A Tale of Two Outbreaks: What the Zika Epidemic Should Teach Us Moving Forward about Brain Health and Infants Born During the Coronavirus Pandemic

By Saami Zakaria

This piece is part of a special series of posts by medical student authors who were solicited to speak on the relationship between COVID, medicine, and neuroethics.

Image courtesy of Pixabay
On March 11th, 2020, the World Health Organization declared COVID-19, the name for the disease caused by SARS CoV-2, a global pandemic.1 It is the best of times, it is the worst of times. Science and medicine have progressed to give us some answers but not enough to overcome a meager societal response to protect those that need it most. In the four years that have passed since the Zika virus was declared an emergency, we must ask ourselves: what lessons should we have learned from the last large outbreak? 

Though first identified in the 1940s and recognized for causing mild symptoms as late as 2007, the Zika virus that we saw spread in the second decade of the 21st century was a different beast altogether. Beginning in French Polynesia in 2013 and probably making its way to Brazil that same year via the Confederations Cup,2 a popular soccer tournament, Zika infections started being widely recognized in Brazil by May of 2015. A few months later, in September, investigators in Brazil began noticing a disturbing trend. Many babies were born with microcephaly, normally a very rare disease in which a baby has a small head and intellectual disabilities. Protecting pregnant women from infection then became a priority,3 albeit months (and possibly years) too late. Microcephaly, seizures, and hearing and vision problems turned out to be a few of the obvious signs of a congenital Zika infection,4 none of which were reported with prior outbreaks. Current research even implies that less obvious and slowly manifesting neurologic signs of a congenital Zika infection may also be present, indicating that children with congenital Zika infections should be monitored throughout their lives.5

The wait for a vaccine, typically a process spanning decades, churns on for the Zika virus. All the while, over 20 million people in the United States alone continue to live in areas where the mosquito that transmits Zika resides year round.6 “We are not ready for the next epidemic,” said Bill Gate in a TED talk he gave five years ago. Five years and many babies with avoidable neurologic abnormalities later, we are doing no better at preventing these viral infections. 

Image courtesy of Pixabay
Current indications point to vastly better outcomes for kids born to mothers infected with SARS CoV-2 than for kids born to mothers with Zika infections. Maternal transmission to infants is low, though individual case reports claim the possibility exists.7,8,9 Most complications of birth so far are limited to those normally arising from pre-term birth and Cesarean section deliveries, both of which are increased in mothers with COVID-19.10 As COVID-19 pneumonia can make it difficult to breathe and thus create hypoxic (low oxygen) conditions, this remains a theoretical risk for fetal growth restrictions, as was reported in a limited number of Severe Acute Respiratory Syndrome (SARS, from the SARS-CoV-1 virus) cases.11 A more complete FAQ list on COVID-19 and pregnancy can be found here

Clinical manifestations from COVID-19 pregnancies thus largely seem unlikely, but until more time has passed and more data have been collected, this is still unknown and aptly reflected as such on the CDC’s website with careful wording like “unlikely,” and “unknown.” The facts remain that pregnancy is a known time of immunosuppression,12 that viral infections in general during pregnancy have been correlated with increased frequencies of child neurodevelopmental disorders through mechanisms outside of congenital infections,13 and that SARS CoV-2 on its own has been linked to neurological problems.14,15 

The United States accounts for almost a quarter of the world’s economy.16 In a country known a lot more for its health and technology sectors than for its oil reserves, the neurological health of its citizens is paramount to keeping it globally competitive. One such metric that can help us examine just how debilitating viral infections can be for individuals and economies alike is the disability-adjusted life-year (DALY) index. One DALY is equivalent to one healthy life-year lost to disability. Data from the most recent Zika outbreak indicate that each baby born with microcephaly will have lost 29.95 DALYs,17 or over a third of the lifespan of most individuals. As health, technology, and other sectors within the United States economy have seen continued increased productivity and steady GDP growth for well over a century,18 it is worth looking at using some of the extra GDP we have accrued as a country to plan to avoid excessive DALY losses from viral outbreaks. As our brains are our most important assets, they must be protected moving forward. 

