Long-term costs of Zika among the many un­knowns of the virus

Modern Healthcare - - NEWS - By Shan­non Much­more

His­tory buffs and in­fec­tious­dis­ease ex­perts have al­ready drawn links be­tween the rubella out­break in the 1960s and the cur­rent spread of Zika.

But drugmakers to­day face greater reg­u­la­tory hur­dles, and the fed­eral gov­ern­ment has yet to ded­i­cate fund­ing to ad­dress the Zika epi­demic. That means a vac­cine and suc­cess­ful meth­ods to stop trans­mis­sion of the virus may be a long time com­ing.

Nearly 75 years ago, an Aus­tralian oph­thal­mol­o­gist no­ticed he was treat­ing cataracts in a sig­nif­i­cant num­ber of new­borns whose moth­ers were in­fected with rubella early in their preg­nan­cies.

It was the first time re­searchers un­der­stood the long-term im­pact of the dis­ease, which, for adults, was vi­rally spread and caused rel­a­tively mild symp­toms—mostly a rash. Doc­tors in other coun­tries be­gan to link rubel­lain­fected moth­ers with ba­bies born with deaf­ness, heart prob­lems, de­vel­op­men­tal dis­abil­i­ties, liver dam­age and bone and joint de­for­mi­ties. And then, be­tween 1964 and 1965, more than 12.5 mil­lion peo­ple in the U.S. be­came in­fected. About 20,000 chil­dren were born with con­gen­i­tal rubella syn­drome.

That was the last time the na­tion ex­pe­ri­enced a scare with the long-term health and fi­nan­cial im­pact now posed to pop­u­la­tions vul­ner­a­ble to the Zika virus, which un­til re­cently was be­lieved to be spread only by mos­qui­toes.

Ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion, the one-year rubella epi­demic cost the coun­try an es­ti­mated $840 mil­lion, which is equiv­a­lent to about $6.5 bil­lion to­day. But Con­gress broke for the sum­mer this month with­out de­bat­ing a $1.1 bil­lion bill to fight the Zika virus.

Last week the CDC an­nounced $60 mil­lion in state grants to sup­port epi­demi­o­logic surveil­lance and in­ves­ti­ga­tion, mos­quito con­trol and mon­i­tor­ing, and lab­o­ra­tory ca­pac­ity. But CDC Di­rec­tor Dr. Thomas Frieden noted in the an­nounce­ment that Con­gress had failed to “pro­vide the ad­di­tional re­sources we need to fully sup­port the Zika re­sponse.”

The World Bank has es­ti­mated the dis­ease will cost the world $3.5 bil­lion in 2016, mostly be­cause of peo­ple avoid­ing travel to ar­eas where the virus is be­ing ac­tively trans­mit­ted. It does not at­tempt to in­clude the costs of chil­dren grow­ing up with mi­cro­cephaly or the cost of de­vel­op­ing a vac­cine.

Reg­u­la­tory and safety re­quire­ments will likely add years and many mil­lions of dol­lars to the ef­fort. In the 1960s, con­sent to par­tic­i­pate in drug clin­i­cal tri­als was given on a rel­a­tively small, sim­ple form and test­ing could be done on a larger pop­u­la­tion. To­day, the Food and Drug Ad­min­is­tra­tion’s vac­cine guid­ance alone is 13 pages long. The process of de­vel­op­ing, test­ing and win­ning ap­proval for a vac­cine of­ten takes more than 10 years.

A study in the Amer­i­can Jour­nal of Pub­lic Health es­ti­mated a ben­e­fit-to-cost ra­tio of nearly 8-to-1 for the rubella vac­cine. The anal­y­sis fac­tored in the costs of pub­lic and pri­vate vac­ci­na­tion pro­grams and med­i­cal at­ten­tion for ad­verse re­ac­tions ver­sus the sav­ings gen­er­ated by elim­i­nat­ing the long-term con­se­quences of con­gen­i­tal rubella syn­drome.

With­out a Zika vac­cine, fed­eral and lo­cal pub­lic health of­fi­cials are spend­ing their own funds to ed­u­cate com­mu­ni­ties about the risk of Zika even as they them­selves learn more about how mos­qui­toes and peo­ple spread the dis­ease.

