Lessons about early neurodevelopment in children exposed to ZIKV in utero

Understanding the multidimensional neurodevelopmental outcomes in children after congenital Zika virus exposure

Since 2016, international research groups have focused on assessing outcomes of children with in utero Zika virus (ZIKV) exposure. While the more severe outcomes of congenital Zika syndrome (CZS) occur in up to 10% of children with antenatal exposure, early findings among ZIKV-exposed children without CZS ages 0-5 years suggest that they may also have differences in multiple domains of neurodevelopment. Thus, longitudinal follow-up of all children with antenatal ZIKV exposure has been recommended. This review presents a summary of neurodevelopmental phenotypes of infants and children following antenatal ZIKV exposure. We present a multidimensional framework to understand child neurodevelopment from an interdisciplinary and whole-child perspective (International Classification of Functioning, Disability and Health model) and multi-domain ZIKV Outcome Toolboxes. The toolboxes are for clinicians, researchers, child educators, and others to implement longitudinal multi-domain neurodevelopmental assessments between ages 0-12 years. Recent innovations in telehealth and neuroimaging can help evaluate outcomes in ZIKV exposed children. The objective is to describe the multiple facets of neurodevelopmental focused care that can support the health, function, and well-being of children with antenatal ZIKV exposure. The research and clinical follow-up strategies are applicable to ZIKV and other congenital infectious or environmental exposures that can impact child neurodevelopment. IMPACT: International longitudinal cohort studies have revealed a range of differences in neurodevelopment among children with antenatal Zika virus (ZIKV) exposure. A multidimensional and whole-child framework is necessary to understand the neurodevelopment of children with antenatal ZIKV exposure in relation to family life, community participation, and environment. Multi-domain toolboxes that utilize parent questionnaires and child evaluations are presented. These toolboxes can be used internationally alongside telehealth, brain imaging, and other innovations to improve understanding of child outcomes.

Viral infections in pregnancy and impact on offspring neurodevelopment: mechanisms and lessons learned

Pregnant individuals with viral illness may experience significant morbidity and have higher rates of pregnancy and neonatal complications. With the growing number of viral infections and new viral pandemics, it is important to examine the effects of infection during pregnancy on both the gestational parent and the offspring. Febrile illness and inflammation during pregnancy are correlated with risk for autism, attention deficit/hyperactivity disorder, and developmental delay in the offspring in human and animal models. Historical viral epidemics had limited follow-up of the offspring of affected pregnancies. Infants exposed to seasonal influenza and the 2009 H1N1 influenza virus experienced increased risks of congenital malformations and neuropsychiatric conditions. Zika virus exposure in utero can lead to a spectrum of abnormalities, ranging from severe microcephaly to neurodevelopmental delays which may appear later in childhood and in the absence of Zika-related birth defects. Vertical infection with severe acute respiratory syndrome coronavirus-2 has occurred rarely, but there appears to be a risk for developmental delays in the infants with antenatal exposure. Determining how illness from infection during pregnancy and specific viral pathogens can affect pregnancy and neurodevelopmental outcomes of offspring can better prepare the community to care for these children as they grow. IMPACT: Viral infections have impacted pregnant people and their offspring throughout history. Antenatal exposure to maternal fever and inflammation may increase risk of developmental and neurobehavioral disorders in infants and children. The recent SARS-CoV-2 pandemic stresses the importance of longitudinal studies to follow pregnancies and offspring neurodevelopment.

Harnessing the power of telemedicine to accomplish international pediatric outcome research during the COVID-19 pandemic

The COVID-19 pandemic occurred during planned neurodevelopmental follow-up of Colombian children with antenatal Zika-virus exposure. The objective of the study was to leverage the institution's telemedicine infrastructure to support international clinical child outcome research. In a prospective cohort study of child neurodevelopment (NCT04398901), we used synchronous telemedicine to remotely train a research team and perform live observational assessments of children in Sabanalarga, Colombia. An observational motor and conceptional standardized tool kit was mailed to Colombia; other materials were translated and emailed; team training was done virtually. Children were recruited by team on the ground. Synchronous activities were video-recorded directly to two laptops, each with a telehealth Zoom link to allow simultaneous evaluation of "table" and "standing" activities, and backup recordings were captured directly on the device in Colombia. The U.S. team attended live over Zoom from four states and five distinct locations, made observational notes, and provided real-time feedback. Fifty-seven, 3-4-year-old children with Zika-virus exposure and 70 non-exposed controls were studied during 10 daytrips. Direct laptop recording ensured complete record of child activities due to internet outages. Telemedicine can be used to successfully perform international neurodevelopmental outcome research in children during the COVID-19 pandemic. Telemedicine can benefit global health studies.

Neurodevelopment in infants with antenatal or early neonatal exposure to SARS-CoV-2

BACKGROUND

Antenatal and neonatal viral exposure may put the developing brain at risk for abnormal neurodevelopment. A clinical program at Children's National Hospital provides detailed follow-up of infants with in utero or neonatal SARS-CoV-2 exposure.

AIMS

To determine impact of early SARS-CoV-2 exposure on neurodevelopment.

STUDY DESIGN

We performed a prospective observational study of infant evaluations between 3/2020 and 11/2021. Demographics, pregnancy and birth details, SARS-CoV-2 data, specialty consultations, and NICU records were extracted from infants' medical records. Infants had neurologic exams and developmental screening with Ages and Stages Questionnaire (ASQ). Correlations between SARS-CoV-2 exposure type and neurodevelopmental outcomes were analyzed.