Ideal habitats and risk factors for having the mosquitos that transmit Zika include dirty water storage containers, standing water, and limited access to piped water. It is then no surprise that children with congenital Zika complications were disproportionately born to women and girls of low socio-economic status,19 acting only to further deepen poverty divides and increase the stigma of disease. A virus yet to come that spreads as rapidly as SARS CoV-2 with neurological consequences as devastating as Zika would be destructive for all and harm already disadvantaged communities to a larger degree. Most recently with COVID-19, the rich and famous have taken precedence in receiving tests over poorer individuals, who have higher death rates. This expands the growing divide between different socioeconomic groups in the United States and contributes to already-present healthcare disparities that dramatically harm health

In many of the countries hit worst by the recent Zika epidemic, women were requested to hold off on pregnancy until the development of a vaccine.20 Indeed, much of the public health response dropped the burden of the crisis on women. Considering that many pregnancies are unintended (49% in the United States) and occur as the result of sexual violence, monolithic requests such as this are out of touch, disingenuous, and continue to highlight the gendered disparities in policy decision making. Furthermore, states in the US, such as Texas and Florida, where the mosquitos that transmit Zika reside, had unintended pregnancy rates considerably higher than the national average and still chose not to expand Medicaid;21 this effectively decreased medical access to women in areas it was needed most. 

Our response to the Zika epidemic highlights notable issues in healthcare surveillance, defined as the “timely dissemination of public health information for assessment and public health response as necessary.”22 That is, while the public health threat was known, the response to it was sparse and disproportionate. Women were expected to hold the burden of controlling the epidemic, with little regard to their own preferences and ability to reasonably do so. More concerningly, policy was not properly formulated to support them. What was left was cloaked institutional sexism and a largely ineffective system in controlling a growing health crisis. 

How can we better today? 

Coordinated social efforts and laws are often the only tools we have to make up for the scientific answers we don’t have. Although the public health response has largely been lacking thus far, collectively we have the tools to improve it. The right solution must encompass two parts. 

Image courtesy of Pixabay
The first: routine random-sample prevalence testing for viruses we already know about should occur in areas where spread is possible. The current CDC recommendations for testing pregnant women for Zika include having symptoms of Zika and/or a history of travel to a country with a current Zika outbreak (no countries have a current outbreak).23 These recommendations are lacking in that they are asking for another outbreak to occur before a response is made. The right response needs to be more proactive. While it may prove too costly to test every pregnancy in a time of no known outbreak, periodic random testing of people in areas with the mosquitos that spread Zika is the right middle ground to catch another Zika outbreak earlier than would have occurred otherwise. Such a solution will benefit all, while simultaneously giving a larger share of the benefit to those normally disproportionately affected from lower socioeconomic classes. 

The second: all viral infections should be presumed dangerous until proven otherwise, not the other way around. This is especially important when it comes to protecting pregnant families and isolating them from viral spread as much as possible. For COVID-19, while the risk to neurological health is still unknown, the lag in testing capacity development in the United States was dangerous and cannot happen again for the next outbreak. Given the unknowns, it is time for organizations like the CDC to start categorizing pregnancy as a higher risk category to begin with for all new suspected viral outbreaks to be cautious, rather than move it there once the damage has been done. 

Of course, it is of utmost importance that a policy like this be created and enforced cautiously. The responsibility of the government is to ensure that no individual group of people is made to shoulder the brunt of the crisis and put its lives on hold. This responsibility must be upheld through actionable government protections. Similarly, public health campaigns must work to establish regional risk factors and educate locals as swiftly as possible, avoiding the mistakes previously highlighted during the Zika epidemic. 

