U.S. and Europe. We describe the case presentation, management, and treatment of ZIKV infection complicated by GBS. A 64-year-old woman with recent travel to the Dominican Republic presented with rash followed by an acute, ascending polyneuropathy consistent with GBS. She was confirmed to have an acute ZIKV infection by detection of ZIKV nucleic acid by reverse transcription-polymerase chain reaction. She met Brighton Collaboration criteria level 1 evidence for GBS. She received two courses of intravenous immunoglobulin and slowly improved, though still had weakness at discharge. More research is needed to identify the pathophysiology behind ZIKV-associated GBS and its optimal treatment. Prevention is fundamental to limiting infection and spread of ZIKV.

Stakeholder Insights from Zika Virus Infections in Houston, Texas, USA, 2016–2017

Responding to Zika virus infections in Houston, Texas, USA, presented numerous challenges across the health system. As the nation’s fourth-largest city, in a subtropical region with high travel volume to Latin America and the Caribbean, Houston was an ideal location for studying experiences encountered by clinicians and public health officials as they responded to the Zika virus crisis. To identify the challenges encountered in the response and to explore strategies to improve future responses to emerging infectious diseases, we interviewed 38 key stakeholders who were clinical, scientific, operational, and public health leaders. From the responses, we identified 4 key challenges: testing, travel screening, patient demographics and immigration status, and insufficient collaboration (between public health officials and clinicians and among clinical providers). We also identified 5 strategic areas as potential solutions: improved electronic health record support, specialty centers and referral systems, standardized forms, centralized testing databases, and joint academic/public health task forces.

Readiness for an Increase in Congenital Zika Virus Infections in the United States: Geographic Distance to Pediatric Subspecialist Care

OBJECTIVE

The study's purpose was to investigate readiness for an increase in the congenital Zika infection (CZI) by describing the distribution of pediatric subspecialists needed for the care of children with CZI.

METHODS

We applied county-level subspecialist counts to US maps, overlaying the geocoded locations of children's hospitals to assess the correlation of hospital and subspecialist locations. We calculated travel distance from census tract centroids to the nearest in-state children's hospital by state (with/without &gt; 100 reported adult Zika virus cases) and by regions corresponding to the likely local Zika virus transmission area and to the full range of the mosquito vector. Travel distance percentiles reflect the population of children 100 miles.

CONCLUSION

The travel distance to pediatric subspecialty care varies widely by state and is likely to be an access barrier in some areas, particularly states bordering the Gulf of Mexico, which may have increasing numbers of CZI cases. (Disaster Med Public Health Preparedness. 2019;13:476-486).

[Analysis of the concept of the Zika Virus congenital syndrome]

The scope of this article is to analyze the concept of the Zika Virus Congenital Syndrome. It is a conceptual analysis, based on Walker and Avant. In order to operationalize the search, a systematic review was conducted. The essence of the concept of the Zika Virus Congenital Syndrome is determined by the following attributes: intracranial calcification, ventriculomegaly, and diminished brain volume. For this syndrome to occur, it is necessary to have the following antecedents: transplacental transmission of a mother infected by the bite of the Aedes SSP mosquito or by sexual contact. Accordingly, this entails a set of signs and symptoms that go beyond fetal or postnatal microcephaly, such as, for example, delayed neuropsychomotor development, auditory and visual abnormalities, craniofacial disproportion, overlapping cranial sutures, prominent occipital bone, excess nuchal skin, epilepsy, irritability, dyskinesia, hypertonia, hypotonia, hemiplegia, hemiparesis, spasticity and hyperreflexia. The concept of the Zika Virus Congenital Syndrome is newly acknowledged. The presence of the set of signs and symptoms by the Zika Virus Congenital Syndrome is determined by intracranial calcification and decreased brain volume, and the baby may present microcephaly at birth or subsequently.

Population-based pregnancy and birth defects surveillance in the era of Zika virus

BACKGROUND

Zika virus is a newly recognized human teratogen; monitoring its impact on the birth prevalence of microcephaly and other adverse pregnancy outcomes will continue to be an urgent need in the United States and worldwide.

METHODS

When the Centers for Disease Control and Prevention (CDC) activated the Emergency Operations Center for the Zika virus outbreak response in January of 2016, public health leadership recognized that a joint, coordinated effort was required between activities focused on the effects of the infection among pregnant women and those focused on birth defects in fetuses and infants. Before the introduction of Zika virus in the Americas, population-based birth defects surveillance occurred independently of pregnancy surveillance activities.

