On Zika's trail

The story of the med­i­cal de­tec­tives who o tracked the deadly dis­ease in Brazil and raised the alarm about the con­nec­tion be­tween the Zika virus and birth anom­alies.

The Star Malaysia - Star2 - - FRONT PAGE - BY ALEXAN­DRA ZAVIS

IN a place where the bite of a com­mon mos­quito has brought crip­pling birth de­fects and early death, they were the de­tec­tives sent to gather clues about the crime.

Ear­lier this year, the four women had been ply­ing the back roads of north- east­ern Brazil for days. Their quarry: new moth­ers who may have been in­fected with the Zika virus dur­ing their preg­nan­cies.

Con­ce­icao Al­can­tara, a 34- year- old woman who had re­cently given birth, is on their list. Her daugh­ter had been born with mi­cro­cephaly, a se­ri­ous con­di­tion that leaves ba­bies with an ab­nor­mally small skull and, of­ten, an un­der­de­vel­oped brain.

Al­can­tara has been re­luc­tant to speak to the in­ves­ti­ga­tors – an Amer­i­can pe­di­a­tri­cian, and two nurses and a phle­botomist from Brazil. She doesn’t want her tiny daugh­ter turned into a pub­lic cu­rios­ity, she says.

As a phys­io­ther­a­pist her­self who’d worked with mi­cro­cephalic ba­bies, Al­can­tara al­ready knows the con­di­tion’s dev­as­tat­ing po­ten­tial im­pact: seizures, learn­ing dis­abil­i­ties, prob­lems with speech, vi­sion, hear­ing and mo­tor func­tion, and for some, a short­ened life span.

Are these re­searchers go­ing to ac­com­plish any­thing?

A lo­cal health worker agrees to take the team to Al­can­tara’s house to see if she might be per­suaded. The health worker guides the group’s small Fiat down nar­row, cob­ble­stoned streets to a cream- coloured house be­hind a for­bid­ding metal gate.

Mar­cia de An­drade, one of the nurses on the team, bangs on the gate while the oth­ers stay in the car. The gate opens a crack, and De An­drade dis­ap­pears in­side.

She is gone nearly an hour. Fi­nally, the gate opens again, and De An­drade mo­tions for the rest of the team to come in­side.

There is now strong sci­en­tific con­sen­sus that Zika, which for decades was thought to be rel­a­tively harm­less and of­ten has no symp­toms, can cause mi­cro­cephaly and other se­ri­ous neu­ro­log­i­cal dam­age – thanks in part to the work done by this and other in­ves­tiga­tive teams.

Brazil had seen an in­crease in mi­cro­cephaly cases un­par­al­leled else­where in the world; early this year, the US Cen­ters for Dis­ease Con­trol and Pre­ven­tion ( CDC) dis­patched re­searchers to the coun­try to help un­ravel the mys­tery.

For a month, the team in the Fiat and seven oth­ers like it fanned out across the north- east­ern state of Paraiba, log­ging thou­sands of miles on un­du­lat­ing coun­try roads and nar­row al­ley­ways.

In May, Brazil­ian health author­i­ties con­firmed 1,434 births since Oc­to­ber 2015 with mal­for­ma­tions that may be Zika- re­lated and were in­ves­ti­gat­ing thou­sands of oth­ers. In June, The New York Times re­ported that there were 234 preg­nant women in the United States with Zika, quot­ing CDC fig­ures.

Zika is be­lieved to have ar­rived in Brazil in 2014, most likely brought in by a trav­eller from the Pa­cific Is­lands. The virus has now reached 60 coun- tries and ter­ri­to­ries, in­clud­ing large swaths of the Amer­i­cas where there is an abun­dance of the Aedes ae­gypti mos­quito that spreads the virus – and al­most no one has the im­mu­nity that has de­vel­oped in parts of Africa and Asia.

The in­crease in mi­cro­cephaly cases in Brazil be­gan in the state of Per­nam­buco, just south of Paraiba. Ge­netic dis­or­ders, cer­tain viruses and other known causes of mi­cro­cephaly did not seem to be an is­sue in these cases.

Some­thing else was go­ing on, and Al­can­tara’s preg­nancy be­came a key piece of the puz­zle.