SUBJECTS

Thirty-four infants evaluated in the SARS-CoV-2 follow-up program.

OUTCOME MEASURES

Abnormal neurologic exams or ASQ scores near or below suggested cut-offs.

RESULTS

Infants received up to three evaluations. Most (28/34; 82 %) were exposed in utero - 16 to symptomatic mothers (IU-S) and 12 to asymptomatic mothers (IU-A). Six were exposed only as a neonate. IU-S had abnormal neurologic exams at mean (SD) age 112 (24) days and ASQ scores near or below cut-offs for all domains more frequently than IU-A or neonatally exposed infants. IU-S were more likely to score below any ASQ cutoff compared to IU-A (P = .04); differences were significant for Fine Motor (P = .01) and Personal-Social (P = .02) domains.

CONCLUSIONS

Early SARS-CoV-2 exposure may impact neurodevelopment, especially among infants exposed in utero to symptomatic gestational parents. Vaccination and other precautions to reduce early-in-life infection may protect against neurodevelopmental delays. Children with early SARS-CoV-2 exposure should have additional longitudinal screening for neurodevelopmental delays.

Knowledge and risk perception of vulnerable women on Zika virus infection at primary health care level in Brazil

Vulnerable low-income groups were most affected by Zika virus (ZIKV)-related neurologic syndrome during the 2014-2016 outbreak in Brazil. Major ZIKV infection response took place in Primary Health Care (PHC), including prevention strategies and risk communication. We aimed to detect knowledge and beliefs, as well as knowledge gaps among vulnerable women at the PHC level. A cross-sectional study was carried out in two low-income urban community settings: a small municipality with few ZIKV infection cases and a large municipality hard-hit by the epidemic. An open-ended data collection instrument centred on ZIKV infection knowledge, sources of information, possible causes, symptoms, risk perception, consequences for pregnant women and PHC point-of-care communication was developed. Interviews were recorded, transcribed and content coded for thematic analysis. Most of the seventy-nine respondents had some knowledge of the disease, acknowledging the vector as the source of infection and associating microcephaly with the disease, but distanced themselves from possible ZIKV infection and related risk. PHC services in both communities did not adequately communicate risk for women and children. In an uncertain future scenario as to disease re-emergence, awareness may be diminished and acquired knowledge lost, configuring a public health challenge that must be overcome.

ADP-ribosyltransferase PARP11 suppresses Zika virus in synergy with PARP12

BACKGROUND

Zika virus (ZIKV) infection and ZIKV epidemic have been continuously spreading silently throughout the world and its associated microcephaly and other serious congenital neurological complications poses a significant global threat to public health. Type I interferon response to ZIKV infection in host cells suppresses viral replication by inducing the expression of interferon-stimulated genes (ISGs).

METHODS

The study aims to demonstrate the anti-ZIKV mechanism of PARP11. PARP11 knock out and overexpressing A549 cell lines were constructed to evaluate the anti-ZIKV function of PARP11. PARP11-/-, PARP12-/- and PARP11-/-PARP12-/- HEK293T cell lines were constructed to explain the synergistic effect of PARP11 and PARP12 on NS1 and NS3 protein degradation. Western blotting, immunofluorescence and immunoprecipitation assay were performed to illustrate the interaction between PARP11 and PARP12.

RESULTS

Both mRNA and protein levels of PARP11 were induced in WT but not IFNAR1-/- cells in response to IFNα or IFNβ stimulation and ZIKV infection. ZIKV replication was suppressed in cells expressed PARP11 but was enhanced in PARP11-/- cells. PARP11 suppressed ZIKV independently on itself PARP enzyme activity. PARP11 interacted with PARP12 and promoted PARP12-mediated ZIKV NS1 and NS3 protein degradation.

CONCLUSION

We identified ADP-ribosyltransferase PARP11 as an anti-ZIKV ISG and found that it cooperated with PARP12 to enhance ZIKV NS1 and NS3 protein degradation. Our findings have broadened the understanding of the anti-viral function of ADP-ribosyltransferase family members, and provided potential therapeutic targets against viral ZIKV infection.

Neurological Findings in Children without Congenital Microcephaly Exposed to Zika Virus in Utero: A Case Series Study

The Zika virus can induce a disruptive sequence in the fetal brain and is manifested mainly by microcephaly. Knowledge gaps still exist as to whether the virus can cause minor disorders that are perceived later on during the first years of life in children who are exposed but are asymptomatic at birth. In this case series, we describe the outcomes related to neurodevelopment through the neurological assessment of 26 non-microcephalic children who had intrauterine exposure to Zika virus. Children were submitted for neurological examinations and Bayley Scales-III (cognition, language, and motor performance). The majority (65.4%) obtained satisfactory performance in neurodevelopment. The most impaired domain was language, with 30.7% impairment. Severe neurological disorders occurred in five children (19.2%) and these were spastic hemiparesis, epilepsy associated with congenital macrocephaly (Zika and human immunodeficiency virus), two cases of autism (one exposed to Zika and Toxoplasma gondii) and progressive sensorineural hearing loss (GJB2 mutation). We concluded that non-microcephalic children with intrauterine exposure to Zika virus, in their majority, had achieved satisfactory performance in all neurodevelopmental domains. One third of the cases had some impairment, but the predominant group had mild alterations, with low occurrence of moderate to severe disorders, similar to other studies in Brazil.