RESULTS

The coordination of pregnancy surveillance and birth defects surveillance implemented through the CDC Zika virus response represents a paradigm shift.

CONCLUSION

Coordination of these surveillance systems provides an opportunity to capture information from both a prospective and retrospective approach. This relatively modest investment in the public health infrastructure can continue to protect pregnant women and their infants during the ongoing response to Zika virus and in the next emergent threat to maternal and child health. Birth Defects Research 109:372-378, 2017. © 2017 Wiley Periodicals, Inc.

Ocular abnormalities in congenital Zika syndrome: a case report, and review of the literature

Background

As the number of children with Zika virus-related complications grows, the long-term developmental trajectory and its effects on families are unknown. We present the first known case of congenital Zika syndrome seen at our institution with significant fundus findings.

Case presentation

A 3-day-old Hispanic baby girl presented with severe microcephaly of 24 cm and temperature instability at birth. Her mother had traveled to Honduras early in pregnancy and testing of amniotic fluid was positive for Zika virus via polymerase chain reaction. A dilated fundus examination was significant for bilateral severe colobomatous chorioretinal atrophy of the macula and pigmentary changes. Neonatal magnetic resonance imaging revealed diffuse lissencephaly with decreased brain volume, atrophic corpus callosum and brainstem, periventricular calcifications, and ventriculomegaly of the lateral ventricles.

Conclusions

Our patient, who presented with the first known case of congenital Zika syndrome in Northern Florida, demonstrated profound bilateral colobomatous chorioretinal atrophy of the macula. The ophthalmologic findings along with severe microcephaly emphasize the neurotropism of the Zika virus, and ultimately are indicative of poor developmental and visual prognosis for affected infants. With the increased prevalence of Zika virus, ophthalmologists should be aware of the associated findings and the importance of an eye-screening examination with a dilated fundus examination within 1 month of life of infants in which congenital Zika syndrome is suspected. A multidisciplinary care approach is essential for the care of affected infants and their families.

Detection of Zika virus infection among asymptomatic pregnant women in the North of Peru

OBJECTIVE

To report an outbreak of ZIKV infection among asymptomatic pregnant women during 2016 in the city of Jaen, Cajamarca.

RESULTS

Zika virus RNA was detected in 3.2% (n = 36) of cases by RT-PCR. The mean age of patients positive for ZIKV infection was 29.6 years. 7 patients (19.4%) infected with ZIKV were in their first-trimester of gestation, 13 (36.1%) were in their second-trimester, and 16 (44%) were in their third-trimester. All of the infected pregnant women were asymptomatic. ZIKV infection remains a major public health issue that calls for constant epidemiological surveillance. It can cause the congenital Zika virus syndrome in the newborns of infected mothers. The lack of molecular diagnostic methods in isolated localities and the similarity of symptoms to other arboviral infections, lead to an under-diagnosis of this disease in endemic areas.

Zika Virus Trafficking and Interactions in the Human Male Reproductive Tract

Sexual transmission of Zika virus (ZIKV) is a matter of great concern. Infectious viral particles can be shed in semen for as long as six months after infection and can be transferred to male and female sexual partners during unprotected sexual intercourse. The virus can be found inside spermatozoa and could be directly transferred to the oocyte during fertilization. Sexual transmission of ZIKV can contribute to the rise in number of infected individuals in endemic areas as well as in countries where the mosquito vector does not thrive. There is also the possibility, as has been demonstrated in mouse models, that the vaginal deposition of ZIKV particles present in semen could lead to congenital syndrome. In this paper, we review the current literature to understand ZIKV trafficking from the bloodstream to the human male reproductive tract and viral interactions with host cells in interstitial spaces, tubule walls, annexed glands and semen. We hope to highlight gaps to be filled by future research and potential routes for vaccine and antiviral development.

The Zika epidemic and abortion in Latin America: a scoping review

BACKGROUND

Latin America presently has the world's highest burden of Zika virus, but there are unexplained differences in national rates of congenital malformations collectively referred to as Congenital Zika Syndrome (CZS) in the region. While Zika virulence and case detection likely contribute to these differences, policy-related factors, including access to abortion, may play important roles. Our goal was to assess perspectives on, and access to, abortion in Latin America in the context of the Zika epidemic.