Her ob­ste­tri­cian had no­ticed dur­ing an ul­tra­sound that the fe­tus’s head was not devel­op­ing nor­mally, and then heard of the cases of mi­cro­cephaly in nearby Per­nam­buco.

Those cases, doc­tors were be­gin­ning to sus­pect, might be linked to Zika. Many of the women had ex­pe­ri­enced a rash typ­i­cal of the virus early in their preg­nan­cies – did Al­can­tara re­mem­ber hav­ing a rash? She did. Her doc­tor found a lab that could test for Zika in her am­ni­otic fluid, and it was pos­i­tive. The find­ing was a break­through – some of the first bi­o­log­i­cal ev­i­dence con­nect­ing the virus to mi­cro­cephaly.

“Never be­fore in his­tory has there been a sit­u­a­tion where a bite from a mos­quito could re­sult in a dev­as­tat­ing mal­for­ma­tion,” says Dr Thomas Frieden, the CDC di­rec­tor.

Over the next few months, the ev­i­dence favour­ing a Zika con­nec­tion mounts. Other coun­tries with out­breaks start re­port­ing cases of mi­cro­cephaly. Brain tis­sue col­lected from still births test pos­i­tive for the virus, as does spinal fluid from ba­bies with mi­cro­cephaly.

In Paraiba, the de­tec­tives start with a list of more than 800 re­ported cases of mi­cro­cephaly in the re­gion, which they win­now to a sam­ple of 190.

They fo­cus on se­vere cases, based on the head’s cir­cum­fer­ence at birth – 32cm for boys and 31.5cm for girls – as well as its size rel­a­tive to body length. Just 3% of new­borns have heads that small.

For each mother who agreed to take part, the re­searchers wanted to en­roll, as a con­trol, three oth­ers whose ba­bies had been born at around the same time and in the same place but who do not have mi­cro­cephaly.

Dr Megumi Itoh, the San Fran­cisco pe­di­a­tri­cian who is on the team with De An­drade, wor­ries how fam­i­lies will re­spond to strangers show­ing up at their homes, ask­ing in­ti­mate ques­tions and tak­ing blood sam­ples.

The re­searchers have a big­ger chal­lenge first: find­ing them. The moth­ers are spread across nearly 57,000sq km, from the densely pop­u­lated coast to the hin­ter­lands of the in­te­rior.

The teams set out in Paraiba’s state cap­i­tal, Joao Pes­soa, of­ten with lit­tle more than a name and a neigh­bour­hood. They go from clinic to clinic search­ing for more in­for­ma­tion – “We lit­er­ally go in and say, ‘ Do you know this mum?’ ” Dr Itoh says. And when the teams lo­cate an ad­dress, the mother might not be home.

In the town of Sao Vi­cente do Serido, an el­derly shop­keeper points the re­searchers to­wards the mu­nic­i­pal health sec­re­tar­iat on a cob­ble­stoned street of houses painted pas­tel yel­low, blue and green.

The town re­cently had its first case of mi­cro­cephaly and ex­pec­tant moth­ers here are des­per­ate to know if their ba­bies might also be at risk.

“It is so good to have you,” says Con­stanca Gon­calves, a pri­mary care co­or­di­na­tor, as she leads the team into an of­fice.

The re­searchers sort through reams of paper­work and use a pil­low to turn a cab­i­net into an ex­am­i­na­tion ta­ble.

Two moth­ers are wait­ing to see them, while an­other hasn’t shown up yet. All have healthy ba­bies and are there to serve as con­trol cases.

A shy mother in shorts and a tank top en­ters the room cradling a sleep­ing baby girl. But there is a prob­lem. The mother, Maria Girdielly, is 17. They need a par­ent’s con­sent to en­roll the pair in the study.

Gon­calves pulls up a num­ber on her cell­phone and di­ales the girl’s mother. She’s busy mak­ing lunch for her em­ployer.

“Can you just come sign the paper­work?” Gon­calves pleads. “We will come in a car to get you and bring you right back.”

The Fiat is dis­patched, and 10 min­utes later Maria’s mother, Creusa dos San­tos, walks into the room. She looks ner­vous.

“You have a chance to help a lot of other moth­ers,” De An­drade says. The woman signs the forms.