References 
  1. WHO Timeline - COVID-19. (2020, April 27). Retrieved May 4, 2020, from https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19 
  2. Faria, N. R., Azevedo, R. do S. da S., Kraemer, M. U. G., Souza, R., Cunha, M. S., Hill, S. C., Thézé, J., Bonsall, M. B., Bowden, T. A., Rissanen, I., Rocco, I. M., Nogueira, J. S., Maeda, A. Y., Vasami, F. G. da S., Macedo, F. L. de L., Suzuki, A., Rodrigues, S. G., Cruz, A. C. R., Nunes, B. T., … Vasconcelos, P. F. C. (2016). Zika virus in the Americas: Early epidemiological and genetic findings. Science (New York, N.Y.), 352(6283), 345–349. https://doi.org/10.1126/science.aaf5036 
  3. Redd, S. C., & Frieden, T. R. (2017). CDC’s Evolving Approach to Emergency Response. Health Security, 15(1), 41–52. https://doi.org/10.1089/hs.2017.0006 
  4. França, G. V. A., Schuler-Faccini, L., Oliveira, W. K., Henriques, C. M. P., Carmo, E. H., Pedi, V. D., Nunes, M. L., Castro, M. C., Serruya, S., Silveira, M. F., Barros, F. C., & Victora, C. G. (2016). Congenital Zika virus syndrome in Brazil: a case series of the first 1501 livebirths with complete investigation. The Lancet, 388(10047), 891–897. https://doi.org/10.1016/S0140-6736(16)30902-3 
  5. Adams Waldorf, K. M., Nelson, B. R., Stencel-Baerenwald, J. E., Studholme, C., Kapur, R. P., Armistead, B., Walker, C. L., Merillat, S., Vornhagen, J., Tisoncik-Go, J., Baldessari, A., Coleman, M., Dighe, M. K., Shaw, D. W. W., Roby, J. A., Santana-Ufret, V., Boldenow, E., Li, J., Gao, X., … Rajagopal, L. (2018). Congenital Zika virus infection as a silent pathology with loss of neurogenic output in the fetal brain. Nature Medicine, 24(3), 368–374. https://doi.org/10.1038/nm.4485 
  6. Poland, G. A., Ovsyannikova, I. G., & Kennedy, R. B. (2019). Zika Vaccine Development: Current Status. Mayo Clinic Proceedings, 94(12), 2572–2586. https://doi.org/10.1016/j.mayocp.2019.05.016 
  7. Dong, L., Tian, J., He, S., Zhu, C., Wang, J., Liu, C., & Yang, J. (2020). Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. JAMA. https://doi.org/10.1001/jama.2020.4621 
  8. Zeng, L., Xia, S., Yuan, W., Yan, K., Xiao, F., Shao, J., & Zhou, W. (2020). Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2020.0878 
  9. Zeng, H., Xu, C., Fan, J., Tang, Y., Deng, Q., Zhang, W., & Long, X. (2020). Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA, 323(18), 1848–1849. https://doi.org/10.1001/jama.2020.4861 
  10. Elshafeey, F., Magdi, R., Hindi, N., Elshebiny, M., Farrag, N., Mahdy, S., Sabbour, M., Gebril, S., Nasser, M., Kamel, M., Amir, A., Emara, M. M., & Nabhan, A. (2020). A systematic scoping review of COVID-19 during pregnancy and childbirth. International Journal of Gynecology & Obstetrics, n/a(n/a). https://doi.org/10.1002/ijgo.13182 
  11. Wong, S. F., Chow, K. M., Leung, T. N., Ng, W. F., Ng, T. K., Shek, C. C., Ng, P. C., Lam, P. W. Y., Ho, L. C., To, W. W. K., Lai, S. T., Yan, W. W., & Tan, P. Y. H. (2004). Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome. American Journal of Obstetrics and Gynecology, 191(1), 292–297. https://doi.org/10.1016/j.ajog.2003.11.019 
  12. Liu, D., Li, L., Wu, X., Zheng, D., Wang, J., Yang, L., & Zheng, C. (2020). Pregnancy and Perinatal Outcomes of Women With Coronavirus Disease (COVID-19) Pneumonia: A Preliminary Analysis. AJR. American Journal of Roentgenology, 1–6. https://doi.org/10.2214/AJR.20.23072 
