A 2013 soccer match could have brought Zika virus to Brazil, researchers say
The Washington Post, Friday March 25, 2016
The Zika virus could have entered Brazil in 2013, two years before it was confirmed here and a year before previously believed, a new study claims. The study examined genetic profiles of seven Brazilian Zika cases.
Scientists said the study presents valuable findings as Brazil's overstretched health service grapples with twin outbreaks of Zika and the birth defect microcephaly. The government has confirmed a link between the two.
"It's very early and limited but valuable information," said Daniel Lucy, an infectious-disease specialist at Georgetown University.
Zika could even have been introduced to Brazil during the 2013 Confederations Cup, a soccer tournament that featured a team from Tahiti - which suffered a Zika epidemic that year.
"We managed to trace the date of introduction between May and September 2013," said Nuno Faria, a researcher at Oxford University and one of the authors of the paper, published Thursday in the journal Science.
The research by scientists from Britain's Oxford University and Brazil's Evandro Chagas Institute is the first to have analyzed the Zika genome found in Brazil. Since reaching here, it has spread to another 33 countries across the Americas.
"This is the first study combing genetic and epidemiological data on the Zika virus in Brazil, so it is a good baseline for future research," Faria said.
Researchers found that Brazil's Zika virus is closely related to the Asian strain of Zika that was behind an outbreak in French Polynesia in 2013. The strain also circulates across Southeast Asia. Zika was first found in Uguanda in 1947, and there is also an African strain.
As many as 1.5 million Brazilians may have caught Zika, the government estimates. It has confirmed nearly a thousand cases of the birth defect microcephaly - which causes babies to be born with abnormally small heads and can lead to motor and cognitive difficulties and problems with hearing and sight. It is investigating thousands more.
But little is known about how Zika got to Brazil. And though Zika is increasingly blamed for the microcephaly outbreak, it unclear how the virus could cause brain damage in fetuses.
Faria said theories that co-infection with a related virus like dengue, or previous exposure to dengue, might be factors, are "very plausible."
"We are providing some first data to help us answer these questions," he said.
The report analyzed seven genomes, including that of one adult with Zika who died and a newborn with microcephaly.
"They did a genetic profile of the Brazilian virus," said Marcos Lago, an infectious disease specialist at the Federal University of Rio de Janeiro. "This is important."
The authors said Zika circulated in Brazil for a year or more before being identified.
In June 2013, Tahiti's national soccer team took part in the Confederations Cup - a trial run for the World Cup a year later - and played in Recife, capital of Brazil's northeastern state of Pernambuco where around a third of microcephaly cases have been concentrated.
But the study also noted a 50 percent rise from 2012 to 2014 in passengers flying to Brazil from countries where Zika circulated - New Caledonia, Indonesia, Malaysia, French Polynesia, Thailand and Cambodia - and said this was a more likely cause.
The 2014 World Cup and a canoeing tournament that year that featured a team from Tahiti have both previously been cited as events that could have led to Zika entering Brazil.
The study did not test the link between Zika and microcephaly, but did find that most suspected microcephaly cases happened at 17 weeks of pregnancy and more severe cases at 14 weeks.
As of March 19, Brazil had confirmed 907 cases of microcephaly and other alterations caused by a congenital disease since last October. Another 4,293 are still being investigated, and 1,471 have been discarded. The latest figures showed that Brazil confirmed 44 new cases in a week. In addition, 12 countries have reported an increase in Guillain-Barré Syndrome, a neurological condition that has been linked to Zika.
In May the research team plans to visit Brazil and profile a thousand genomes using a portable new technology. "It's going to be targeting genetic surveillance," Faria said.
Mostrando postagens com marcador doenças. Mostrar todas as postagens
Mostrando postagens com marcador doenças. Mostrar todas as postagens
sexta-feira, 25 de março de 2016
segunda-feira, 8 de fevereiro de 2016
Zika virus: uma tragedia brasileira, e universal... - The New York Times
Matérias horripilantes na imprensa internacional para este Carnaval, que provavelmente vai ficar na história, como um equivalente brasileiro de pestes universais de tempos passados.
Nem a sociedade, nem as autoridades se deram ainda conta da extrema gravidade da situação.
Paulo Roberto de Almeida
Matérias do The New York Times, February 8, 2016
The Zika Virus and Brazilian Women's Right to Choose
Debora Diniz
Brazil is in a state of crisis. Since October, there have been more than 4,000 suspected cases of babies born with a neurological syndrome associated with the Zika virus. The Health Ministry has suggested that women avoid pregnancy until the epidemic has passed or more is known about it.
I am a Brazilian woman. My friends who are planning to have children soon are worried about Zika. But they don't need to be too concerned. In our well-to-do neighborhood in Brasília, the capital, there has not been a single case of a baby with the birth defects associated with the Zika epidemic. As far as I know, not one woman here has even been infected by the virus.
Lost in the panic about Zika is an important fact: The epidemic mirrors the social inequality of Brazilian society. It is concentrated among young, poor, black and brown women, a vast majority of them living in the country's least-developed regions. The women at greatest risk of contracting Zika live in places where the mosquito is part of their everyday lives, where mosquito-borne diseases like dengue andchikungunya were already endemic. They live in substandard, crowded housing in neighborhoods where stagnant water, the breeding ground for disease-carrying mosquitoes, is everywhere. These women can't avoid bites: They need to be outdoors from dawn until dusk to work, shop and take care of their children. And they are the same women who have the least access to sexual and reproductive health care.
The Zika epidemic has given Brazil a unique opportunity to look at inequality and reproductive rights, and to change how the country treats women. Asking women to avoid pregnancy without offering the necessary information, education, contraceptives or access to abortion is not a reasonable health policy. Sexual and reproductive rights for all women, poor and rich, must be taken seriously. The government should immediately offer a comprehensive package of sexual and reproductive health care to all Brazilian women, with a specific focus on those at most risk of Zika infection.
Brazil has some of the world's strictest abortion laws. The procedure is legal only in cases when the life of the woman is in danger of complications, or she was raped, or she is carrying an anencephalic fetus. Knowledge that a child will suffer from serious neurological problems is not grounds for legally terminating a pregnancy. That doesn't mean that abortion is uncommon, though.
In 2010, I conducted a national survey that found that by age 40, one in five Brazilian women had had at least one abortion. The overwhelming majority of these abortions were illegal and performed in unsafe conditions. According to Brazilian law, more than five million women should have spent time in prison. They would have amounted to almost 10 times our current prison population, which is the fourth largest in the world. In abortion, too, Brazil's economic inequality is a factor: Wealthy women can pay to secure safe abortions; most women can't.
The poor women who are most likely to contract Zika face tremendous barriers to getting safe abortions. They are forced to carry their pregnancies in fear. Public health clinics in poor communities rarely offer either the blood test that detects the presence of the virus or the ultrasound that can diagnose birth defects. We in Brazil need to know their stories to repair the harm inflicted by the government's negligence in controlling the outbreak.
Low-paid women and domestic workers are the true face of the Zika virus. In Brazil, it is usually women who are responsible for family planning and child care. They will also be the caregivers of disabled, dependent children. Some news reports have included accounts of women being abandoned by their partners after the birth of a baby with neurological problems. The state shouldn't abandon them, too. It needs to provide financial support and social services for the poor women and their children who are suffering from the effects of Zika.
The Health Ministry must help Brazil's women. In the short term, the government needs to control the mosquitoes by destroying their habitat and working with the international community to advance knowledge about how to stop the disease. But that's only a start. Women need to be given the power to manage their own pregnancies.
While family planning is a constitutional right, many women have trouble getting contraceptives because of poverty or inconvenience. This must change. And sexual and reproductive education must be a topic in Brazil's public schools.
The government must finally give women basic control over their reproductive lives - accessible and affordable contraception, and safe and legal abortion. The organization I founded, Anis - Institute of Bioethics, is preparing to present a case to the Supreme Court with these demands. Ever since we announced our plans, I have been receiving phone calls from women from all over the country; some have seen their childbearing dreams turned into nightmares because of the Zika virus. Others worry about how they will get health care for their disabled children. Many wonder how many more will have to suffer or die before abortion is a right.
Brazil Finds Zika Virus in Human Urine and Saliva, but Risk Is Unclear
Vinod Sreeharsha & Simon Romero
Scientists Find Zika in Saliva and Urine
A Brazilian health institute found traces of the Zika virus in certain bodily fluids of two patients, but said more research is needed to determine if the infection can be transmitted through the fluids.
Brazilian scientists said Friday that they had detected the presence of the Zika virus in samples of human saliva and urine, a first for Brazil.
The Brazilian researchers warned that the virus might have the potential to spread through kissing or urine, but they were quick to point out that this still remains to be proved. Nonetheless, the announcement amplified concern in Brazil with many people pointing out the possible impact to the annual Carnival celebration, which began on Friday.
"It is something we have to further investigate," said Dr. Myrna Bonaldo, the head of the Flavivirus Molecular Biology Laboratory at Fiocruz, a prominent research institute here. "We are not yet sure if Zika can be transmitted to others" through saliva or urine, she said.
The findings point to the frenetic efforts by researchers in Brazil and other countries to determine the risks posed by the mosquito-borne Zika virus as it spreads through more than two dozen countries in the Americas.
