Friday, June 10th, 2016
By Betsy McKay
At the U.S.’s doorstep, one quarter of the territory’s population could be infected by year’s end, giving health authorities a rare chance to study the virus
SAN JUAN, Puerto Rico—The Zika virus is creeping north toward the continental U.S., and Alberto de la Vega has started to detect its signs.
In ultrasounds he gives pregnant women who are infected with the virus in this American territory, he has seen a 22-week-old fetus with serious brain damage and two others with stunted growth. He is bracing for more.
“If you ask me in a month,” says Dr. de la Vega, an obstetrician-gynecologist and chief of a high-risk-pregnancy unit at the capital’s University Hospital, “we may have 10 times the detection rate.”
Zika has blanketed three-quarters of this lush island over the past six months, say health authorities, who expect it to keep spreading now that it is prime mosquito season. More than 1,350 people have tested positive for Zika since the beginning of the epidemic here, including 168 pregnant women. One patient died. Thousands more are likely infected without symptoms, health authorities say.
Puerto Rico’s battle with Zika is giving local and U.S. health authorities a rare chance to better understand the disease as it makes its relentless march across the Americas.
The island has advantages over Latin American and Caribbean nations that lack its modern medical system. It has strong public-health surveillance and anticipated Zika’s arrival, unlike Brazil, where the virus spread unnoticed for months.
“This is the best shot we have at understanding the natural spectrum of the disease,” says Johnny Rullán, former secretary of health and former state epidemiologist for the territory.
Puerto Rico has been hit harder than any mainland U.S. state is likely to be, U.S. health authorities say. The Aedes aegypti mosquito that spreads Zika teems here, flourishing in the steamy climate and dense neighborhoods. It invades the many homes lacking screens and air conditioning. It incubates in unsealed septic tanks, old tires and other places where stagnant water stands.
The island’s protracted economic crisis has strained the health-care system and efforts to kill off mosquitoes. Puerto Rico is defaulting on payments it owes on $70 billion of debt, and U.S. Congress is considering forming a federal oversight board to supervise its finances.
The Centers for Disease Control and Prevention estimates 25% of Puerto Rico’s 3.5 million population will be infected with Zika by the end of 2016, says Tyler Sharp, epidemiologist in the CDC’s dengue branch, based in San Juan, which researches dengue and other viruses that are transmitted by the same mosquitoes as Zika.
About 40 million people a year travel between the U.S. and areas where Zika is circulating, according to the CDC. Puerto Rico is a popular destination, with regular daily flights to and from multiple cities on the U.S. mainland. Cruise ships make regular stops.
The spread of Zika by mosquitoes hasn’t been detected on the U.S. mainland yet. Public-health officials say they expect that to happen this summer, though, particularly in the South where Aedes mosquitoes are most common. All it will take, they say, is for someone who got infected elsewhere to get bitten by mosquitoes once they return home. Those mosquitoes may then spread the virus to others.
Public-health officials say they don’t believe U.S. outbreaks would be large, because most people are protected from mosquitoes in their homes with window screens. But it is a matter of how quickly doctors or mosquito-control officials detect the circulating virus.
In Puerto Rico, mosquito-control programs have been cut back in the budget crisis, rendering spraying campaigns spotty, although it isn’t clear how much the budget cuts affected the offending mosquito’s spread. The insecticide used most widely didn’t work against the mosquito, and one that replaced it works only in some places, says Steve Waterman, chief of the CDC’s dengue branch. Puerto Rico’s health department didn’t respond to requests for comment.
The Obama administration has asked Congress for emergency funds to combat Zika, including in Puerto Rico. Congress is deliberating over the amount to allot. Meanwhile, the federal government has sent some aid and redirected dollars from other needs.
Puerto Rico’s emergency management agency has led cleanup campaigns around the island, says its chief, Angel Crespo, collecting 1.2 million discarded tires, dropping larvicide into abandoned pools, educating residents and training local brigades in fumigation. For now, Mr. Crespo says, “we’re moving forward with our own resources.”
Protecting the mothers
The island’s housing department is installing screens in doors and windows of public-housing apartments occupied by pregnant women, spending about $500,000 out of funds for regular capital improvements. “For us this is a priority,” says Housing Secretary Alberto Lastra Power.
Ganasha Reynoso, seven months pregnant with her second child, a boy, was relieved when workers installed screens in three doors and 10 windows of her two-bedroom apartment two months ago in San Juan’s Residencial Ernesto Ramos Antonini housing project.