  13. Shin Yim, Y., Park, A., Berrios, J., Lafourcade, M., Pascual, L. M., Soares, N., Yeon Kim, J., Kim, S., Kim, H., Waisman, A., Littman, D. R., Wickersham, I. R., Harnett, M. T., Huh, J. R., & Choi, G. B. (2017). Reversing behavioural abnormalities in mice exposed to maternal inflammation. Nature, 549(7673), 482–487. https://doi.org/10.1038/nature23909 
  14. Mao, L., Jin, H., Wang, M., Hu, Y., Chen, S., He, Q., Chang, J., Hong, C., Zhou, Y., Wang, D., Miao, X., Li, Y., & Hu, B. (2020). Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurology. https://doi.org/10.1001/jamaneurol.2020.1127 
  15. Xydakis, M. S., Dehgani-Mobaraki, P., Holbrook, E. H., Geisthoff, U. W., Bauer, C., Hautefort, C., Herman, P., Manley, G. T., Lyon, D. M., & Hopkins, C. (2020). Smell and taste dysfunction in patients with COVID-19. The Lancet Infectious Diseases, 0(0). https://doi.org/10.1016/S1473-3099(20)30293-0 
  16. Silver, C. (2020, March 18). The Top 20 Economies in the World. Investopedia. Retrieved May 17, 2020, from https://www.investopedia.com/insights/worlds-top-economies/ 
  17. Alfaro-Murillo, J. A., Parpia, A. S., Fitzpatrick, M. C., Tamagnan, J. A., Medlock, J., Ndeffo-Mbah, M. L., Fish, D., Ávila-Agüero, M. L., Marín, R., Ko, A. I., & Galvani, A. P. (2016). A Cost-Effectiveness Tool for Informing Policies on Zika Virus Control. PLoS Neglected Tropical Diseases, 10(5). https://doi.org/10.1371/journal.pntd.0004743 
  18. Roser, M. (2013). Economic Growth. Our World in Data. https://ourworldindata.org/economic-growth 
  19. Lowe, R., Barcellos, C., Brasil, P., Cruz, O. G., Honório, N. A., Kuper, H., & Carvalho, M. S. (2018). The Zika Virus Epidemic in Brazil: From Discovery to Future Implications. International Journal of Environmental Research and Public Health, 15(1). https://doi.org/10.3390/ijerph15010096 
  20. Fabrizio, M (2016). Words Do Matter: How Anti-Zika Rhetoric Perpetuates Regional Sexism. Retrieved May 29, 2020, from http://www.coha.org/words-do-matter-how-anti-zika-rhetoric-perpetuates-regional-sexism/ 
  21. Bond, J. (2017). Zika, Feminism, and the Failures of Health Policy. Washington and Lee Law Review Online, 73(2), 841. 
  22. Klingler, Corinna, et al. "Ethical issues in public health surveillance: a systematic qualitative review." BMC Public Health 17.1 (2017): 295. 
  23. Testing for Zika Virus. (2014, November 5). CDC. https://www.cdc.gov/zika/symptoms/diagnosis.html 
______________

Saami Zakaria is a medical student at Thomas Jefferson University. Before starting medical school, he graduated with a B.S in Biomedical Engineering from the University of Virginia, and then completed a one-year HIV research fellowship at the National Institutes of Health. In medical school, he plays an active role on student council, enjoys doing research, and launched a local recurring TEDx event with two classmates. He is also an exercise and nutrition aficionado, having written articles about the latter as well.

Want to cite this post?

Zakaria, S. (2020). A Tale of Two Outbreaks: What the Zika Epidemic Should Teach Us Moving Forward about Brain Health and Infants Born During the Coronavirus Pandemic. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2020/06/a-tale-of-two-outbreaks-what-zika.html

Comments

Follow Us

Follow Us
Emory Neuroethics on Facebook

Emory Neuroethics on Twitter

AJOB Neuroscience on Facebook