Brazilian doctors have already linked Zika to an increase in babies born with abnormally small heads, a condition known asmicrocephaly, though research teams are still trying to prove this connection.
French scientists had already published research last year in the Journal of Clinical Virology that located the Zika virus in human saliva following an outbreak of the virus in 2013 and 2014 in French Polynesia.
The Brazilian researchers at Fiocruz said that their studies had detected the virus in an active form in human saliva and urine samples.
Dr. Bonaldo and officials at the institute said that they had obtained the samples from two patients with Zika-like symptoms; one was found to have the virus in urine, the other had Zika in the saliva sample. It remained unclear whether the tiny sample size was enough to produce solid conclusions.
"The significance of the results is unclear," said Dr. Peter J. Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine. "We know, for example, that dengue is only transmitted via Aedes mosquito bites, and yet we can find the dengue genome in urine and saliva. So more research would need to be done to determine if Zika can be transmitted via kissing."
"For now," Dr. Hotez added, "it still seems highly likely that the overwhelming number of cases of Zika are transmitted through mosquito bites."
The announcement at Fiocruz on Friday morning quickly spread on social media, sowing confusion among some in Brazil.
"I'm trying to remain calm, but this is really some troubling news," said Kalina de Andrade, 28, a cashier at a store in the seaside Botafogo neighborhood of Rio.
Ms. de Andrade, who is five months pregnant, said that it had become increasingly difficult to discern all the risks associated with Zika ever since the federal authorities declared an emergency after the outbreak of the virus several weeks ago.
"The government needs to get better at explaining to the population what this means," she said, emphasizing that annual Carnival celebrations officially got underway here on Friday. "With Carnival starting, people are going to be having sexual relations and exchanging saliva," she said. "That means the virus could spread even more."
The researchers at Fiocruz said that they had conducted tests to rule out the presence of dengue and chikungunya, viruses that are part of the same family and transmitted by the same mosquito, Aedes aegypti.
A potential upside to Friday's revelation could involve developing urine tests as a diagnostic tool to determine when patients in Brazil have Zika. Brazil still lacks widespread availability to tests for Zika, a virus that shows no symptoms in most of the people who get it.
How a Medical Mystery in Brazil Led Doctors to Zika
Donald G. Mcneil Jr., Simon Romero and Sabrina Tavernise
A sudden, sharp increase in babies with "no foreheads and very strange heads" was baffling doctors in Brazil. That set off a search for answers that led to a little-known pathogen, the Zika virus.
Something strange was happening last August in the maternity wards of Recife, a seaside city perched onBrazil's easternmost tip, where the country juts into the Atlantic.
"Doctors, pediatricians, neurologists, they started finding this thing we never had seen," said Dr. Celina M. Turchi, an infectious diseases researcher at the Oswaldo Cruz Foundation, a prominent scientific institute in Brazil.
"Children with normal faces up to the eyebrows, and then you have no foreheads and very strange heads," she recalled, referring to the condition known as microcephaly. "The doctors were saying, 'Well, I saw four today,' and, 'Oh that's strange, because I saw two.'"
Aside from their alarming appearance, many of the babies seemed healthy.
"They cried," Dr. Turchi said. "They breast-fed well. They just didn't seem to be ill."
Doctors were stumped.
They did not know it then, but they were seeing the first swell of a horrifying wave. A little-known pathogen - the Zika virus, carried by mosquitoes - had been circulating in Brazil for at least a year. It would later become the chief suspect in the hunt to work out what had happened to those newborns.
Since then, those tiny babies have led the World Health Organization to declare a public health emergency. They have prompted warnings to pregnant women to avoid countries where the virus is circulating, even to refrain from unprotected sex with men who have visited those countries, following a report of sexual transmission of the virus in Dallas last week.
They have led health ministers of five countries to say something so unthinkable that none had ever uttered it before: Women, please delay having children.
The virus now threatens the economies of fragile nations and the 2016 Summer Olympics in Rio de Janeiro. It has opened a new front in the debate in heavily Roman Catholic countries about a woman's right tobirth control and abortion.
And the children stricken with microcephaly, or abnormally small heads, have doctors everywhere asking: What is this virus? How could it have been around for almost 70 years without us realizing its power? What do we tell our patients about a bug that can hide in a mosquito's proboscis and a man's semen, even in human saliva or urine? What do we tell young women who ask if their unborn babies are safe?
"This epidemic is an unfolding story," said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases. "As with Ebola, this virus is something that could exist for years under the radar, and we don't know until we get thousands of cases what it really does."
"With Zika, we're seeing new twists and turns every week."
To doctors in Recife, whatever was striking the babies seemed to have fallen like a bolt from the blue.
In reality, it had been building for months. It had even been frequently discussed among clinicians - but no one had realized what was on the horizon.
Seeing the Same Symptoms
A year earlier, doctors say, the first patients had started trickling into public hospitals in Natal, capital of the state of Rio Grande do Norte, about 200 miles up the coast from Recife.
It was a few weeks after the 2014 World Cup, and Natal had been one of the host cities of the soccer championship, which draws fans from all over the world.
Many patients lived on the city's margins, others in settlements dotted across the sertão, northeast Brazil's arid hinterland.
Almost all had the same symptoms: a flat pinkish rash, bloodshot eyes,fever, joint pain and headaches. None were desperately ill, but the similarities were striking.
"That scared some patients and doctors, and my team," said Aline Bezerra, a nurse and the municipal epidemiologist. "We knew nothing other than that it might be some kind of light dengue."
Tests ruled that out, along with other common viruses, but the patients kept coming. One day in January 2015, 100 showed up at the state's hospitals.
"We alerted the federal authorities that we were dealing with something urgent and new," said Dr. Kleber Luz, an infectious diseases specialist at the Federal University of Rio Grande do Norte. "But their reaction was sluggish."
By last March, the spread of a "doença misteriosa" - the mystery disease - had become impossible to ignore. It appeared in two more states nearby. Then it reached Salvador, a city of 2.5 million.
Doctors speculated that it was an allergy; that it was roseola, a childhood illness; that it was a new variant of Fifth Disease, a facial rash that gives children a "slapped-cheek" look.
"People were claiming it was polluted water," said Dr. Gúbio Soares, a virologist at the Federal University of Bahia in Salvador. "I began thinking it was something transmitted by mosquitoes."
Working in his modest lab with a colleague, Dr. Silvia Sardi, Dr. Soares kept testing blood samples.
Other doctors were doing the same. Over 6,800 samples were tested, according to news reports, from victims ranging from 4 months to 98 years old. Parvovirus, dengue, chikungunya and other suspects were all ruled out.
Finally, in April, Dr. Soares and Dr. Sardi were sure: It was Zika.
"I actually felt a sense of relief," Dr. Soares said. "The literature said it was much less aggressive than viruses we already deal with in Brazil."
In the capital, Brasília, the health minister at the time, Dr. Arthur Chioro, felt the same way.
"Zika virus doesn't worry us," he told reporters in May, after the Oswaldo Cruz Foundation had confirmed Dr. Soares's findings. "It's a benign disease." Dengue hemorrhagic fever, on the other hand, killed hundreds of Brazilians each year.
But on ProMED Mail, an online service run by the International Society for Infectious Diseases, the reaction was not so sanguine.
"The arrival of Zika virus in Brazil is not good news," wrote Thomas M. Yuill, an emeritus professor of veterinary science and wildlife ecology at the University of Wisconsin-Madison.
Not only did Brazil have "abundant mosquitoes and a large population of susceptible people," he wrote, but so did much of the Americas.
Two weeks earlier, an American mosquito disease expert working in Rio de Janeiro had scoffed on ProMED about an unconfirmed report that it was Zika. The virus fit the symptoms, he wrote, but it was circulating only in Africa and Asia, and in the South Pacific, half a world away, in a different ocean.
He was right about where the virus had been, but not about where it was now.
An Island-Hopping Virus
For years, virus hunters on ProMED and other outbreak alert networks had been watching, fascinated, as Zika made long, slow and erratic progress eastward across the Pacific, island-hopping as American forces had done during World War II, albeit in reverse.
In 2007, it hit Yap Island, in Micronesia, east of the Philippines and north of Australia. It could have come to Yap from anywhere in Asia.
In October 2013, the Zika virus raced through the many islands of French Polynesia, including Tahiti and Bora Bora. In early 2014, it bounced to the Cook Islands, just to the west, and New Caledonia, close to Australia.
It also leapt to Easter Island, home of the giant stone heads, its official arrival in the Western Hemisphere.
It is still island-hopping. American Samoa and Tonga are having outbreaks now.
Scott C. Weaver, a virologist at the University of Texas Medical Branch in Galveston, wrote an article in 2009 warning that Zika was approaching the Americas. The virus was so obscure that, trying to be helpful in an interview, he explained: "Its closest relative is Spondweni" - a virus named for a place in South Africa that is no longer even on maps.
The Zika Forest in Uganda still is; the virus was discovered there in a monkey in 1947. Since then, the Zika virus had been considered mild compared to its killer cousins: yellow fever, dengue, West Nile and Japanese encephalitis. Until 2013, there was no evidence Zika had ever hospitalized anyone.
Tracking Its Path to Brazil
Back in Brazil, on May 14, it was definite. The mysterious outbreaks - by then in cities all over Brazil, including Rio de Janeiro - had all been caused by Zika.
Who had brought the virus to Brazil? There are two theories.