METHODS

We conducted a scoping review of peer-reviewed and gray literature published between January 2015 and December 2016, written in English, Spanish, Portuguese, or French. We searched PubMed, Scielo, and Google Scholar for literature on Zika and/or CZS and abortion, and used automated and manual review methods to synthesize the existing information.

RESULTS

36 publications met our inclusion criteria, the majority of which were qualitative. Publications were generally in favor of increased access to safe abortion as a policy-level response for mitigating the impact of CZS, but issues with implementation were cited as the main challenge. Aside from the reform of abortion regulation in Colombia, we did not find evidence that the Zika epidemic had triggered shifts in abortion policy in other countries.

CONCLUSION

Abortion policy in the region remained largely unchanged following the Zika epidemic. Further empirical research on abortion access and differential rates of CZS across Latin American countries is required.

Zika virus infection in a pregnant Canadian traveler with congenital fetal malformations noted by ultrasonography at 14-weeks gestation

BACKGROUND

Following emergence of Zika virus in the Americas, a devastating new congenital syndrome has been documented, leading to significant morbidity among Zika-infected fetuses and neonates.

CASE PRESENTATION

A 29-year-old pregnant woman infected with Zika virus at 9-weeks gestation in Trinidad presented with one-month of fever, headache, and myalgia with persistent viremia. Significant fetal abnormalities were identified at 14-week ultrasound, which is the earliest ultrasound to describe a severely affected fetus following Zika virus infection to our knowledge.

CONCLUSIONS

We discuss the implications of prolonged maternal viremia and the spectrum of congenital Zika syndrome detectable by fetal ultrasound.

Two Infants with Presumed Congenital Zika Syndrome, Brownsville, Texas, USA, 2016-2017

Since 2007, Zika virus has spread through the Pacific Islands and the Americas. Beginning in 2016, women in Brownsville, Texas, USA, were identified as possibly being exposed to Zika virus during pregnancy. We identified 18 pregnant women during 2016-2017 who had supportive serologic or molecular test results indicating Zika virus or flavivirus infection. Two infants were evaluated for congenital Zika syndrome after identification of prenatal microcephaly. Despite standard of care testing of mothers and neonates, comparative results were unreliable for mothers and infants, which highlights the need for clinical and epidemiologic evidence for an accurate diagnosis. A high index of suspicion for congenital Zika syndrome for at-risk populations is useful because of current limitations of testing.

Zika Virus Disease for the Neurointensivist

Zika virus (ZIKV) is a mosquito-borne and sexually transmitted flavivirus currently spreading throughout the Pacific and Western Hemisphere. ZIKV infection is often either asymptomatic or causes a self-limiting illness with symptoms such as rash, fever, myalgia, arthralgia, headache, or conjunctivitis. Rarely, ZIKV infection has been associated with conditions such as severe thrombocytopenia, microcephaly and other developmental abnormalities, acute polyneuropathy/Guillain-Barré syndrome, myelitis, meningoencephalitis, transient encephalopathy, provoked seizures, and various ophthalmologic conditions. Optimal treatment of these ZIKV-associated conditions is currently unclear and is largely guided by expert opinion or case reports/series. Further studies are needed to establish best treatment practices. This review concentrates on caring by neurointensivists for the patient affected with Zika virus-expected to flare up again in the summer.

Cardiac findings in infants with in utero exposure to Zika virus- a cross sectional study

Background

Antenatal exposure to Zika virus (ZIKV) is related to severe neurological manifestations. A previous study in Brazil reported an increased incidence of non-severe congenital heart defects in infants with diagnosis of congenital Zika syndrome but without laboratory confirmation of ZIKV infection in the mother or infant. The objective of this study is to report echocardiographic (ECHO) findings in infants with laboratory confirmed antenatal exposure to ZIKV.

Methodology

Cross sectional study of cardiologic assessments of infants born between November 2015 and January 2017 with confirmed vertical exposure to ZIKV in Rio de Janeiro, Brazil.

Results

The study enrolled 120 children with a median age of 97 days (1 to 376 days). In utero exposure to ZIKV was confirmed in 97 children (80,8%) through positive maternal polymerase chain reaction (PCR) results during pregnancy or a positive PCR result at birth; 23 additional children (19.2%) had maternal positive PCR results during pregnancy and postnatally. Forty- eight infants (40%) had cardiac defects noted on ECHO. Thirteen infants (10.8%) had major cardiac defects (atrial septal defect, ventricular septal defect, patent ductus arteriosus). None of the defects were severe. The frequency of major defects was higher in infants whose mothers had a rash in the 2nd trimester of pregnancy, or who had altered Central Nervous System (CNS) imaging postnatally or were preterm.