“I’m worried because I know about the microcephaly risk,” says Ms. Reynoso, 20, referring to a condition caused by Zika in which babies have undersized skulls that can signal brain damage. She added that she is also using mosquito repellent. She tested negative for Zika and prays she doesn’t get infected before delivery. She may have to move to a larger apartment after the birth. She says she would miss the screens but understands it is “a privilege for pregnant women.”
Federal and Puerto Rico scientists are using the spread of Zika on the island to study birth defects related to the virus, its link to Guillain-Barré syndrome and other neurological complications, and how long the virus persists in semen and other bodily fluids. The virus is transmitted primarily by mosquitoes but also through sexual contact.
They are hoping to answer critical questions about the risk that an infected pregnant woman will have a child with birth defects. Experts plan to track babies for three years after birth to Zika-infected mothers to see if they develop problems not evident in utero or at birth. They also hope to figure out what percentage of people infected with Zika develop no symptoms.
“We’re going to be generating some good information,” says the CDC’s Dr. Waterman, “that will be useful for public health and clinical medicine by the end of the year or early next year.”
Gloria Rodríguez Vega, chief of the critical-care department at the HIMA San Pablo hospital in Caguas, hopes a new system to track Guillain-Barré syndrome, or GBS, will shed light on debilitating neurological complications Zika may cause.
Dr. Rodríguez Vega has provided intensive care to three Zika-positive GBS patients this year. She normally sees four to five patients a year with GBS, a neurological condition that can cause temporary paralysis, among other symptoms. She also treated a Zika-positive patient who had encephalitis, another condition scientists suspect may have a link to the virus. That patient tested positive for Zika, while other causes were ruled out. “When it takes months to recuperate,” she says, “that will affect society.”
Island health authorities have targeted Zika-prevention messages to women, offering education in hospitals and clinics. They hand out Zika-prevention kits assembled by the CDC and CDC Foundation, a nonprofit organization, with repellent, mosquito nets, brochures and a condom to remind couples of the possibility of sexual transmission.
In a group session for pregnant women and partners at University Hospital, Carmen Zorrilla, an obstetrician-gynecologist for high-risk pregnancies, calmly describes the risks of Zika, where the virus had come from and how to prevent infection.
Liliana Sanchez, 39, is 20 weeks pregnant and says she is afraid but not panicked. “Most important is to use repellent,” she says, adding she wants to keep other family members from infection.
“I like your attitude,” Dr. Zorrilla tells her, “because it’s prevention without fear.”
Dr. Zorrilla helped develop the strategy for preventing HIV transmission from mothers to their children and led its implementation in Puerto Rico. Zika is another disease for which women need special support, she says.
Others are trying to improve access to contraception. About two-thirds of pregnancies in Puerto Rico are unintended, and teenage birthrates are high.
Nabal Bracero, a reproductive endocrinologist who heads the Puerto Rico section of the American Congress of Obstetricians and Gynecologists and a reproductive-health nonprofit, is leading an effort to train physicians around the island to insert IUDs.
Studies have shown long-acting forms of contraception are highly effective at preventing pregnancy. Dr. Bracero hopes the Zika crisis will force change in two obstacles to getting them: Insurance reimbursement rates to physicians for inserting IUDs are low, and patients must navigate bureaucratic steps to get them.
Pregnant women are typically tested for Zika at a minimum in their first and second trimesters, with or without symptoms, and get ultrasounds to monitor their babies—steps that protect their health and allow public-health officials to gather data that may provide clues about the disease.
Of more than 50 Zika-infected pregnant patients seen by University Hospital’s Dr. de la Vega, three had fetuses with abnormalities, he says. The 22-week-old fetus, whose mother had initially tested negative for Zika, had the same heartbreaking symptoms Brazilian doctors have found: microcephaly, calcifications in the brain—an indication of inflammation—and poor growth of some brain structures.
The other two showed stunted growth. “This worries us a lot,” he says. There are other cases of concern in which the head may be in the lower ranges of growth, he says, “but it is still too early to tell.”
He expects to see many more abnormalities because there are now women who became pregnant when Zika was already circulating. Doctors believe birth-defect risks are highest early in pregnancy.
“We live on a tropical island. We’re accustomed to hearing that a hurricane is forming in Africa and it’s coming this way,” Dr. de la Vega says. “It’s that kind of stressful situation.”