The first, offered by Brazilian scientists who analyzed airline flight patterns, was that it arrived in the crowds of soccer fans who had flocked to the 12 host cities in the 2014 World Cup. If the Natal outbreak was truly the first, that theory has credence.
A second, proposed by French scientists connected to the Pasteur Institute in Paris who had investigated the outbreak in Polynesia, was that it arrived a few weeks later, during the Va'a World Sprint, a canoe race in Rio that attracted teams from several Polynesian islands.
Since the virus is believed to persist in the blood for up to 10 days, it presumably came from an island then having an outbreak. But in a world as interconnected as ours has become, it may be spread not by a foreigner from faraway lands, but by any international traveler.
The first case of Zika infection detected in New York City was found in December 2013 - six months before the virus is thought to have reached Brazil - in a 48-year-old traveler who lives near Central Park but has asked to remain unidentified.
When he walked into Traveler's Medical Service on Madison Avenue, he had just returned from a long trek through Ecuador, Peru, Bolivia, Chile, Easter Island and Hawaii, with a stopover in French Polynesia.
Dyan J. Summers, the nurse practitioner who first saw him, said he pulled his shirt out of his bluejeans and peeled it off, exposing a pinkish rash he said he had had for 11 days.
"I took one look and said, 'Dengue fever,'" she recalled in an interview last week. "He said, 'I'm not so sure. I think it's Zika.'"
Ms. Summers was startled: "I'd heard of Zika, but nobody was thinking about Zika."
"But this is a very, very bright guy," she continued. "He travels a lot, he knows about safe water and safe altitudes for malaria. He was right on the money, that guy. In Polynesia, he had read articles in the local paper about Zika."
She took blood immediately and again 20 days later, and sent both samples to the Centers for Disease Control and Prevention in Atlanta. Their tests showed that he had antibodies to dengue, West Nile and Zika, but the count of Zika antibodies had shot up.
In researching Zika, Ms. Summers said, her very bright patient had found an article about a scientist in Colorado who had infected his wife with the virus after returning from Africa.
"Because of that paper, I advised him not to have unprotected sex with his common-law wife," she said.
"What's weirder," she added. "He knew there were cases of Guillain-Barré connected to it."
Their exchange was strangely prescient.
At the time, Polynesian and French doctors were just beginning to diagnose Guillain-Barré syndrome, a form of temporary paralysis that starts in the hands and feet. Along with infant microcephaly, the syndrome has turned out to be one of the Zika epidemic's chief fears.
It is an autoimmune attack on nerve cells that can be triggered by several viruses or bacteria. It is usually temporary, though it can last for weeks; but if the paralysis reaches the muscles powering the lungs, and the patient is not quickly put on a respirator, it can kill.
Ms. Summers's caution was right: Last week, the Centers for Disease Control and Prevention gave similar advice about unprotected sex to all Americans.
Hints a Virus Isn't Benign
In May, after it was confirmed that Zika was circulating in Brazil, it took only a few weeks for doctors to suspect that Dr. Chioro, the health minister, had been mistaken. There were hints that the virus was anything but benign.
In Maceió, Recife and other cities, cases of Guillain-Barré began to spike. Dr. María Lúcia Brito, a neurologist in Recife, saw 50 patients with it in 2015, up from 14 the year before.
"It was obvious - a shift occurred when Zika cases started to rise," she said.
Then, in July, a pair of twins were born in Recife. One was healthy; the other was microcephalic. Their parents took them in early August to be examined by Dr. Vanessa van der Linden, a prominent neurologist.
She diagnosed the cause as an infection that had reached one baby in the womb, and tested mother and baby for rubella, syphilis andtoxoplasmosis, three known causes of microcephaly.
The results were negative, so she started testing for genetic mutations like Down syndrome.
In September, the Hospital Barão de Lucena, the public hospital in Recife where she works, saw a surge in cases: five microcephalic babies were suddenly in her care.
The same thing was happening elsewhere. The hospital where her mother was a pediatric neurologist suddenly had seven cases.
"That's when I thought, 'Something is terribly wrong,' " Dr. van der Linden said.
She soon learned that several of the mothers remembered having the "mystery disease" - the Zika rash - early in their pregnancies.
But tests of the infants for the Zika infection were all negative. Their mothers had been ill months earlier, and in adults the virus usually disappears in 10 days or less. It is still unclear how long it persists in a fetus.
In early October, the national health ministry asked Dr. Turchi, the Oswaldo Cruz Foundation epidemiologist, to investigate. She went to hospitals, including those in Recife. Doctors were running tests for various viruses, but they were all coming up blank.
"The pediatricians were saying, 'We've never seen anything like this,' " she said. "These kids are different. This is something new."
Young Mothers in Shock
Dr. Kátia Petribu, a hospital psychiatrist in Recife, remembers the mothers. They were ghosts - mute, expressionless figures in corridors holding babies whose foreheads seemed to have vanished.
Many of the mothers were young, one just 14. "They were in a state of shock," she said. "They were unable to talk."
Dr. Petribu had trouble sleeping. She could not get them out of her mind.
Normally, she worked with patients with obsessive-compulsive disorder. But she decided to refocus on these women, who so clearly needed help.
"They come with nothing," she said. "No food. They travel by bus for hours, arrive at 7 a.m., and wait for hours to be seen."
Many were young rural women with no understanding of why their children looked so different. A 16-year-old showed up with her own mother, who was worried about missing a perfect day to sell cold drinks on the beach.
Dr. Mauricio L. Nogueira, a doctor from southern Brazil who had seen no cases in his region, which is as far from the tropical north as Quebec is from Miami, remembers visiting a hospital in the northern city of Salvador. He is still haunted by what he saw: 25 microcephalic children, all born in the previous 10 days.
That was "really shocking for me," he said. "Until then, I was just reading reports."
One mother, he said, looked up at him and asked, "Hey, doctor, his head is going to grow, right?"
"It was really painful," he said.
Frustration was growing, too, for Dr. Turchi, the epidemiologist. "If we had known what was going on, that would have been one thing," she said. "But there was no book to follow. We had no map."
She shelved her work on the dengue virus and skipped Christmas with her mother.
"I couldn't sleep for several weeks," she said. "It was the most important thing I have seen in my entire career. It was a tragedy, but it was like we were seeing history in front of us, day by day. It was a Zika's connection to microcephaly was suspected but very difficult to confirm. Dr. Turchi set up a quick "case control" study, the epidemiologist's classic tool, comparing babies born with the condition and those without it.
Dr. David L. Heymann, chairman of the World Health Organization committee that recommended the declaration of the public health emergency, said in an interview last week that very tool - a case control study following two sets of pregnant women, some who had Zika and some who did not - was what his committee needed to prove whether Zika causes microcephaly, and whether it does so alone or requires a cofactor like a prior infection with dengue.
"Sorting out a rare event will take a lot of women," he said, and they must be followed for months.
At Last, 'a Road to Follow'
But Dr. Turchi did not have months.
She called every scientist she knew, and they came from all over Brazil. One flew in from London. Dr. Turchi gave the group a name: MERG, the Microcephaly Epidemic Research Group.
"It was like a house on fire - everyone grabs a bucket and does what they can," she said. Some scientists stayed in her apartment, talking late into the night. "It's like when you like something and you have people who like the same thing, you can talk for hours without feeling tired," she said. "It's like discussing football. You never stop talking. It's an obsession."
A turning point came in early November: Dr. Adriana Melo in Paraíba State, just north of Recife, had drawn amniotic fluid from a pregnant woman and found Zika virus in it. Then brain tissue from two stillbirths was tested. Again, Zika.
"At last we had a road to follow," Dr. Turchi said. "A map."
One of those who flew in to help in the detective work was Dr. Laura C. Rodrigues, an epidemiologist at the London School of Hygiene and Tropical Medicine on contract to the Pan American Health Organization.
"It was the kind of call where you dropped everything," she said. "There had never been a congenital malformation by mosquito before, not ever. It was totally outside our experience."
With the discovery of Zika in malformed fetuses, Dr. Turchi's team has been able to turn to the kind of task Dr. Heymann described. They have recruited about 1,000 pregnant women with Zika symptoms, and are following healthy and microcephalic newborns in the same areas. They work nights and weekends, eating sandwiches from the institute's shop or meals of rice, beans and chicken provided by a research assistant's mother.
There are now so many reported cases of microcephaly that a new problem has arisen: too many false alarms.
Anxious obstetricians across Brazil have reported babies who merely have small heads, or babies whose mothers had other problems, like severe alcoholism or family histories of malformations, conditions that should have excluded them from the research.
Brazil has already changed its definition of a small head, to 32 centimeters around from 33 centimeters, and may revise it again soon.
Dr. Turchi defends those decisions, saying a broad net had to be cast at first because so little was known.
"We didn't want to get just the severe cases; we wanted to look at the broadest possible spectrum of the disease," she said. "Then we can narrow it later."
'Perfect Epidemic Curve'
Loosed on a continent where no one is immune, Zika has the potential to infect tens of millions of people. It is now being transmitted in 33 countries with about 600 million inhabitants, the W.H.O. says. Health officials in Brazil are investigating thousands of reported cases of microcephaly that may be linked to the virus.
Now a bright spot has appeared.
In Recife, and Pernambuco State around it, microcephaly cases have been declining for about three weeks. It is unclear exactly why, but researchers are starting to wonder if the epidemic has peaked.