Conclusions

Infants with in utero ZIKV exposure have a higher prevalence of major cardiac defects, however none were severe enough to require immediate intervention. For this reason, guidelines for performance of postnatal ECHO in this population should follow general newborn screening guidelines, which significantly reduces the burden of performing emergent fetal or neonatal ECHOs in a setting where resources are not available, such as most Brazilian municipalities.

We performed cardiologic assessment of 120 infants born between November 2015 and January 2017 with confirmed vertical exposure to Zika virus (ZIKV). The diagnosis of ZIKV exposure was confirmed by PCR in maternal blood specimens and/or amniotic fluid during pregnancy and/or infant specimens including PCR of the cerebrospinal fluid (CSF) and/or urine following birth. Our study found a 10.8% incidence of structural heart defects in infants with a history of intrauterine exposure to ZIKV, a rate considerably higher than that observed in the general population. However, no patients were found to have severe structural heart defects. The presence of major defects was increased in infants whose mothers had a history of rash in the 2nd trimester, infants with altered CNS imaging and/or preterm infants. As severe heart defects requiring immediate intervention were not identified, guidelines for performance of postnatal ECHO in this population should follow the same criteria as the ones applicable to newborns in general, particularly since resources for performance of fetal and neonatal echocardiograms are not routinely available in most Brazilian municipalities

Ophthalmologic Manifestations Associated With Zika Virus Infection

Vision plays an important role in the development of communication, social interaction, spatial awareness, and the motor skills needed to explore the environment. In the past 2 years, researchers have described the broad spectrum of clinical features that comprise congenital Zika syndrome (CZS). The ocular manifestations are considered 1 important pillar of this new entity. The most characteristic ophthalmic findings include chorioretinal scars and focal pigmentary changes seen in the macular region. Since these findings were first reported, other researchers have validated and extended them, leading to a more complete picture of the spectrum of ocular manifestations related to CZS. In this article, we summarize the current knowledge on the ocular implications of CZS and emphasize the importance of early rehabilitation to enhance visual performance in affected children.

The Likely Impact of Congenital Zika Syndrome on Families: Considerations for Family Supports and Services

Congenital Zika virus infection has obvious implications for infants, and considerable research has addressed the nature and consequences of congenital Zika syndrome (CZS). Children with classic CZS meet the criteria for "children with medical complexity," and ongoing research is required to understand the range of needs and optimal treatment options. Far less attention has been given to the consequences of CZS for families, which are both immediate and lifelong. Although families of children with CZS have much in common with families of other children with disabilities, at least 4 features of CZS have special family implications: (1) the severity of the impact on children with obvious abnormalities at birth, coupled with the anticipation of a lifetime of caregiving and economic burdens; (2) uncertainty about the unfolding consequences, both for obviously affected children and for exposed children with no symptoms at birth; (3) a lack of specialized professional knowledge about the course of the disease or treatment options; and (4) social isolation, a lack of social or community supports, and potential stigma. Supporting families will require a family-centered approach to services, extensive care coordination, access to evolving new information, ongoing surveillance, formal and informal supports, and individualized child and family services.

Development of Infants With Congenital Zika Syndrome: What Do We Know and What Can We Expect?

The association between Zika virus infection during pregnancy and severe birth defects in infants has led to worldwide attention focused on the mechanisms of the disease and the prevention of future exposure. Surveillance efforts around the world continue with the goal of identifying and monitoring all potentially exposed women and their newborns. For infants who were born with congenital Zika syndrome (CZS) and their families, an uncertain future awaits. As infants who were born with CZS during the most recent outbreak enter their second year of life, new developments in the outcomes of the condition continue to unfold, providing some insight into the likely long-term sequalae. In this article, I review the literature on emerging findings regarding the impact of CZS on the developing infant and provide some predictions regarding the long-term outcomes and lifetime needs of these children and their families.

Zika clinical updates: implications for pediatrics

PURPOSE OF REVIEW

Zika virus (ZIKV), a mosquito-borne flavivirus, has gained recognition over the past few years as an important new cause of congenital infection. As a result, it is critical that pediatricians understand its epidemiology, clinical presentation, clinical sequelae, and management.

RECENT FINDINGS

The recent ZIKV epidemiology, clinical presentation of acute infection in children and complications, perinatal infection, and congenital infection will be summarized in this ZIKV review. This will be followed by a brief summary on ZIKV diagnosis, management, treatment, and prevention.

