{"id":8009,"date":"2016-02-07T15:25:48","date_gmt":"2016-02-07T20:25:48","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8009"},"modified":"2016-02-08T09:00:56","modified_gmt":"2016-02-08T14:00:56","slug":"twelve-zika-questions-one-id-doctors-answers-sort-of","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/twelve-zika-questions-one-id-doctors-answers-sort-of\/2016\/02\/07\/","title":{"rendered":"Twelve Zika Questions, One ID Doctor’s Answers (Sort Of)"},"content":{"rendered":"

\"Aedes_aegypti\"<\/a>Got a Zika question? Welcome to the club — once again, as with any “new” or “emerging” infection, this is uncharted territory, and there are plenty of answers to these questions that could be summarized with 3 words: We Don’t Know.<\/em><\/p>\n

But never mind that — ever-intrepid ID doctors are\u00a0most assuredly called upon as experts, even though for obvious reasons the overwhelming majority of us have never seen a case. Remember this outbreak<\/a> from 2014? The time from first description of an infectious outbreak to the widespread demand for information is fast.\u00a0<\/em>People (patients, doctors, the vast public) have questions, and we need to try and answer them. For the record, with Zika, the obstetricians are in the same boat.<\/p>\n

In that spirit, I thought I’d share some of the more common or challenging questions I’ve received on Zika, along with my best efforts at answering them. These answers may well be out of date soon, so\u00a0I enthusiastically refer you to the outstanding Zika coverage on\u00a0the CDC\u00a0site<\/a>, which is being updated regularly.<\/p>\n