"It looks like a perfect epidemic curve," Dr. Turchi said. "You see where it started, then went up, and now it's going down."
But that decline, and the general sigh of relief it portends, is occurring only in the one spot in the hemisphere where transmission of the virus hit earliest and was most intense.
Zika was just getting started there a year before the microcephaly cases began. And now the virus is virtually everywhere south of Florida and Texas.
And Guillain-Barré, the harbinger of microcephaly, is being spotted farther from the epidemic's epicenter in Brazil.
Colombia, Venezuela, Suriname and El Salvador, where mosquitoes thrive year-round, all have reported Guillain-Barré cases. Colombia has "an explosion" of them, its health minister said, with three deaths.
There have also been dozens of confirmed Zika rashes and fevers in the United States, all so far in returning travelers, except for the person infected through sex in Texas by a traveler returning from Venezuela.
Air travel maps show the United States' potential to be a kind of viral pincushion; Zika may arrive from anywhere. Since four out of five victims never have any symptoms, there is no way to spot it at the border.
The C.D.C. thinks it is all but inevitable that there will be at least small outbreaks here. But how far they spread will depend on how aggressively mosquitoes are killed.
Now that the world is alert to the danger and is fighting back, and women are even contemplating delaying pregnancies, scientists say it is unlikely that Brazil's national nightmare will be repeated elsewhere on such a scale.
In Recife, Dr. Turchi was hopeful.
"I'm more comfortable now," she said. "I see so many people working as a team and so much international concern. Now it has become clear to the whole world."
The Wall Street Journal, February 8, 2016
Brazil Health Researchers Say Zika Virus Is Active in Saliva, UrinePaul Kiernan, Reed Johnson and Rogerio Jelmayer
Pregnant women advised to take precautions to avoid coming in contact with others' saliva; other researchers suggest such fears are overblown
As many as 1.5 million Brazilians may be infected by the mosquito-borne Zika virus. With Brazil at the forefront of the latest global health scare, and as the host of this year's Olympic Games, Dipti Kapadia explains three things Brazil is doing to combat the Zika virus. Photo: Getty Images
Brazilian health researchers said Friday the Zika virus is active in saliva and urine, sparking fears about possible new infection routes on the eve of the nation's sexually charged Carnival festivities.
Brazil's leading medical-research institute, the Rio-based Oswaldo Cruz Foundation, said researchers' tests showed that the "entire genetic sequence" of the virus was present and "replicating" in samples of saliva and urine that it examined.
Officials of the foundation, known as Fiocruz, recommended that pregnant women take precautions by staying away from large crowds and avoiding sharing cups and utensils with people who show symptoms of the virus.
Artur Timerman, president of Brazil's Society of Dengue and Arbovirus, criticized the institute for publicizing its findings at a news conference rather than through the time-consuming but professionally sanctioned route of peer-reviewed scientific journals.
"The irresponsible thing that has happened is that Fiocruz has released this through the press," Dr. Timerman said. "This is creating a panic, a fear, that in my view is disproportional."
Fiocruz officials said it hasn't yet been determined whether Zika can be transmitted through those fluids. Brazil's Health Ministry, which oversees the institute, said in a separate statement Friday that additional research would be needed to do so.
"The fact that you've got an active virus in saliva and urine isn't proof that transmission can occur. But there may be a possibility of infection of other people through those fluids," said Paulo Gadelha,Fiocruz's president.
Coming on the eve of Brazil's wild Carnival festivities, the announcement prompted a flurry of comments from hundreds of viewers watching the news conference live on a social-media platform. One of the biggest street parties in the world, Brazil's alcohol-fueled Carnival parades often involve revelers kissing total strangers. Public urination is also rampant.
"Carnival is over, guys," one viewer lamented.
The virus, which is thought to be transmitted mainly by mosquito bites, usually produces mild symptoms, if any. But it has become a major international concern since Brazilian authorities linked it to complications, including a rare birth defect called microcephaly in which babies are born with dangerously small skulls and underdeveloped brains. Earlier this week, the World Health Organization declared possible complications from Zika a global health emergency.
Speaking at a separate news conference on Friday, Tom Frieden, director of the Atlanta-based Centers for Disease Control and Prevention, said there was little data on the likelihood of Zika virus transmission through saliva or urine, and only three confirmed cases of transmission through sexual contact. "There are unknowns," Frieden said. "We're still learning more about how it works in the body."
When asked if the CDC concurred with Fiocruz's advisory, Frieden said the CDC is still gathering the data and would provide information when it becomes available so women can decide what is safe. "We have not issued guidance" on kissing, Frieden said.
Fiocruz's latest findings come on the back of a wave of recent evidence that mosquitoes aren't the Zika virus's only vector for spreading. Brazilian health officials in the city of Campinas this week reported two cases of Zika being transmitted through blood transfusions. The CDC said Wednesday that a person in Texas contracted the virus through sexual contact with a partner who had recently traveled to an area where Zika was circulating. On Friday it urged pregnant women to avoid unprotected sex with male partners who have traveled to such areas.
Much Zika research to date has been based on the assumption that the virus was transmitted primarily, or even exclusively, through mosquito bites, according to Joseph Conlon, technical adviser for the U.S.-based nonprofit American Mosquito Control Association. Friday's announcement could change that, he said.
"If it can be transmitted by any bodily fluid, that complicates matters considerably," Mr. Conlon said. "We're going to have to look beyond the mosquitoes and we're going to have to do a lot of case management."
Uncertainty has driven much of the Zika panic worldwide. Discovered in a monkey in Uganda's Zika Forest in 1947, the virus traveled through parts of Africa, Asia and the Pacific Islands before reaching Brazil a couple of years ago, researchers say. Symptoms don't appear in as many as four out of every five cases; when they do, they tend to be far milder than those of other mosquito-borne pathogens like dengue fever.
But that has made it hard for health officials to determine how prevalent the disease is and what, if any, relation it has to microcephaly.
Given the uncertainty, Fiocruz's recommendations to pregnant women were premature, said Marcio Fernandes, an epidemiologist at both the Federal University of Rio de Janeiro and the Rio state health authority.
"We shouldn't lose focus on combatting the main transmission pathway, which is the mosquito," Mr. Fernandes said. "Even the HIV virus has been isolated in saliva, but the quantity is so small that it isn't able to be transmitted through saliva."
Reuters, February 8, 2016
Doctors puzzle over severity of defects in some Brazilian babiesBill Berkrot & Anthony Boadle
Experts on microcephaly, the birth defect that has sparked alarm in the current Zika virus outbreak, say they are struck by the severity of a small number of cases they have reviewed from Brazil.
Consultations among doctors in Brazil and the United States have increased in the last two weeks, and some of the leading authorities on the condition are finding patterns of unusual devastation in scans of the newborns' malformed brains.
While it's not known how representative the scans are, the early observations of these doctors point to a tough road ahead for the babies, their families and their communities and heighten the concern surrounding Zika, which is suspected of causing microcephaly.
"We are in the process of very rapid information gathering on what has been seen," said Dr. William Dobyns, a geneticist at Seattle Children's Hospital. "The condition that I've been able to review, very preliminarily, is more severe than simple microcephaly."
The Zika virus is transmitted by mosquito, causing mild symptoms in about 20 percent of cases, and most people experience no illness at all. But a spike in reported microcephaly cases among babies in areas of Brazil with Zika outbreaks has triggered an international effort to determine whether the virus causes the condition. The suspected association moved the World Health Organization (WHO) on Monday to declare an international health emergency.
Dobyns has spent 30 years researching and treating microcephaly, a condition defined by abnormally small heads in newborns that can lead to developmental disabilities, from mild to severe. The U.S. Centers for Disease Control and Prevention (CDC) has sought out his expertise in understanding the unfolding epidemic.
With a small group of geneticists and other microcephaly specialists, he recently reviewed scans of a handful of babies sent by a colleague in Brazil. All the experts were struck by the scale of malformations, he said.
"These children have a very severe form of microcephaly," Dobyns said. "The brain is not just small, it's small with malformations of the cerebral cortex and calcifications. It has the appearance of a very severe, destructive injury to the brain."
Particularly alarming, Dobyns said, is the presence in the Brazilian cases of excess spinal fluid between the brain and skull of the babies.
"If the brain is growing and then suddenly shrinks, then you'll see fluid between the brain and skull," he said. "It has a pattern that suggests that the brain has actually decreased in size."
Dr. Leonardo Vedolin, a neuroradiologist and researcher at the Moinhos de Vento hospital in Porto Alegre, Brazil, shared with Dobyns scans of two more microcephalic babies this week. The doctors belong to a brain defects study group that convenes via videoconference each month. The group is now focused on Zika.
Neither Vedolin nor Brazil's Health Ministry were able to provide a breakdown on the severity of confirmed microcephaly cases. In general, Vedolin said, 5 percent of microcephaly cases are severe. But the proportion appears greater among the cases in Brazil, he said.
THE CASELOAD
Public health officials in Brazil are investigating more than 4,000 cases of suspected microcephaly, and have confirmed more than 400. Prior to the Zika outbreak, Brazil saw on average 163 cases annually of microcephaly over the past five years, according to WHO. In 17 of the new cases, the presence of Zika was identified in the mother or the baby.
