February 4, 2016

expert reaction reports of Zika case in a pregnant woman in Spain, who was infected in Colombia

A pregnant woman in Spain has been diagnosed with Zika virus having recently returned from Colombia where she is thought to have been infected.

All our previous output on this subject can be seen here.

Prof. Trudie Lang, Director of the Global Health Network, University of Oxford, said:

“The Zika outbreak in Brazil is a difficult, complex and emerging situation. It is very important to keep reminding ourselves that the link between Zika virus and birth defects has still not been proven, and this perhaps the most pressing research question.

“The WHO and public health agencies are in a very difficult position as they need to make recommendations and judgements on limited evidence. They are certainly in the difficult situation of being damned if you do and damned if you don’t. In an emerging outbreak situation everyone would be happier to be later criticised for over-reacting rather than failing to act.

“Research efforts are continuing on the basis that this is still an unknown and therefore until we have clear evidence from quality rigorous studies to the contrary it is correct that public health advice defaults to cautious. Meanwhile we need to address how research can be sped up and quality evidence gathered in an expedited way. Collaboration and sharing needs to be facilitated by governments, lawyers and research regulators. It is critical the research is led from the regions and capacity development elements are put into place within these research efforts that can be sustainable.

“There is a very difficult balance to be struck to ensure first and foremost that local research capacity and recognition is protected and able to flourish whilst enabling appropriate and fairly agreed collaborations to speed up evidence generation. The trouble is that many of the laws and regulations that have been put in place to protect local research interests – and absolutely quite rightly and in the right spirit – may prove too restrictive and now make even good and mutually beneficial collaborations difficult, in terms of sharing data and samples between countries and organisations.”

Dr Louise Sigfrid, Clinical Research Fellow, PREPARE, University of Oxford, said:

“There is currently not enough data to ascertain the relationship between Zika virus infection in pregnancy and microcephaly. There is an urgent need for rapid research to ascertain if Zika virus infection in pregnancy can cause microcephaly, still birth or other complications in the baby. Moreover, research to establish what the actual risk is that a baby will develop complications if a woman is infected with Zika virus at different stages of the pregnancy.

“All pregnant women who have visited affected areas during the pregnancy are likely to have blood and other samples (e.g. urine) sent to special reference laboratories for diagnostics and offered an ultrasound. They will most likely also be offered follow up by regular ultrasounds throughout the pregnancy.

“In the UK the recommendation is follow up with four-weekly ultrasounds. Any abnormal findings would be followed up by specialists, and blood taken to look for other infections with known risk of birth defects (e.g. toxoplasma, rubella, parvovirus, CMV).”

Dr Derek Gatherer, Lecturer in the Division of Biomedical and Life Sciences, Lancaster University, said:

“Spain has become the latest country to have Zika imported via travellers returning from Latin America. We have already had a handful in the UK, and the USA has had upwards of two dozen.  These cases do not pose any risk to the general population of Spain or any other European or North American country, since although one potential vector, Aedes albopictus, does exist in some Mediterranean coastal regions of Spain, we have no reason to believe that any outbreak could be sustained in human populations in Spain given the general level of infrastructural development of that country. For similar reasons, chikungunya failed to establish itself in Italy after the 2007 outbreak, and both dengue and chikungunya have only caused very sporadic problems in the South-eastern USA.

“The question as to the wellbeing of the pregnancy in one infected female cannot be answered without further information. Since her pregnancy may have been in relatively early stages when she was infected, there may be a risk. We have no statistics as yet on the frequency of microcephaly in infected pregnant women, nor any hard data on the riskiest parts of pregnancy. The matter is now in the hands of the obstetrician caring for the pregnant woman. Ultrasound imaging will be a priority.”

Dr Ed Wright, Senior Lecturer in Medical Microbiology, University of Westminster, said:

“The importation of further cases of Zika virus into Europe is of no surprise, however, what stands out in this situation is that one of the individuals is pregnant.  With a possible link between Zika virus infection and microcephaly, concern has been raised regarding the health of the baby.  At the moment there is not enough evidence to give a definitive answer to this question due to insufficient or conflicting data. For example, Brazil has seen an increase in microcephaly cases that coincides with the outbreak of Zika virus, while no cases of microcephaly have been linked to Zika virus infections seen in neighbouring Columbia.  Whether that link stands up to scientific scrutiny is something scientists and healthcare professionals are urgently trying to determine.  Collection of accurate, reliable epidemiological and clinical data over the coming weeks and months will hopefully provide the answers we need so at risks groups can be given appropriate advice and support.”

