Emerging Research About Zika Virus.

Not just any virus – Worse on the fetus than we thought!
Abortion debate brought to the forefront.

Medical scientists have been racing to understand the epidemic of Zika virus worldwide but particularly, because of the rapidity of spread and the number of persons infected, in the Western Hemisphere. Much is still unknown, there is no effective treatment or vaccine, diagnostic tests are not readily available, and there appear to be substantial’ morbidities to developing fetuses and adults alike. The disease is known to be spread by mosquitoes, through sexual contact, and probably blood transfusion. It is not surprising that concern over Zika virus is changing people’s travel plans including to the 2016 Summer Olympics in Rio de Janeiro, Brazil.  It is causing aditional and justifiable concern to pregnant women and their partners, especially those without access to contraception or safe abortion.

It is natural to be apprehensive in the face of major epidemics. I have worried worried personally as a physician caring for patients with new diseases such as Lassa Fever, Legionnaire’s Disease, or AIDS; or outbreaks of drug resistant strains of old-time diseases such as Tuberculosis.  Public concern over Zika has been amplified by the rapidity of spread, the scientific and medical unknowns, and the assumed serious complications in adults and developing fetuses alike.  I am not surprised that the scientific community is responding to the challenge.

In fact, the rapidity of publication is the fastest I have seen in my 50 years in the academic community!  An example that spun my head was an article appearing in the New England Journal of Medicine on March 5 of this week which apparently included data collected as recently as February of this year. It is a preliminary report of the effects of Zika virus infection in pregnant women in Rio de Janeiro, Brazil – the heartland of the current epidemic. The effects on the fetus are more diverse and more frequent even than had been feared. I will describe these, and challenge the antiabortion community to tell us what it thinks pregnant women who contract Zika infection should do. I suggest that there is no scientific evidence that their infections or any abnormalities of their fetuses are God’s will. I maintain that the emergence of Zika virus is a game-changer for the societal issues surrounding abortion.

The Study.
A network of physicians in Rio collected from September 2015 through February 2016 a total of 88 women who were both pregnant and who had a recent rash compatible with Zika virus infection. The women were followed until they delivered or up to the time of publication. Special blood testing showed that 72 (82%) of these women with rashes tested positive for Zika virus. (Recall that not every person with Zika gets a rash.) Doppler sonograms of the uterus were done on 42 of the infected women and all of the Zika-negative women. Twenty-eight Zika virus infected women declined imaging studies because the study center was too far away, or because they did not want to know about any possible fetal abnormalities.  Of the 42 Zika-infected women who had ultrasounds, 12 (29%) had fetal abnormalities compared to none of the 16 Zika-negative women. The abnormalities included microcephaly (5 fetuses), ventricular calcifications or other central nervous system lesions (7 fetuses), and abnormal amniotic fluid volumes or abnormalities of cerebral or umbilical artery blood flow (7 fetuses). There were two fetal deaths at 36 and 38 weeks of gestation. Eight of the 42 women delivered their babies and the ultrasounds were confirmed. The conclusion of the investigators was that, “despite mild clinical symptoms, Zika virus infection during pregnancy appears to be associated with grave outcomes, including fetal death, placental insufficiency, fetal growth restriction, and central nervous system injury.” I wonder if the vascular and placental abnormalities are evidence of adverse effects on the vascular system as well. Abnormalities were not restricted to women who were infected early in pregnancy but occurred when infected at all stages.

No doubt the investigators will continue to follow and report on the study. These medical scientists displayed the built-in conservatism and skepticism of good investigators by stating that more studies need to be done to confirm their findings. In my view, this is the kind of report that does not need a statistician to tell you that something bad is the matter.

Zika Virus likes nerve cells.
Another recent study done at Johns Hopkins showed that (at least the original strains isolated from Africa) Zika virus has a particular affinity for infecting young neuron [brain] cells in cell culture. This may or may not have bearing on the central nervous system findings in human fetuses or the neurological syndrome of Guillain-Barré syndrome in adults.  Other investigators found a 20-fold bump in the incidence of Guillain-Barré syndrome in French Polynesia following the Zika epidemic there two years ago lending strong evidence to that connection.  More to come I am sure.

The virus itself infects fetal brains.
As I write this article, the March 10 issue of the New England Journal contains a report of a young European woman who became pregnant in Brazil and acquired Zika virus infection during the 13th week of her pregnancy. Ultrasound at 29 weeks of pregnancy showed fetal abnormalities, and at 32 weeks even more profound abnormalities including calcifications of the brain and placenta, and microcephaly. The mother requested an abortion for medical reasons. At autopsy, the brain of the fetus was profoundly abnormal. The virus was shown to be abundantly present in the brain with damage to the spinal cord as well. Analysis of the genetic makeup of the virus was consistent with the strain from the far east and French Polynesia.

In my opinion, we can no longer speak of “suspected” fetal abnormalities as a result of the Zika virus infection. We will learn more.  The peculiar affinity of the virus for human neurons raises the possibility that even non-pregnant adults or children could conceivably get neurological complications – especially if they are immunocompromised. This story has not yet played out. We still unavoidably tread the path between panic and justifiable concern. Passivity is not an option. This is not the wrath of God for our misdeeds.

One lesson we can learn.
The impact of the current virus infection on our communities reinforces the case that we need a comprehensive healthcare and public health system that includes all Americans and which has links to other medical communities around the world. In particular, the impact of Zika virus infection provides all the evidence we need that both men and women, but particularly women, need access to the full range of reproductive and family-planning services including contraception, prenatal education and care, and yes, termination of pregnancy.

A second harder lesson.
The decision of a woman to terminate her pregnancy must never be a casual one, but it is one she has the right to make on her own, and surely if her own life is at risk from the pregnancy.  The fact that many of the women in the study from Brazil declined ultrasound examination because they “did not want to know” is evidence of the difficulty and seriousness applied by women to such a decision. I suspect the forceful opposition to abortion by religious authorities in Brazil was a factor. Legal abortion may not even be available.  I suspect some of the women felt they had no choice but to proceed with their pregnancies. The emerging fact that serious fetal abnormalities can occur even in late infections, or that the abnormalities might not be seen until later in pregnancy can only make the decision of a woman to terminate her pregnancy all the more difficult. She should be neither shamed nor bullied nor coerced. Neither can she have the option of a safe medical abortion taken away by the placement of medically unjustifiable obstacles by religiously motivated or timid legislators.

Going the wrong way in Kentucky.
Here in Kentucky, to my knowledge, we have only a single clinic where abortions can be legally performed, but our government seems hell-bent to close even that one. Better in their minds to deny women the right to all basic reproductive care than permit surgical or medical abortion.  Our male-dominated legislature recently passed a “Rape Me Twice” bill requiring women seeking abortion to undergo medically unnecessary ultrasounds – included those using the vaginal probe necessary to visualize early pregnancies.  No doubt many of these men actually believe that even the birth of a child with profound developmental abnormalities represents God’s will, or that abortion is a sin because the Bible says so, or because their preacher says so.  Others simply fear that the highly motivated swing vote of antiabortion crusaders and fund-raisers will cost them their good-paying jobs at the next election.

I would be interested to hear from our lawmakers in the Comments section below how they would council a woman who had contracted Zika virus infection while she was pregnant, and why they would stand in her way from having an abortion if that was her choice.  No doubt some highly scripted responses may follow, but in my opinion these will be both inadequate if not immoral. We have come a long way as a community to be able to make difficult decisions at the end of life.  We must learn to make similar decisions at the beginning of life as well, and for the same ethical or moral reasons.

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine
9 March 2016