A study of 35 Brazilian babies born with microcephaly during the Zika outbreak reported by the CDC Jan. 29 added strength to the suspected connection.
The mothers of all 35 infants had lived in or visited Zika virus-affected areas during pregnancy, the report said. Twenty-five infants had severe microcephaly, and 17 had at least one neurologic abnormality.
Dr. Frank Esper, an infectious disease expert from Rainbow Babies & Children's Hospital in Cleveland, said he expects a steady wave of studies on Zika and microcephaly that will provide a much clearer picture over the first half of 2016.
By the broadest definition, about 2.3 percent of all babies are microcephalic, Dobyns said. Some cases are so mild they involve no complications at all.
About one tenth of one percent of the cases are so severe that lifelong care is required, he said. There are many known causes, including a wide range of genetic disorders such as Down syndrome, as well as oxygen deprivation to the fetus, cytomegalovirus and severe fetal alcohol syndrome.
Lifespan in severe cases can be months or as long as 10 years, depending on proximity to good medical care, Dobyns said.
Dr. Dawn Nolt, a member of the American Association of Pediatrics' (AAP) Committee on Infectious Diseases, and other doctors, said more severely affected children often require treatment for epileptic seizures, as well as physical, respiratory and speech therapy. They may need help with everyday activities, such as eating or walking.
"It's crucial to go to a care center with good neurology and genetics teams that can evaluate the child comprehensively," said Dr. Ghayda Mirzaa, a pediatric neurologist and colleague of Dobyns at Seattle Children's.
Doctors in Recife, Brazil are sending mothers with afflicted babies for therapy to help stimulate eyesight, hearing and motor skills to minimize retardation in mental and physical development.
There are a handful of centers of microcephaly research and treatment in the U.S., including Dobyns' hospital in Seattle. The consultations of physicians like Dobyns in the Brazil cases is informal at this point but could form the basis for an organized exchange of expertise that will inform the ongoing care of the children of the epidemic.
"We need to get the message out that this is real, and coming, without getting everybody to panic," Dobyns said. "There will be a steep curve of new information coming in."
Nem a sociedade, nem as autoridades se deram ainda conta da extrema gravidade da situação.
Paulo Roberto de Almeida
Matérias do The New York Times, February 8, 2016
The Zika Virus and Brazilian Women's Right to Choose
Debora Diniz
Brazil is in a state of crisis. Since October, there have been more than 4,000 suspected cases of babies born with a neurological syndrome associated with the Zika virus. The Health Ministry has suggested that women avoid pregnancy until the epidemic has passed or more is known about it.
I am a Brazilian woman. My friends who are planning to have children soon are worried about Zika. But they don't need to be too concerned. In our well-to-do neighborhood in Brasília, the capital, there has not been a single case of a baby with the birth defects associated with the Zika epidemic. As far as I know, not one woman here has even been infected by the virus.
Lost in the panic about Zika is an important fact: The epidemic mirrors the social inequality of Brazilian society. It is concentrated among young, poor, black and brown women, a vast majority of them living in the country's least-developed regions. The women at greatest risk of contracting Zika live in places where the mosquito is part of their everyday lives, where mosquito-borne diseases like dengue andchikungunya were already endemic. They live in substandard, crowded housing in neighborhoods where stagnant water, the breeding ground for disease-carrying mosquitoes, is everywhere. These women can't avoid bites: They need to be outdoors from dawn until dusk to work, shop and take care of their children. And they are the same women who have the least access to sexual and reproductive health care.
The Zika epidemic has given Brazil a unique opportunity to look at inequality and reproductive rights, and to change how the country treats women. Asking women to avoid pregnancy without offering the necessary information, education, contraceptives or access to abortion is not a reasonable health policy. Sexual and reproductive rights for all women, poor and rich, must be taken seriously. The government should immediately offer a comprehensive package of sexual and reproductive health care to all Brazilian women, with a specific focus on those at most risk of Zika infection.
Brazil has some of the world's strictest abortion laws. The procedure is legal only in cases when the life of the woman is in danger of complications, or she was raped, or she is carrying an anencephalic fetus. Knowledge that a child will suffer from serious neurological problems is not grounds for legally terminating a pregnancy. That doesn't mean that abortion is uncommon, though.
In 2010, I conducted a national survey that found that by age 40, one in five Brazilian women had had at least one abortion. The overwhelming majority of these abortions were illegal and performed in unsafe conditions. According to Brazilian law, more than five million women should have spent time in prison. They would have amounted to almost 10 times our current prison population, which is the fourth largest in the world. In abortion, too, Brazil's economic inequality is a factor: Wealthy women can pay to secure safe abortions; most women can't.
The poor women who are most likely to contract Zika face tremendous barriers to getting safe abortions. They are forced to carry their pregnancies in fear. Public health clinics in poor communities rarely offer either the blood test that detects the presence of the virus or the ultrasound that can diagnose birth defects. We in Brazil need to know their stories to repair the harm inflicted by the government's negligence in controlling the outbreak.
Low-paid women and domestic workers are the true face of the Zika virus. In Brazil, it is usually women who are responsible for family planning and child care. They will also be the caregivers of disabled, dependent children. Some news reports have included accounts of women being abandoned by their partners after the birth of a baby with neurological problems. The state shouldn't abandon them, too. It needs to provide financial support and social services for the poor women and their children who are suffering from the effects of Zika.
The Health Ministry must help Brazil's women. In the short term, the government needs to control the mosquitoes by destroying their habitat and working with the international community to advance knowledge about how to stop the disease. But that's only a start. Women need to be given the power to manage their own pregnancies.
While family planning is a constitutional right, many women have trouble getting contraceptives because of poverty or inconvenience. This must change. And sexual and reproductive education must be a topic in Brazil's public schools.
The government must finally give women basic control over their reproductive lives - accessible and affordable contraception, and safe and legal abortion. The organization I founded, Anis - Institute of Bioethics, is preparing to present a case to the Supreme Court with these demands. Ever since we announced our plans, I have been receiving phone calls from women from all over the country; some have seen their childbearing dreams turned into nightmares because of the Zika virus. Others worry about how they will get health care for their disabled children. Many wonder how many more will have to suffer or die before abortion is a right.
Brazil Finds Zika Virus in Human Urine and Saliva, but Risk Is Unclear
Vinod Sreeharsha & Simon Romero
Scientists Find Zika in Saliva and Urine
A Brazilian health institute found traces of the Zika virus in certain bodily fluids of two patients, but said more research is needed to determine if the infection can be transmitted through the fluids.
Brazilian scientists said Friday that they had detected the presence of the Zika virus in samples of human saliva and urine, a first for Brazil.
The Brazilian researchers warned that the virus might have the potential to spread through kissing or urine, but they were quick to point out that this still remains to be proved. Nonetheless, the announcement amplified concern in Brazil with many people pointing out the possible impact to the annual Carnival celebration, which began on Friday.
"It is something we have to further investigate," said Dr. Myrna Bonaldo, the head of the Flavivirus Molecular Biology Laboratory at Fiocruz, a prominent research institute here. "We are not yet sure if Zika can be transmitted to others" through saliva or urine, she said.
The findings point to the frenetic efforts by researchers in Brazil and other countries to determine the risks posed by the mosquito-borne Zika virus as it spreads through more than two dozen countries in the Americas.
Brazilian doctors have already linked Zika to an increase in babies born with abnormally small heads, a condition known asmicrocephaly, though research teams are still trying to prove this connection.
French scientists had already published research last year in the Journal of Clinical Virology that located the Zika virus in human saliva following an outbreak of the virus in 2013 and 2014 in French Polynesia.
The Brazilian researchers at Fiocruz said that their studies had detected the virus in an active form in human saliva and urine samples.
Dr. Bonaldo and officials at the institute said that they had obtained the samples from two patients with Zika-like symptoms; one was found to have the virus in urine, the other had Zika in the saliva sample. It remained unclear whether the tiny sample size was enough to produce solid conclusions.
"The significance of the results is unclear," said Dr. Peter J. Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine. "We know, for example, that dengue is only transmitted via Aedes mosquito bites, and yet we can find the dengue genome in urine and saliva. So more research would need to be done to determine if Zika can be transmitted via kissing."
"For now," Dr. Hotez added, "it still seems highly likely that the overwhelming number of cases of Zika are transmitted through mosquito bites."
The announcement at Fiocruz on Friday morning quickly spread on social media, sowing confusion among some in Brazil.
"I'm trying to remain calm, but this is really some troubling news," said Kalina de Andrade, 28, a cashier at a store in the seaside Botafogo neighborhood of Rio.
Ms. de Andrade, who is five months pregnant, said that it had become increasingly difficult to discern all the risks associated with Zika ever since the federal authorities declared an emergency after the outbreak of the virus several weeks ago.
"The government needs to get better at explaining to the population what this means," she said, emphasizing that annual Carnival celebrations officially got underway here on Friday. "With Carnival starting, people are going to be having sexual relations and exchanging saliva," she said. "That means the virus could spread even more."
The researchers at Fiocruz said that they had conducted tests to rule out the presence of dengue and chikungunya, viruses that are part of the same family and transmitted by the same mosquito, Aedes aegypti.
A potential upside to Friday's revelation could involve developing urine tests as a diagnostic tool to determine when patients in Brazil have Zika. Brazil still lacks widespread availability to tests for Zika, a virus that shows no symptoms in most of the people who get it.