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  1. I’m pregnant or know someone who’s pregnant. Can I\/she travel to — [insert country close to one of the countries that has Zika transmission,<\/a> but is\u00a0not currently listed]? \u00a0<\/em><\/strong>Yes … but … with a caveat. It’s a highly dynamic situation, and just like dengue and chikungunya, Zika is likely to be reported in many of these adjacent countries soon (especially in the Caribbean). Not only that, incidence frequently rises quickly in countries after they\u00a0first report the disease. So why not change those travel plans if possible?<\/li>\n
  2. I’m pregnant or know someone who’s pregnant. Can I\/she travel to Florida (or Alabama or Mississippi or Louisiana or Texas or Hawaii)? \u00a0<\/em><\/strong>Yes. There has been no mosquito-borne Zika transmission in the USA yet<\/em>, though likely there will be\u00a0sporadic cases\u00a0soon. But just like dengue and chikungunya, it seems that a widespread outbreak is unlikely — we have more resources for mosquito control, and way more air conditioning.<\/li>\n
  3. How long after returning from [insert Zika country here] can someone safely get pregnant? After all, since 80% of people who get it are asymptomatic, how does one know if Zika infection even occurred<\/em>? \u00a0<\/strong>We don’t know the precise duration of viremia for Zika, or whether the duration of viremia correlates with symptoms. (My gut feeling is that it will, but who knows.) Estimates are that viremia clears on average in about a week. So right now it seems prudent to wait at least a couple of weeks after returning before trying to get pregnant, maybe a month to be on the safe side.<\/li>\n
  4. A guy travelled to [insert Zika location here]. How long after travel should he wait before having sex with his pregnant partner?<\/strong> \u00a0<\/em>We don’t know how long Zika virus remains in semen after infection, nor (again) whether this duration correlates with symptomatic infection (again, my guess is that it does). Since Zika acquisition during pregnancy is what we’re trying to avoid, these guidelines<\/a><\/strong> recommend abstinence or condom use during the pregnancy, which makes sense to me. Now what about the more common scenario, partner isn’t<\/em> pregnant? Next question, please.<\/li>\n
  5. A guy travelled to [insert Zika location here]. How long after travel should he wait before having sex with his non-pregnant partner? <\/em><\/strong>\u00a0The guidelines linked in the previous question\u00a0state that these\u00a0couples “might consider abstaining from sexual activity or using condoms consistently and correctly during sex,” but no duration for this “safe sex” practice is given. Note the use of the word, “might” — this is CDC parlance for, “Look, we’re not going to tell you that doing nothing is\u00a0totally safe, but we don’t feel that<\/em> strongly about this recommendation.” (Check out the rabies guidelines<\/a><\/strong> for plenty of “mights” in this mode.) After all, Zika infection is pretty mild, and there have only been 2 documented sexual transmissions. In fact, one could argue that if other forms of contraception are being used, that transmitting the infection would have a benefit — namely, immunity for a future pregnancy. For worried folks, I’ve been saying they “might” as well wait a month. For unworried folks, I’m not saying anything.\u00a0Importantly, there is no evidence that prior infection with Zika will have a negative impact on future pregnancies, once the infection clears.<\/li>\n
  6. Can’t the woman who wants to get pregnant — or even the guy with the pregnant partner —\u00a0just get a Zika blood test when they return from a Zika country\/region, and find out if they were infected? That would make us all less anxious. \u00a0<\/em><\/strong>Not yet. Zika testing is now done mostly\u00a0through CDC (someone from Florida told me\u00a0they had local access to testing), and there isn’t\u00a0the capacity to test everyone. This is why testing is now recommended only for pregnant women who were in Zika transmission areas. Initially it was recommended only for women with symptoms; this was\u00a0broadened last week to include all<\/em> pregnant women,<\/a><\/strong> even those without symptoms. And remember, the test isn’t so great — there is extensive cross-reactivity with dengue and prior Yellow fever vaccination. So while it would be ideal\u00a0to have a widely available, rapid, and accurate Zika test, our current test misses on all these marks.\u00a0I suspect (hope) this will improve shortly.<\/li>\n
  7. I read a vaccine is in the works. When will it be available?<\/strong> \u00a0<\/em>Vaccines take years to develop, and many, many millions of dollars. While some have stated that it should be technically feasible to produce a Zika vaccine, that doesn’t mean it will work in humans, or even that if one does work, that it will be marketed.\u00a0So put this one on the way<\/em> back burner (unless you’re a vaccine researcher).<\/li>\n
  8. The virus was discovered decades ago. Why hasn’t the link to microcephaly been reported before? \u00a0<\/em><\/strong>A couple of theories, not mutually exclusive: 1) It is likely that in areas where Zika is already established, initial\u00a0infections predominantly occur during the pre-childbearing years, which induces immunity. 2) The incidence of an infection is often highest after infections enter a community\u00a0for the first time, as the pathogen encounters a large pool of susceptible hosts. In areas with established infection, the combination of some regional\u00a0immunity and lower incidence means that fewer women acquire the infection during pregnancy —\u00a0making it\u00a0much harder to identify an association.<\/li>\n
  9. I read that some countries with Zika transmission are recommending that women delay pregnancy — isn’t the virus still going to be around for years to come, maybe indefinitely?\u00a0They can’t be expected to delay having babies indefinitely.<\/strong>\u00a0 This is a controversial recommendation, and indeed the WHO does not endorse it. However, it makes some sense, largely for the reasons cited in the previous question —\u00a0the\u00a0delay could\u00a0allow immunity-inducing infection to occur in some non-pregnant women of childbearing age. Even\u00a0if this\u00a0doesn’t happen, the incidence of infection should be sharply\u00a0lower once a substantial fraction of the population has been infected.<\/li>\n
  10. How do we know that Zika even causes microcephaly? I’m a skeptic.<\/strong> \u00a0<\/em>It’s true that we don’t know definitively\u00a0that Zika causes microcephaly. And it’s highly likely that reporting bias has to at least some degree increased the number of cases, especially in Brazil. But the number of cases reported in Zika-transmission countries\u00a0is\u00a0many fold higher than usual, beyond what public health officials would consider solely the result of reporting bias — read this excellent piece in the New York Times<\/em><\/a>,<\/strong> which conveys vividly what was happening as the epidemic accelerated. Lending further support to the connection, researchers have isolated the virus from babies with microcephaly<\/a>, <\/strong>and there are now reports that French Polynesia may well have had an increase in CNS abnormalities in babies around the time that their Zika outbreak occurred in 2014.\u00a0Finally, one needs to consider the source of the travel advice — our CDC is very cautious about issuing such travel warnings\u00a0(substantial geopolitical and economic consequences), and would not make this\u00a0recommendation unless the evidence were\u00a0very strong.<\/li>\n
  11. How about Zika and the Guillain-Barr\u00e9 syndrome syndrome?<\/strong>\u00a0<\/em>Though there have been reports of Guillain-Barr\u00e9 syndrome after Zika virus infection, whether Zika causes this neurologic syndrome is not conclusively established\u00a0— more research is needed here, though again the anecdotal data are suggestive. There are, of course, other infections linked to Guillain-Barr\u00e9, most notably campylobacter, so the association is plausible.<\/li>\n
  12. I hear the virus can be transmitted not just by Aedes\u00a0aegypti, but also the much more widespread Aedes\u00a0albopictus. Isn’t it just a matter of time before this virus is charging through the United States like it is through Central and South America? \u00a0<\/strong><\/em>With the important upfront caveat that prognostications on disease spread are notoriously iffy, experts in vector-borne illnesses do not think that this scenario is likely — related to the lower “efficiency” of viral transmission from\u00a0Aedes albopictus,<\/em> and the experiences to date with dengue and chikungunya. But sure, there will always be worst-case scenarios — and noisy champions of these views who get lots of attention.<\/li>\n<\/ol>\n

    You ID doctors and obstetricians out there — any other questions you’re getting? And from anyone, feel free to offer\u00a0corrections, insights, other queries, or whatever general thoughts you have\u00a0in the comments section below.<\/p>\n

    Hey, isn’t there a “football” game on later today?<\/p>\n

    [youtube http:\/\/www.youtube.com\/watch?v=2sD_8prYOxo]<\/p>\n","protected":false},"excerpt":{"rendered":"

    Got a Zika question? Welcome to the club — once again, as with any “new” or “emerging” infection, this is uncharted territory, and there are plenty of answers to these questions that could be summarized with 3 words: We Don’t Know. But never mind that — ever-intrepid ID doctors are\u00a0most assuredly called upon as experts, […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,8,9],"tags":[1119,1120,1118],"class_list":["post-8009","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-patient-care","category-policy","tag-aedes-aegypti","tag-aedes-albopictus","tag-zika"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8009","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=8009"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8009\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=8009"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=8009"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=8009"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}