As of early September, Zika had become a global epidemic with cases reported in more than 50 countries, mostly in South America and the Caribbean, and in 48 U.S. states, according to the Centers for Disease Control and Prevention (CDC). When local transmission first began in Miami this summer, the nation’s academic medical centers were ready.
Physicians and scientists responded rapidly across a continuum that included public education, treatment for pregnant women and infants, and research on Zika’s effects on fetal development.
Preparedness efforts launched
The University of Miami Hospital began preparing their response to the Zika epidemic at the beginning of 2016. Still, locally transmitted cases in Miami sparked concern among pregnant women across the city. Zika has been linked to microcephaly, a neurological birth defect that causes abnormal brain development, in infants whose mothers were infected while pregnant.
“Women are nervous,” said Christine Curry, MD, PhD, an OB/GYN who has led the response to the epidemic at the University of Miami Hospital. “Pregnant women in particular are really trying to decide what level of risk for getting infected they are willing to tolerate.” Some women, Curry added, are avoiding areas affected by Zika, while others have decided to relocate to other parts of Miami or the country for the remainder of their pregnancies.
About a month before the first reported case of local Zika transmission in the continental United States, Jeanne Sheffield, MD, director of the Division of Maternal-Fetal Medicine and professor of gynecology and obstetrics at Johns Hopkins Medicine, said “it was just a matter of when” local transmission would start. Preparedness efforts at Hopkins began at the end of 2015, starting with standardized protocols for evaluating pregnant women with Zika and infants whose mothers were infected.
Back in Miami, preparedness efforts are focused on education—both at the hospital level and for patients, Curry noted. At University of Miami and Jackson Memorial Hospitals, all pregnant women are screened for Zika risk factors by both physicians and nurses. Women receiving routine prenatal care or attending prenatal classes are counseled on Zika and mosquito bite prevention. The hospitals now offer Zika testing to pregnant women based on CDC recommendations.
One of the more difficult aspects of the Zika epidemic, especially in terms of preparation, is the lack of knowledge, particularly how the virus effects a fetus at different stages of pregnancy.
“I probably say, ‘I’m not sure’ or ‘We don’t know’ more than any other answer,” said Curry, who is also an assistant professor of obstetrics and gynecology at the University of Miami. “As a doctor, you want to give answers and reassure people. I think it’s a matter of being honest with people and then offering to see them again because this is changing every month.”
At Texas Children’s Pavilion for Women in Houston, a team of maternal-fetal medicine physicians run a weekly Zika clinic to evaluate and counsel pregnant women who have traveled to Zika-affected areas or have had exposure to the virus. One of the main benefits for patients has been access to a group of physicians who are dedicated to staying updated as new research on Zika emerges, according to Catherine Squire Eppes, MD, a maternal-fetal medicine specialist at Texas Children’s and assistant professor of obstetrics and gynecology at Baylor College of Medicine. “The perception on the patient side has been that if they are either exposed or if they have positive testing for Zika that they will have a baby who is affected, and I think we’ve been able to downgrade a lot of those fears,” Eppes said.
While institutions have done what they can to prepare, the emergence of Zika has highlighted again the importance of federal funding in enabling a rapid and effective response to public health emergencies. After months of debate over funding, on Thursday, Sept. 29, Congress passed a bill that included $1.1 billion in emergency supplemental support for Zika response efforts. The bill includes funding for vaccine development, diagnostics, and other research at the CDC, National Institutes of Health (NIH), and other agencies. The day before the bill was passed, the AAMC signed a letter encouraging Congress to approve Zika funding. With only limited funds available, over the past few months, agencies have reallocated funding from other existing initiatives, including a portion of unused funds originally designated for international Ebola efforts. Among other letters urging Congress to fund Zika response initiatives, the AAMC joined more than 40 organizations that signed a June 6 letter to U.S. House members, calling on Congress to “provide new funding rather than repurposed funds from other high-priority public health programs.”
“I probably say, ‘I’m not sure’ or ‘We don’t know’ more than any other answer. As a doctor, you want to give answers and reassure people. I think it’s a matter of being honest with people and then offering to see them again because this is changing every month.”
Christine Curry, MD, PhD, University of Miami Hospital
Meanwhile, research continues and, with the goal of accelerating Zika findings, NIH announced an expedited review process for Zika-related studies. Researchers can submit proposals at any time, with NIH aiming to complete the application review and funding process in 10 to 16 weeks. "This is a much faster way to turn around ideas and better understand the impact of Zika virus, the diagnostics, and the basic sciences," said Catherine Y. Spong, MD, acting director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
In early August, the National Institute of Allergy and Infectious Diseases (NIAID) launched a Phase I clinical trial of a Zika vaccine candidate in humans. If the vaccine candidate is found to be safe and effective, NIAID plans to launch Phase 2 trials in Zika-epidemic countries in early 2017. The University of Maryland School of Medicine and the Emory Vaccine Center at Emory's Woodruff Health Sciences Center are testing sites for the vaccine.
In addition, NIH will be examining the effects of the virus with the Zika in Infants and Pregnancy (ZIP) study, which launched in June in Puerto Rico. In collaboration with a Brazilian research organization, NIH intends to enroll up to 10,000 pregnant women at 15 sites in countries with active local Zika transmission. The study will follow infants for one year after birth, with the hope of learning the full scope of Zika in pregnancy to help drive medical and public health responses.
As physicians and scientists in the academic medicine community continue efforts to respond to the epidemic, it’s "exciting to hear new information every day,” Eppes said. “I think this is one of the most rapidly evolving epidemics that affects pregnancy in recent times. People are collaborating across countries to try to get answers.”