How a Medical Mystery in Brazil Led Doctors to Zika
Donald G. Mcneil Jr., Simon Romero and Sabrina Tavernise
A sudden, sharp increase in babies with "no foreheads and very strange heads" was baffling doctors in Brazil. That set off a search for answers that led to a little-known pathogen, the Zika virus.
Something strange was happening last August in the maternity wards of Recife, a seaside city perched onBrazil's easternmost tip, where the country juts into the Atlantic.
"Doctors, pediatricians, neurologists, they started finding this thing we never had seen," said Dr. Celina M. Turchi, an infectious diseases researcher at the Oswaldo Cruz Foundation, a prominent scientific institute in Brazil.
"Children with normal faces up to the eyebrows, and then you have no foreheads and very strange heads," she recalled, referring to the condition known as microcephaly. "The doctors were saying, 'Well, I saw four today,' and, 'Oh that's strange, because I saw two.'"
Aside from their alarming appearance, many of the babies seemed healthy.
"They cried," Dr. Turchi said. "They breast-fed well. They just didn't seem to be ill."
Doctors were stumped.
They did not know it then, but they were seeing the first swell of a horrifying wave. A little-known pathogen - the Zika virus, carried by mosquitoes - had been circulating in Brazil for at least a year. It would later become the chief suspect in the hunt to work out what had happened to those newborns.
Since then, those tiny babies have led the World Health Organization to declare a public health emergency. They have prompted warnings to pregnant women to avoid countries where the virus is circulating, even to refrain from unprotected sex with men who have visited those countries, following a report of sexual transmission of the virus in Dallas last week.
They have led health ministers of five countries to say something so unthinkable that none had ever uttered it before: Women, please delay having children.
The virus now threatens the economies of fragile nations and the 2016 Summer Olympics in Rio de Janeiro. It has opened a new front in the debate in heavily Roman Catholic countries about a woman's right tobirth control and abortion.
And the children stricken with microcephaly, or abnormally small heads, have doctors everywhere asking: What is this virus? How could it have been around for almost 70 years without us realizing its power? What do we tell our patients about a bug that can hide in a mosquito's proboscis and a man's semen, even in human saliva or urine? What do we tell young women who ask if their unborn babies are safe?
"This epidemic is an unfolding story," said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases. "As with Ebola, this virus is something that could exist for years under the radar, and we don't know until we get thousands of cases what it really does."
"With Zika, we're seeing new twists and turns every week."
To doctors in Recife, whatever was striking the babies seemed to have fallen like a bolt from the blue.
In reality, it had been building for months. It had even been frequently discussed among clinicians - but no one had realized what was on the horizon.
Seeing the Same Symptoms
A year earlier, doctors say, the first patients had started trickling into public hospitals in Natal, capital of the state of Rio Grande do Norte, about 200 miles up the coast from Recife.
It was a few weeks after the 2014 World Cup, and Natal had been one of the host cities of the soccer championship, which draws fans from all over the world.
Many patients lived on the city's margins, others in settlements dotted across the sertão, northeast Brazil's arid hinterland.
Almost all had the same symptoms: a flat pinkish rash, bloodshot eyes,fever, joint pain and headaches. None were desperately ill, but the similarities were striking.
"That scared some patients and doctors, and my team," said Aline Bezerra, a nurse and the municipal epidemiologist. "We knew nothing other than that it might be some kind of light dengue."
Tests ruled that out, along with other common viruses, but the patients kept coming. One day in January 2015, 100 showed up at the state's hospitals.
"We alerted the federal authorities that we were dealing with something urgent and new," said Dr. Kleber Luz, an infectious diseases specialist at the Federal University of Rio Grande do Norte. "But their reaction was sluggish."
By last March, the spread of a "doença misteriosa" - the mystery disease - had become impossible to ignore. It appeared in two more states nearby. Then it reached Salvador, a city of 2.5 million.
Doctors speculated that it was an allergy; that it was roseola, a childhood illness; that it was a new variant of Fifth Disease, a facial rash that gives children a "slapped-cheek" look.
"People were claiming it was polluted water," said Dr. Gúbio Soares, a virologist at the Federal University of Bahia in Salvador. "I began thinking it was something transmitted by mosquitoes."
Working in his modest lab with a colleague, Dr. Silvia Sardi, Dr. Soares kept testing blood samples.
Other doctors were doing the same. Over 6,800 samples were tested, according to news reports, from victims ranging from 4 months to 98 years old. Parvovirus, dengue, chikungunya and other suspects were all ruled out.
Finally, in April, Dr. Soares and Dr. Sardi were sure: It was Zika.
"I actually felt a sense of relief," Dr. Soares said. "The literature said it was much less aggressive than viruses we already deal with in Brazil."
In the capital, Brasília, the health minister at the time, Dr. Arthur Chioro, felt the same way.
"Zika virus doesn't worry us," he told reporters in May, after the Oswaldo Cruz Foundation had confirmed Dr. Soares's findings. "It's a benign disease." Dengue hemorrhagic fever, on the other hand, killed hundreds of Brazilians each year.
But on ProMED Mail, an online service run by the International Society for Infectious Diseases, the reaction was not so sanguine.
"The arrival of Zika virus in Brazil is not good news," wrote Thomas M. Yuill, an emeritus professor of veterinary science and wildlife ecology at the University of Wisconsin-Madison.
Not only did Brazil have "abundant mosquitoes and a large population of susceptible people," he wrote, but so did much of the Americas.
Two weeks earlier, an American mosquito disease expert working in Rio de Janeiro had scoffed on ProMED about an unconfirmed report that it was Zika. The virus fit the symptoms, he wrote, but it was circulating only in Africa and Asia, and in the South Pacific, half a world away, in a different ocean.
He was right about where the virus had been, but not about where it was now.
An Island-Hopping Virus
For years, virus hunters on ProMED and other outbreak alert networks had been watching, fascinated, as Zika made long, slow and erratic progress eastward across the Pacific, island-hopping as American forces had done during World War II, albeit in reverse.
In 2007, it hit Yap Island, in Micronesia, east of the Philippines and north of Australia. It could have come to Yap from anywhere in Asia.
In October 2013, the Zika virus raced through the many islands of French Polynesia, including Tahiti and Bora Bora. In early 2014, it bounced to the Cook Islands, just to the west, and New Caledonia, close to Australia.
It also leapt to Easter Island, home of the giant stone heads, its official arrival in the Western Hemisphere.
It is still island-hopping. American Samoa and Tonga are having outbreaks now.
Scott C. Weaver, a virologist at the University of Texas Medical Branch in Galveston, wrote an article in 2009 warning that Zika was approaching the Americas. The virus was so obscure that, trying to be helpful in an interview, he explained: "Its closest relative is Spondweni" - a virus named for a place in South Africa that is no longer even on maps.
The Zika Forest in Uganda still is; the virus was discovered there in a monkey in 1947. Since then, the Zika virus had been considered mild compared to its killer cousins: yellow fever, dengue, West Nile and Japanese encephalitis. Until 2013, there was no evidence Zika had ever hospitalized anyone.
Tracking Its Path to Brazil
Back in Brazil, on May 14, it was definite. The mysterious outbreaks - by then in cities all over Brazil, including Rio de Janeiro - had all been caused by Zika.
Who had brought the virus to Brazil? There are two theories.
The first, offered by Brazilian scientists who analyzed airline flight patterns, was that it arrived in the crowds of soccer fans who had flocked to the 12 host cities in the 2014 World Cup. If the Natal outbreak was truly the first, that theory has credence.
A second, proposed by French scientists connected to the Pasteur Institute in Paris who had investigated the outbreak in Polynesia, was that it arrived a few weeks later, during the Va'a World Sprint, a canoe race in Rio that attracted teams from several Polynesian islands.
Since the virus is believed to persist in the blood for up to 10 days, it presumably came from an island then having an outbreak. But in a world as interconnected as ours has become, it may be spread not by a foreigner from faraway lands, but by any international traveler.
The first case of Zika infection detected in New York City was found in December 2013 - six months before the virus is thought to have reached Brazil - in a 48-year-old traveler who lives near Central Park but has asked to remain unidentified.
When he walked into Traveler's Medical Service on Madison Avenue, he had just returned from a long trek through Ecuador, Peru, Bolivia, Chile, Easter Island and Hawaii, with a stopover in French Polynesia.
Dyan J. Summers, the nurse practitioner who first saw him, said he pulled his shirt out of his bluejeans and peeled it off, exposing a pinkish rash he said he had had for 11 days.
"I took one look and said, 'Dengue fever,'" she recalled in an interview last week. "He said, 'I'm not so sure. I think it's Zika.'"
Ms. Summers was startled: "I'd heard of Zika, but nobody was thinking about Zika."
"But this is a very, very bright guy," she continued. "He travels a lot, he knows about safe water and safe altitudes for malaria. He was right on the money, that guy. In Polynesia, he had read articles in the local paper about Zika."
She took blood immediately and again 20 days later, and sent both samples to the Centers for Disease Control and Prevention in Atlanta. Their tests showed that he had antibodies to dengue, West Nile and Zika, but the count of Zika antibodies had shot up.
In researching Zika, Ms. Summers said, her very bright patient had found an article about a scientist in Colorado who had infected his wife with the virus after returning from Africa.