SUMMARY

The field of clinical research in ZIKV has rapidly evolved over recent months. It is critical that pediatricians continue to stay up-to-date with the continuously evolving understanding of the clinical aspects of ZIKV to ensure optimal identification and management of affected infants and children. Given the recent changes in Centers for Disease Control and Prevention guidelines to limit screening of asymptomatic pregnant women in the United States with possible ZIKV exposure, comprehensive ZIKV clinical knowledge becomes even more crucial.

Zika virus infection in children: epidemiology and clinical manifestations

PURPOSE

The purpose of this review is to comprehensively review Congenital Zika Syndrome in regard to their epidemiology and clinical manifestations.

METHODS

This subject review of congenital Zika syndrome was composed after conducting a thorough review of the available literature on this topic using PubMed and other primary sources.

RESULTS

The first epidemic of Zika virus infection in Brazil was followed by an unexpected sharp increase in the incidence of infants born with microcephaly and the description of a new disease, the congenital Zika syndrome. This review focuses on the epidemiological and clinical aspects of Zika infection in children. We conducted a brief historical account of the virus description in 1947, the rare cases of Zika infection occurring up to 2007, and the first epidemics in the Pacific between 2007 and 2014. We also discussed the isolation of the virus in Brazil in 2015 and its spread in the Americas, the microcephaly outbreak in Brazil and its association with Zika virus, and the current epidemiological panorama. We address the known clinical spectrum of Zika virus infection in the pediatric population, including manifestations of acute infection and congenital Zika syndrome, with emphasis on cranial, ophthalmic, and orthopedic abnormalities.

CONCLUSION

While much has been learned about congenital Zika syndrome, the full spectrum of this infection is not yet known. This review is based on current, limited data about Zika vírus infection. As more information becomes available, we will have a more accurate picture of this new disease.

Zika Virus Infection in Pregnancy: Maternal, Fetal, and Neonatal Considerations

An infection with the Zika virus (ZIKV) is usually mild, with nonspecific symptoms and most often asymptomatic. However, because of its causal relationship with severe congenital malformations, the ZIKV epidemic became an imperative for mobilization, renewed strategies for vector control, and biomedical research. A congenital Zika syndrome (CZS) has been characterized with 5 distinctive features that focus on brain development abnormalities (including microcephaly and brain calcifications), retinal manifestations, and defects on extremities including congenital contractures and hypertonia. The CZS could be just "the tip of the iceberg", pending the documentation of a spectrum of disease that could manifest later in life, from mild dysfunction to severe disease. It will be a matter of time for neurodevelopmental abnormalities, learning disabilities, and other unknown but yet-to-be-described outcomes to be associated with intrauterine ZIKV infection. In addition, ZIKV infection during pregnancy has been associated with other adverse outcomes. Reports mostly include ZIKV-affected pregnancies, and it will be difficult to clearly establish causality without appropriate control groups. We are summarizing some of the known or reported consequences of such infection during pregnancy. Women of reproductive age and particularly pregnant women are the most vulnerable to the adverse consequences of the ZIKV epidemic. Vector control programs need to be expanded to curtail new infections. Research is needed to develop safe and effective treatments, a preventive or therapeutic vaccine, and specific and sensitive tests and to diagnose and identify correlates of long-term immunity. Vaccines and treatments should be safe to be used in pregnancy. To do nothing would allow thousands of pregnant women to expose their fetuses to an infection that causes birth defects and other problems. Prenatal diagnosis technology development is necessary to be able to predict or diagnose adverse fetal outcomes related to ZIKV. Moreover, these tests should be used in a manner similar to the testing/screening method for neural tube defects and common chromosomal anomalies during prenatal care.

Zika Virus: A Review for Pediatricians

For the past several years, the Zika virus has been a topic of conversation among pediatric health care providers in many settings. This article provides current answers to many questions that may be posed to pediatricians, including inquiries about clinical presentation, testing, and prevention. Although infants born with congenital Zika syndrome often have microcephaly, there are other characteristic features, such as eye abnormalities, that one should recognize. Additionally, testing for the syndrome must be considered in all infants at risk for infection, including those who are asymptomatic at birth. Maternal travel to an endemic region or sexual intercourse with an exposed person shortly before or during pregnancy may put an infant at risk for infection. [Pediatr Ann. 2017;46(11):e428-e432.].