Dr James Logan, Senior Lecturer and Director of arctic, Department of Disease Control, London School of Hygiene & Tropical Medicine, said:

“These imported cases are not surprising and we are likely to see more in other countries in the weeks to come. It is important to note, however, that Zika was picked up abroad and not in Spain. Pregnant women in particular should be aware of the risks when they travel to high risk countries and if they do choose to travel they should take appropriate precautions which include using an insect repellent containing DEET at a concentration between 20-50%. They should also cover up with long sleeved clothing and can wear permethrin impregnated clothing.

“Importantly they should be aware that mosquitoes that transmit the disease bite readily during day. Bed nets, which only work at night, should still be recommended due to the risk of other insect borne diseases.”

Prof. Jonathan Ball, Professor of Molecular Virology, University of Nottingham, said:

“It’s a really unfortunate development but it was almost inevitable that a pregnant woman would become infected visiting the worst hit areas. That is why very recent advice is for pregnant women to avoid travel to those countries.

“Even though there is a reported link between Zika infection during pregnancy and a risk of a baby being born with microcephaly, we can’t yet be absolutely sure.

“If this link is proven beyond reasonable doubt we still don’t know what the chances are of a baby developing this condition, nor if there are particular times during the pregnancy when the baby is at most risk.

“It does provide a salutary reminder, if one were needed, that there is so much that we do not know about this virus even though we’ve been aware of it for many decades.”

Dr Nathalie MacDermott, Clinical Research Fellow, Imperial College London, said:

“It’s difficult to comment on individual cases since we don’t know enough detail, although there are reports that the woman is in her second trimester of pregnancy.  In general, given the possible association of microcephaly occurring in the unborn infants of women infected with Zika virus in pregnancy, any Zika infection in pregnancy is of great concern. It is unlikely that all infants where the mother is infected with Zika during pregnancy would suffer congenital malformations but further research into the association is required.

“Infants are most at risk of congenital abnormalities occurring when viral infections known to affect infant development occur in the mother during the first 12 weeks of pregnancy. This is because this is when the infant is developing most rapidly and is most susceptible to insults and interruptions in development. While further research as to exactly when Zika infection may affect the developing infant is required, infection of the mother during the first trimester or early second trimester would be most concerning.

“Women infected with Zika during pregnancy should be offered serial ultrasound scans to monitor the infant’s growth and head circumference, these should be offered at least monthly. The mother should also be referred to a foetal medicine doctor for further assessment and monitoring of the infant including possible foetal MRI scanning to look at the size of the head and the structures of the brain, as well as assessing for any other possible associated abnormalities.”

Prof. Paul Reiter, recently retired consultant on mosquitoes and mosquito-borne diseases and Professor of Medical Entomology, Pasteur Institute, said:

“The only mosquito capable of transmitting Zika in Europe is Aedes albopictus.

“For several reasons it is considered a poor vector compared to Aedes aegypti but unlike that species it can survive the winter, in the egg stage.

“In Catalonia, the “season” will probably be similar to that in our study site in Nice: eggs will probably hatch in mid-May and the adult populations will begin to rise in early June.

“Thus, at present, there is no danger that transmission will occur.”

* http://www.msssi.gob.es/gabinete/notasPrensa.do?id=3895

Declared interests:

Prof. Trudie Lang: “Trudie is Professor of Global Health Research at the University of Oxford, is a member of the ISARIC (International Severe Acute Respiratory and Emerging Infection Consortium) network and director of the Global Health Network.”

Dr Louise Sigfrid: “My post is funded by PREPARE (the EU funded European Platform for European Preparedness Against (Re-) emerging Epidemics.”

Dr Derek Gatherer: “No relevant conflicts of interest.”

Dr Ed Wright: “No conflicts of interest.”

Prof. Paul Reiter: “I am not in any monetary relationship with Oxitec. However, as a professional, I have been enthusiastic about their technology for many years and act as an advisor on mosquito biology and behaviour.  My direct involvement with them has been as follows: In 2005 they funded a PhD student to work on male dispersal. He worked with the Asian Tiger mosquito (not a transgenic; there was none of this species). Most of his work was on Reunion Island (no Ae. aegypti there). Apart from their obvious interest in the results, Oxitec had no involvement in the study.  I also had a post-doc who worked for two years in a laboratory study on mating behaviour of the transgenic vs wild type. She was mainly funded by the Institut Pasteur.”

Dr James Logan: “Dr Logan is a Senior Lecturer in Medical Entomology at the London School of Hygiene and Tropical Medicine with grant funding to research personal protection against disease transmission. He is also the Director of arctec – a centre at the London School which evaluates vector control technologies.”

Prof. Jonathan Ball: “No conflicts of interest.”

Dr Nathalie MacDermott: “I am a paediatrician. I am also undertaking a PhD in Ebola virus disease at Imperial College London funded by the Wellcome Trust.”