"Because of that paper, I advised him not to have unprotected sex with his common-law wife," she said.
"What's weirder," she added. "He knew there were cases of Guillain-Barré connected to it."
Their exchange was strangely prescient.
At the time, Polynesian and French doctors were just beginning to diagnose Guillain-Barré syndrome, a form of temporary paralysis that starts in the hands and feet. Along with infant microcephaly, the syndrome has turned out to be one of the Zika epidemic's chief fears.
It is an autoimmune attack on nerve cells that can be triggered by several viruses or bacteria. It is usually temporary, though it can last for weeks; but if the paralysis reaches the muscles powering the lungs, and the patient is not quickly put on a respirator, it can kill.
Ms. Summers's caution was right: Last week, the Centers for Disease Control and Prevention gave similar advice about unprotected sex to all Americans.
Hints a Virus Isn't Benign
In May, after it was confirmed that Zika was circulating in Brazil, it took only a few weeks for doctors to suspect that Dr. Chioro, the health minister, had been mistaken. There were hints that the virus was anything but benign.
In Maceió, Recife and other cities, cases of Guillain-Barré began to spike. Dr. María Lúcia Brito, a neurologist in Recife, saw 50 patients with it in 2015, up from 14 the year before.
"It was obvious - a shift occurred when Zika cases started to rise," she said.
Then, in July, a pair of twins were born in Recife. One was healthy; the other was microcephalic. Their parents took them in early August to be examined by Dr. Vanessa van der Linden, a prominent neurologist.
She diagnosed the cause as an infection that had reached one baby in the womb, and tested mother and baby for rubella, syphilis andtoxoplasmosis, three known causes of microcephaly.
The results were negative, so she started testing for genetic mutations like Down syndrome.
In September, the Hospital Barão de Lucena, the public hospital in Recife where she works, saw a surge in cases: five microcephalic babies were suddenly in her care.
The same thing was happening elsewhere. The hospital where her mother was a pediatric neurologist suddenly had seven cases.
"That's when I thought, 'Something is terribly wrong,' " Dr. van der Linden said.
She soon learned that several of the mothers remembered having the "mystery disease" - the Zika rash - early in their pregnancies.
But tests of the infants for the Zika infection were all negative. Their mothers had been ill months earlier, and in adults the virus usually disappears in 10 days or less. It is still unclear how long it persists in a fetus.
In early October, the national health ministry asked Dr. Turchi, the Oswaldo Cruz Foundation epidemiologist, to investigate. She went to hospitals, including those in Recife. Doctors were running tests for various viruses, but they were all coming up blank.
"The pediatricians were saying, 'We've never seen anything like this,' " she said. "These kids are different. This is something new."
Young Mothers in Shock
Dr. Kátia Petribu, a hospital psychiatrist in Recife, remembers the mothers. They were ghosts - mute, expressionless figures in corridors holding babies whose foreheads seemed to have vanished.
Many of the mothers were young, one just 14. "They were in a state of shock," she said. "They were unable to talk."
Dr. Petribu had trouble sleeping. She could not get them out of her mind.
Normally, she worked with patients with obsessive-compulsive disorder. But she decided to refocus on these women, who so clearly needed help.
"They come with nothing," she said. "No food. They travel by bus for hours, arrive at 7 a.m., and wait for hours to be seen."
Many were young rural women with no understanding of why their children looked so different. A 16-year-old showed up with her own mother, who was worried about missing a perfect day to sell cold drinks on the beach.
Dr. Mauricio L. Nogueira, a doctor from southern Brazil who had seen no cases in his region, which is as far from the tropical north as Quebec is from Miami, remembers visiting a hospital in the northern city of Salvador. He is still haunted by what he saw: 25 microcephalic children, all born in the previous 10 days.
That was "really shocking for me," he said. "Until then, I was just reading reports."
One mother, he said, looked up at him and asked, "Hey, doctor, his head is going to grow, right?"
"It was really painful," he said.
Frustration was growing, too, for Dr. Turchi, the epidemiologist. "If we had known what was going on, that would have been one thing," she said. "But there was no book to follow. We had no map."
She shelved her work on the dengue virus and skipped Christmas with her mother.
"I couldn't sleep for several weeks," she said. "It was the most important thing I have seen in my entire career. It was a tragedy, but it was like we were seeing history in front of us, day by day. It was a Zika's connection to microcephaly was suspected but very difficult to confirm. Dr. Turchi set up a quick "case control" study, the epidemiologist's classic tool, comparing babies born with the condition and those without it.
Dr. David L. Heymann, chairman of the World Health Organization committee that recommended the declaration of the public health emergency, said in an interview last week that very tool - a case control study following two sets of pregnant women, some who had Zika and some who did not - was what his committee needed to prove whether Zika causes microcephaly, and whether it does so alone or requires a cofactor like a prior infection with dengue.
"Sorting out a rare event will take a lot of women," he said, and they must be followed for months.
At Last, 'a Road to Follow'
But Dr. Turchi did not have months.
She called every scientist she knew, and they came from all over Brazil. One flew in from London. Dr. Turchi gave the group a name: MERG, the Microcephaly Epidemic Research Group.
"It was like a house on fire - everyone grabs a bucket and does what they can," she said. Some scientists stayed in her apartment, talking late into the night. "It's like when you like something and you have people who like the same thing, you can talk for hours without feeling tired," she said. "It's like discussing football. You never stop talking. It's an obsession."
A turning point came in early November: Dr. Adriana Melo in Paraíba State, just north of Recife, had drawn amniotic fluid from a pregnant woman and found Zika virus in it. Then brain tissue from two stillbirths was tested. Again, Zika.
"At last we had a road to follow," Dr. Turchi said. "A map."
One of those who flew in to help in the detective work was Dr. Laura C. Rodrigues, an epidemiologist at the London School of Hygiene and Tropical Medicine on contract to the Pan American Health Organization.
"It was the kind of call where you dropped everything," she said. "There had never been a congenital malformation by mosquito before, not ever. It was totally outside our experience."
With the discovery of Zika in malformed fetuses, Dr. Turchi's team has been able to turn to the kind of task Dr. Heymann described. They have recruited about 1,000 pregnant women with Zika symptoms, and are following healthy and microcephalic newborns in the same areas. They work nights and weekends, eating sandwiches from the institute's shop or meals of rice, beans and chicken provided by a research assistant's mother.
There are now so many reported cases of microcephaly that a new problem has arisen: too many false alarms.
Anxious obstetricians across Brazil have reported babies who merely have small heads, or babies whose mothers had other problems, like severe alcoholism or family histories of malformations, conditions that should have excluded them from the research.
Brazil has already changed its definition of a small head, to 32 centimeters around from 33 centimeters, and may revise it again soon.
Dr. Turchi defends those decisions, saying a broad net had to be cast at first because so little was known.
"We didn't want to get just the severe cases; we wanted to look at the broadest possible spectrum of the disease," she said. "Then we can narrow it later."
'Perfect Epidemic Curve'
Loosed on a continent where no one is immune, Zika has the potential to infect tens of millions of people. It is now being transmitted in 33 countries with about 600 million inhabitants, the W.H.O. says. Health officials in Brazil are investigating thousands of reported cases of microcephaly that may be linked to the virus.
Now a bright spot has appeared.
In Recife, and Pernambuco State around it, microcephaly cases have been declining for about three weeks. It is unclear exactly why, but researchers are starting to wonder if the epidemic has peaked.
"It looks like a perfect epidemic curve," Dr. Turchi said. "You see where it started, then went up, and now it's going down."
But that decline, and the general sigh of relief it portends, is occurring only in the one spot in the hemisphere where transmission of the virus hit earliest and was most intense.
Zika was just getting started there a year before the microcephaly cases began. And now the virus is virtually everywhere south of Florida and Texas.
And Guillain-Barré, the harbinger of microcephaly, is being spotted farther from the epidemic's epicenter in Brazil.
Colombia, Venezuela, Suriname and El Salvador, where mosquitoes thrive year-round, all have reported Guillain-Barré cases. Colombia has "an explosion" of them, its health minister said, with three deaths.
There have also been dozens of confirmed Zika rashes and fevers in the United States, all so far in returning travelers, except for the person infected through sex in Texas by a traveler returning from Venezuela.
Air travel maps show the United States' potential to be a kind of viral pincushion; Zika may arrive from anywhere. Since four out of five victims never have any symptoms, there is no way to spot it at the border.
The C.D.C. thinks it is all but inevitable that there will be at least small outbreaks here. But how far they spread will depend on how aggressively mosquitoes are killed.
Now that the world is alert to the danger and is fighting back, and women are even contemplating delaying pregnancies, scientists say it is unlikely that Brazil's national nightmare will be repeated elsewhere on such a scale.
In Recife, Dr. Turchi was hopeful.
"I'm more comfortable now," she said. "I see so many people working as a team and so much international concern. Now it has become clear to the whole world."
The Wall Street Journal, February 8, 2016
Brazil Health Researchers Say Zika Virus Is Active in Saliva, UrinePaul Kiernan, Reed Johnson and Rogerio Jelmayer
Pregnant women advised to take precautions to avoid coming in contact with others' saliva; other researchers suggest such fears are overblown
As many as 1.5 million Brazilians may be infected by the mosquito-borne Zika virus. With Brazil at the forefront of the latest global health scare, and as the host of this year's Olympic Games, Dipti Kapadia explains three things Brazil is doing to combat the Zika virus. Photo: Getty Images
Brazilian health researchers said Friday the Zika virus is active in saliva and urine, sparking fears about possible new infection routes on the eve of the nation's sexually charged Carnival festivities.