Of­fi­cials in Utah are deal­ing with the re­cent dis­cov­ery that an el­derly man in­fected with Zika may have

For a woman with a pos­i­tive test for Zika, one fe­tal medicine spe­cial­ist would sug­gest an ul­tra­sound ev­ery three to four weeks be­gin­ning two weeks af­ter ex­po­sure to ex­am­ine the brain struc­ture.

trans­mit­ted it to his care­giver. The el­derly pa­tient has since died.

Dr. Sonja Ras­mussen, di­rec­tor of the CDC’s Divi­sion of Pub­lic Health In­for­ma­tion Dis­sem­i­na­tion and in­com­ing pres­i­dent of the Ter­a­tol­ogy So­ci­ety, said one of the scari­est as­pects of Zika virus is how much is still un­known.

Re­searchers are un­sure whether a woman must be symp­to­matic to pass the virus along to her fe­tus or whether it mat­ters at what stage of the preg­nancy the woman is in­fected.

Dr. Sarah Obi­can, as­sis­tant pro­fes­sor of ma­ter­nal fe­tal medicine at the Uni­ver­sity of South Florida, said preg­nant women typ­i­cally get what is called a dat­ing ul­tra­sound in their first trimester. The doc­tor can do a rudi­men­tary anatomy check but will not be able to tell much of any­thing about brain struc­ture. At 18 to 20 weeks, a doc­tor can use an ul­tra­sound to look at a baby’s growth by com­par­ing the size of the fe­mur and ab­domen to the brain cir­cum­fer­ence.

For a woman with a pos­i­tive test for Zika, Obi­can would sug­gest an ul­tra- sound ev­ery three to four weeks be­gin­ning two weeks af­ter ex­po­sure to ex­am­ine the brain struc­ture. That in­for­ma­tion can only tell so much, how­ever. “I have no idea about func­tion,” she said. “I can only say if there is ab­nor­mal­ity in the struc­ture there is a higher chance.”

Doc­tors study­ing Zika and pre­par­ing to work with pa­tients say they don’t ex­pect sig­nif­i­cant dif­fi­culty get­ting blood tests and ad­di­tional ul­tra­sounds cov­ered by health plans be­cause they are part of nec­es­sary pre­na­tal care.

The price of an ul­tra­sound de­pends on the lo­ca­tion of the test, type of equip­ment used and other fac­tors, but it can be rel­a­tively ex­pen­sive. “In­sur­ance can give you a hard time, but good doc­u­men­ta­tion helps,” Obi­can said.

One thing that’s cer­tain is that chil­dren with mi­cro­cephaly will need a full range of phys­i­cal, oc­cu­pa­tional and speech ther­apy through­out their lives. Some will likely re­quire help with feed­ing and other ac­tiv­i­ties of daily life.

There isn’t enough in­for­ma­tion to es­ti­mate life ex­pectancy, she said, but chil­dren with fe­tal brain dis­rup­tion at the level of se­vere mi­cro­cephaly can need sev­eral mil­lion dol­lars worth of med­i­cal care into adult­hood. The emo­tional costs for a fam­ily, she added, are also stag­ger­ing.

Dr. Ed­ward R.B. Mc­Cabe, chief med­i­cal of­fi­cer for the March of Dimes, said there is a range of treat­ments de­pend­ing on the sever­ity of mi­cro­cephaly, but many ba­bies will need de­vel­op­men­tal ser­vices in the first six months of life. “Th­ese in­ten­sive early in­ter­ven­tion ser­vices would in­clude phys­i­cal, oc­cu­pa­tional, speech and hear­ing ther­apy,” he said. “And to­day, both de­vel­op­men­tal and be­hav­ioral pe­di­a­tri­cians are in short sup­ply, so this will not be easy on any fam­ily.”

There is not enough in­for­ma­tion to know whether there would be a large dif­fer­ence in pay­ment through Med­i­caid ver­sus pri­vate in­sur­ance, he said. “The big­gest un­known is the lack of ex­pe­ri­ence with this level of se­vere mi­cro­cephaly.”

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