In the af­ter­noon, they visit a clinic in Juazeir­inho, the town where they would meet Al­can­tara the next day.

Wait­ing for them is Sabrina Ma­teus, her mother and her two- month- old son, who was born with mi­cro­cephaly.

Af­ter mea­sur­ing the in­fant’s head, Dr Itoh takes pho­to­graphs to doc­u­ment its shape and pro­por­tions.

De An­drade as­sures the 17- year- old mother that they will not be shared on so­cial me­dia net­works – a worry in a coun­try where cu­rios­ity about the con­di­tion has meant that its vic­tims are some­times treated like char­ac­ters in a na­tional freak show.

The baby screams as an­other team mem­ber draws a sam­ple of his blood, then one from his mother. An an­ti­body test will in­di­cate whether they have been ex­posed to the virus.

Did she ex­pe­ri­ence any rashes dur­ing her preg­nancy, De An­drade asks the mother. Any fever? Headaches? Joint pain? Red eyes? She shakes her head no.

Had she had any other in­fec­tions? Was she ex­posed to pes­ti­cides? Did she drink? No.

De An­drade writes down each an­swer on a stan­dard­ised form. The ques­tions con­tinue for half an hour.

Many Brazil­ians re­mained doubt­ful that the surge in mi­cro­cephaly could be traced to Zika for a long time. Var­i­ous other the­o­ries gained pop­u­lar cur­rency: ex­pired vac­cines, ge­net­i­cally mod­i­fied mos­qui­toes re­leased to com­bat dengue fever, a lar­vi­cide used to pre­vent mos­qui­toes from breed­ing in stand­ing wa­ter.

Gov­ern­ment of­fi­cials hoped at that time that the CDC’s study would pro­vide a de­fin­i­tive an­swer. In the end, 600 moth­ers agreed to par­tic­i­pate in the re­search.

A pre­lim­i­nary anal­y­sis was not sur­pris­ing: Moth­ers whose ba­bies have mi­cro­cephaly were more likely than other women to have ex­pe­ri­enced symp­toms dur­ing preg­nancy that could be caused by Zika. There were no other ob­vi­ous ex­pla­na­tions for the epi­demic.

Around the globe, health author­i­ties be­gan to take pre­cau­tions as word spread.

But the re­searchers still need to find answers to ques­tions such as why some ba­bies were born healthy while oth­ers have for­ever changed the lives of their fam­i­lies. Dr Itoh un­der­stands that the puz­zle she be­gan solv­ing is lay­ing new jig­saw pieces around the world. But that only means the dis­ease de­tec­tives need to hurry.

“It’s mind- bog­gling to me that a virus could do this,” she says. – Los An­ge­les Times/ Tri­bune News Ser­vice

— tnS

Vi­tal numbers: A note­book be­long­ing to Dr Meg Itoh, an epi­demic in­tel­li­gence of­fi­cer with the US Cen­ters for Dis­ease Con­trol and pre­ven­tion, used for track­ing pa­tients as part of the CDC and Brazil’s in­ves­ti­ga­tion into the con­nec­tion be­tween women hav­ing the Zika virus when they are preg­nant and mi­cro­cephaly in their ba­bies.

Af­ter mea­sur­ing a child’s head dr Itoh ( cen­tre) is show­ing teenaged mother Sabrina where her baby’s head mea­sure­ment of 34.2cm falls on a growth chart – well be­low the 1/ 3 per­centile of ba­bies that age.

— pho­tos: tnS

Vi­tal re­search: dr Itoh ( left) mea­sur­ing the head of five­month- old Adrielly rufino, as she is held by her mother Maria.

‘ She’s every­thing in my life. It doesn’t mat­ter what she has, what she has, for me, it’s noth­ing,’ says Maria da Luz Men­des San­tos about her daugh­ter, Heloyse, who was born with mi­cro­cephaly. ‘ She brought a lot of hap­pi­ness to my fam­ily.’

Six- month- old eloisa de oclaceo is part of the con­trol group of ba­bies with­out mi­cro­cephaly.

re­searchers Mar­cilia Souza ( left) and Veron­ica dan­tas pre­par­ing sam­ples for anal­y­sis in a lab in Brazil.

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