Brazil's leading medical-research institute, the Rio-based Oswaldo Cruz Foundation, said researchers' tests showed that the "entire genetic sequence" of the virus was present and "replicating" in samples of saliva and urine that it examined.
Officials of the foundation, known as Fiocruz, recommended that pregnant women take precautions by staying away from large crowds and avoiding sharing cups and utensils with people who show symptoms of the virus.
Artur Timerman, president of Brazil's Society of Dengue and Arbovirus, criticized the institute for publicizing its findings at a news conference rather than through the time-consuming but professionally sanctioned route of peer-reviewed scientific journals.
"The irresponsible thing that has happened is that Fiocruz has released this through the press," Dr. Timerman said. "This is creating a panic, a fear, that in my view is disproportional."
Fiocruz officials said it hasn't yet been determined whether Zika can be transmitted through those fluids. Brazil's Health Ministry, which oversees the institute, said in a separate statement Friday that additional research would be needed to do so.
"The fact that you've got an active virus in saliva and urine isn't proof that transmission can occur. But there may be a possibility of infection of other people through those fluids," said Paulo Gadelha,Fiocruz's president.
Coming on the eve of Brazil's wild Carnival festivities, the announcement prompted a flurry of comments from hundreds of viewers watching the news conference live on a social-media platform. One of the biggest street parties in the world, Brazil's alcohol-fueled Carnival parades often involve revelers kissing total strangers. Public urination is also rampant.
"Carnival is over, guys," one viewer lamented.
The virus, which is thought to be transmitted mainly by mosquito bites, usually produces mild symptoms, if any. But it has become a major international concern since Brazilian authorities linked it to complications, including a rare birth defect called microcephaly in which babies are born with dangerously small skulls and underdeveloped brains. Earlier this week, the World Health Organization declared possible complications from Zika a global health emergency.
Speaking at a separate news conference on Friday, Tom Frieden, director of the Atlanta-based Centers for Disease Control and Prevention, said there was little data on the likelihood of Zika virus transmission through saliva or urine, and only three confirmed cases of transmission through sexual contact. "There are unknowns," Frieden said. "We're still learning more about how it works in the body."
When asked if the CDC concurred with Fiocruz's advisory, Frieden said the CDC is still gathering the data and would provide information when it becomes available so women can decide what is safe. "We have not issued guidance" on kissing, Frieden said.
Fiocruz's latest findings come on the back of a wave of recent evidence that mosquitoes aren't the Zika virus's only vector for spreading. Brazilian health officials in the city of Campinas this week reported two cases of Zika being transmitted through blood transfusions. The CDC said Wednesday that a person in Texas contracted the virus through sexual contact with a partner who had recently traveled to an area where Zika was circulating. On Friday it urged pregnant women to avoid unprotected sex with male partners who have traveled to such areas.
Much Zika research to date has been based on the assumption that the virus was transmitted primarily, or even exclusively, through mosquito bites, according to Joseph Conlon, technical adviser for the U.S.-based nonprofit American Mosquito Control Association. Friday's announcement could change that, he said.
"If it can be transmitted by any bodily fluid, that complicates matters considerably," Mr. Conlon said. "We're going to have to look beyond the mosquitoes and we're going to have to do a lot of case management."
Uncertainty has driven much of the Zika panic worldwide. Discovered in a monkey in Uganda's Zika Forest in 1947, the virus traveled through parts of Africa, Asia and the Pacific Islands before reaching Brazil a couple of years ago, researchers say. Symptoms don't appear in as many as four out of every five cases; when they do, they tend to be far milder than those of other mosquito-borne pathogens like dengue fever.
But that has made it hard for health officials to determine how prevalent the disease is and what, if any, relation it has to microcephaly.
Given the uncertainty, Fiocruz's recommendations to pregnant women were premature, said Marcio Fernandes, an epidemiologist at both the Federal University of Rio de Janeiro and the Rio state health authority.
"We shouldn't lose focus on combatting the main transmission pathway, which is the mosquito," Mr. Fernandes said. "Even the HIV virus has been isolated in saliva, but the quantity is so small that it isn't able to be transmitted through saliva."
Reuters, February 8, 2016
Doctors puzzle over severity of defects in some Brazilian babiesBill Berkrot & Anthony Boadle
Experts on microcephaly, the birth defect that has sparked alarm in the current Zika virus outbreak, say they are struck by the severity of a small number of cases they have reviewed from Brazil.
Consultations among doctors in Brazil and the United States have increased in the last two weeks, and some of the leading authorities on the condition are finding patterns of unusual devastation in scans of the newborns' malformed brains.
While it's not known how representative the scans are, the early observations of these doctors point to a tough road ahead for the babies, their families and their communities and heighten the concern surrounding Zika, which is suspected of causing microcephaly.
"We are in the process of very rapid information gathering on what has been seen," said Dr. William Dobyns, a geneticist at Seattle Children's Hospital. "The condition that I've been able to review, very preliminarily, is more severe than simple microcephaly."
The Zika virus is transmitted by mosquito, causing mild symptoms in about 20 percent of cases, and most people experience no illness at all. But a spike in reported microcephaly cases among babies in areas of Brazil with Zika outbreaks has triggered an international effort to determine whether the virus causes the condition. The suspected association moved the World Health Organization (WHO) on Monday to declare an international health emergency.
Dobyns has spent 30 years researching and treating microcephaly, a condition defined by abnormally small heads in newborns that can lead to developmental disabilities, from mild to severe. The U.S. Centers for Disease Control and Prevention (CDC) has sought out his expertise in understanding the unfolding epidemic.
With a small group of geneticists and other microcephaly specialists, he recently reviewed scans of a handful of babies sent by a colleague in Brazil. All the experts were struck by the scale of malformations, he said.
"These children have a very severe form of microcephaly," Dobyns said. "The brain is not just small, it's small with malformations of the cerebral cortex and calcifications. It has the appearance of a very severe, destructive injury to the brain."
Particularly alarming, Dobyns said, is the presence in the Brazilian cases of excess spinal fluid between the brain and skull of the babies.
"If the brain is growing and then suddenly shrinks, then you'll see fluid between the brain and skull," he said. "It has a pattern that suggests that the brain has actually decreased in size."
Dr. Leonardo Vedolin, a neuroradiologist and researcher at the Moinhos de Vento hospital in Porto Alegre, Brazil, shared with Dobyns scans of two more microcephalic babies this week. The doctors belong to a brain defects study group that convenes via videoconference each month. The group is now focused on Zika.
Neither Vedolin nor Brazil's Health Ministry were able to provide a breakdown on the severity of confirmed microcephaly cases. In general, Vedolin said, 5 percent of microcephaly cases are severe. But the proportion appears greater among the cases in Brazil, he said.
THE CASELOAD
Public health officials in Brazil are investigating more than 4,000 cases of suspected microcephaly, and have confirmed more than 400. Prior to the Zika outbreak, Brazil saw on average 163 cases annually of microcephaly over the past five years, according to WHO. In 17 of the new cases, the presence of Zika was identified in the mother or the baby.
A study of 35 Brazilian babies born with microcephaly during the Zika outbreak reported by the CDC Jan. 29 added strength to the suspected connection.
The mothers of all 35 infants had lived in or visited Zika virus-affected areas during pregnancy, the report said. Twenty-five infants had severe microcephaly, and 17 had at least one neurologic abnormality.
Dr. Frank Esper, an infectious disease expert from Rainbow Babies & Children's Hospital in Cleveland, said he expects a steady wave of studies on Zika and microcephaly that will provide a much clearer picture over the first half of 2016.
By the broadest definition, about 2.3 percent of all babies are microcephalic, Dobyns said. Some cases are so mild they involve no complications at all.
About one tenth of one percent of the cases are so severe that lifelong care is required, he said. There are many known causes, including a wide range of genetic disorders such as Down syndrome, as well as oxygen deprivation to the fetus, cytomegalovirus and severe fetal alcohol syndrome.
Lifespan in severe cases can be months or as long as 10 years, depending on proximity to good medical care, Dobyns said.
Dr. Dawn Nolt, a member of the American Association of Pediatrics' (AAP) Committee on Infectious Diseases, and other doctors, said more severely affected children often require treatment for epileptic seizures, as well as physical, respiratory and speech therapy. They may need help with everyday activities, such as eating or walking.
"It's crucial to go to a care center with good neurology and genetics teams that can evaluate the child comprehensively," said Dr. Ghayda Mirzaa, a pediatric neurologist and colleague of Dobyns at Seattle Children's.
Doctors in Recife, Brazil are sending mothers with afflicted babies for therapy to help stimulate eyesight, hearing and motor skills to minimize retardation in mental and physical development.
There are a handful of centers of microcephaly research and treatment in the U.S., including Dobyns' hospital in Seattle. The consultations of physicians like Dobyns in the Brazil cases is informal at this point but could form the basis for an organized exchange of expertise that will inform the ongoing care of the children of the epidemic.
"We need to get the message out that this is real, and coming, without getting everybody to panic," Dobyns said. "There will be a steep curve of new information coming in."
Assinar:
Postagens (Atom)